Question

Mr. Smith is a 55 Yr. old African American male that came to the ED complaining of chest pain and shortness of breath. Mr. Smith appears anxious, diaphoretic, and uncomfortable. He rates his chest pain as 9 on a pain scale of 10. Mr. smith has a history of hypertension, hyperlipidemia, and chronic bronchitis. He admits to smoking 1 back per day and tries to exercise but is usually too busy.

Objective data: B/P-190/88, HR-120, R-20, Sa02-94% (Room air), T-99

Cardiac monitor shows tachycardia with an occasional PVC.

Subjective data: Mr. Smith rates chest pain as 9 out of 10. Mr. Smith is anxious and states he feels "like he is going to die".

Describe how you would do your nursing assessment on Mr. Smith for beginning to the end?

What nursing intervention could the nurse provide to Mr. Smith?

Answer 1

Patient History:  Discuss the history of current illness/injury (i.e. chest pain of 9 on pain scale of 10 and SOB), relevant past history, allergies and reactions, medications, immunisation status, implants and family and social history. Recent overseas travel should be discussed and documented.

General Appearance: Assessment of the patients’ overall physical, emotional and behavioral state. Considerations include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.

• Mood and affect
• Personal hygiene
• Communication

Vital signs: Temperature:99 deg F

Respiratory Rate: 20 rpm

Heart Rate: HR-120 bpm

Blood Pressure: 190/88 mm Hg

Oxygen Saturation: 94% (Room air)

Pain: 9 on pain scale of 10

Additional Measurements:

• Weight: daily as clinically indicated.
• Height: as clinically indicated.
• Blood sugar level (BSL): as clinically indicated

Physical assessment::Observation/inspection, palpation, percussion and auscultation are techniques used to gather information. Primary assessment (Airway, Breathing, Circulation and Disability) and Focussed systems assessment.

Airway: noises, secretions, cough,

Breathing: bilateral air entry and movement, breath sounds, respiratory rate, rhythm, work of breathing: - spontaneous/ laboured/supported

Circulation: pulses (location, rate, rhythm and strength); temperature (peripheral and central), skin colour and moisture, skin turgor, capillary refill time (central and Peripheral); skin, lip, oral mucosa and nail bed colour. ECG rate and rhythm.

Skin: Colour, turgor, lesions, bruising, wounds, pressure injuries.

Hydration/Nutrition: Assess hydration and nutrition status, type of diet, IV fluids.

Output: Assess Bowel and Bladder routine(s), incontinence management urine output, bowels. Review fluid balance activity
Blood sugar levels as clinically indicated.

Risk Assessment: pressure injury risk assessment, falls risk assessment,
Wellbeing: Assess for Mood, sleeping habits and outcome, coping strategies, reaction to admission, emotional state, comfort objects, support networks, reaction to admission and psychosocial assessments.

Neurological System :

• Arm and leg movements, assess both right and left limb and document any differences.
• Pupil size, shape and reaction to light.
• Importance of Vital signs. Vital sign changes are late signs of brain deterioration. Respiratory pattern provides a clear indication of brain functioning. Note for Cheyne Stokes, rapid, irregular, clustered, gasping or ataxic breathing. Temperature alterations may indicate dysfunction of the hypothalamus or the brain stem. Blood pressure increases with increased intracranial pressure. Pulse rates initially rise as a compensatory mechanism, and then slow in instances of increased intracranial pressure.

Respiratory System::

History

• Onset + duration of symptoms cough / shortness of Breath
• Triggers ( dust / aerosol / pollen)

Inspection/Observation:

• Observe the overall appearance of the child: alert, orientated, active/hyperactive/drowsy, irritable.
• Colour(centrally and peripherally): pink, flushed, pale, mottled, cyanosed , clubbing
• Respiratory rate, rhythm and depth (shallow, normal or deep)
• Respiratory effort (Work of Breathing -WOB): mild, moderate, severe, inspiratory: expiratory ratio, shortness of breath
• Use of accessory muscles (UOAM): intercostal/subcostal/suprasternal/supraclavicular/substernal retractions, head bob, nasal flaring, tracheal tug.
• Symmetry and shape of chest
• Tracheal position
• Audible sounds: vocalisation, wheeze, stridor, grunt, cough - productive/paroxysmal
• Monitor for oxygen saturation: 94%

Auscultation

• Listen for absence /equality of breath sounds
• Auscultate lung fields for bilateral adventitious noises e.g.: wheeze, crackles, stridor etc.

Palpation

• Bilateral symmetry of chest expansion
• Skin condition – temperature, turgor and moisture
• capillary refill (central/peripheral)
• Fremitus (tactile)
• Subcutaneous emphysema

Cardiovascular:

Inspection:

• Examine circulatory status and hydration status of upper and lower extremities:
• Colour (central and peripheral): pink, flushed, pale, mottled, cyanosed, clubbing
• Capillary Refill Time (CRT): brisk (< 2 sec) or sluggish
• Presence of oedema (central and/or peripheral)
• Hydration status: Skin turgor, oral mucosa

Palpation:

• Palpate central and peripheral pulses for rate, rhythm and volume
• Skin condition – temperature(peripheral and central), turgor and diaphoresis

Auscultation:

• Auscultate the apical pulse
• Compare peripheral pulse and apical pulse for consistency (the rate and rhythm should be similar).
• Auscultate the chest for heart sounds and murmurs

Gastrointestinal :

History: Pain, cramping, nausea, vomiting,

Inspection :

• Shape /symmetry of the abdomen (flat, rounded, distended, scaphoid)
• Contour of the abdomen
• Distention, Visible peristalsis

Palpation

• Light palpation only to identify, Tenderness, Distention, pain

Auscultation

• Four quadrants (RUQ, RLQ, LUQ, LLQ) for bowel motility
• Bowel sounds present (frequency / character)

Renal

An assessment of the renal system includes all aspects of urinary elimination

• Urinary pattern, incontinence, frequency, urgency, dysuria
• Hydration status including fluid balance, BPand weight, Urine output

Musculoskeletal :

Inspection : Joint range of motion, Joints for redness or swelling

Palpation: Limbs for muscle mass, tone, strength

Skin : Colour of the skin, Any Bruising/wounds/pressure injuries, Hair: observe the condition of the scalp

Palpate: Skin temperature, moisture, turgor, oedema, deformities, hematomas and crepitus

Eye :

Inspection/Observation

• Bilateral symmetry, shape, and placement of eye in relation to the ears.
• Bilateral symmetry ,size and shape of the pupils, reactivity to light
• Conjunctiva, and eyelids for inflammation, color and discharge
• Color of sclera

Ear/Nose/Throat (ENT):

Inspection  

• Inspect ears for symmetry, shape and position.
• Observe for any external trauma, obvious cerumen, inflammation, redness.
• Inspect nose for symmetry, nasal patency, tenderness, septal deviation, bleeding, discharge.
• Inspect lips for shape, symmetry, color, dryness, and fissures at the corners of the mouth
• Inspect gingival tissue noting color and condition.
• Observe for bleeding gums, trauma to tongue or oral cavity,
• Look for excessive fluid/secretions in the mouth

Nursing Interventions:

Nursing Assessment

In assessing the patient with angina, ask regarding the following:

• Location of pain.
• Characteristics of pain.
• Health history.
• Pain scale.
• Onset of pain.
• Cause of pain.
• Measures that relieve pain.
• Other symptoms that occur with pain.

- The nurse should instruct the patient to sit or rest in bed in a semi-Fowler’s position when they experience angina, and administer nitroglycerin sublingually as per physician's advice.

- Elevate head of bed if patient is short of breath.

- Monitor heart rate and rhythm. Monitor vital signs every 5 min during initial anginal attack.

- Auscultate breath sounds and heart sounds. Listen for murmurs.

- Stay with patient who is experiencing pain or appears anxious. Maintain quiet, comfortable environment. Restrict visitors as necessary.

- Provide light meals. Have patient rest for 1 hr after meals.

- Provide supplemental oxygen as indicated.

- Instruct patient to notify immediately when chest pain occurs.

- Assess and document patient response to medication.

- Monitor and documents effects or adverse response to medications, noting BP, heart rate, and rhythm.

- Monitor pulse oximetry or ABGs as indicated.

- Identify precipitating event, if any: frequency, duration, intensity, and location of pain.

- Observe for associated symptoms: dyspnea, nausea and vomiting, dizziness, palpitations, desire to micturate.

- Evaluate reports of pain in jaw, neck, shoulder, arm, or hand (typically on left side).

- Evaluate mental status, noting development of confusion, disorientation.

- Note skin color and presence and quality of pulses.

- Providing information about the illness, its treatment, and methods of preventing its progression are important nursing interventions.

- Provide for adequate rest periods. Perform self-care activities, as indicated.

- The nurse reviews the assessment findings, identifies the level of activity that causes the patient’s pain, and plans the patient’s activities accordingly

- Balancing activity and rest is an important aspect of the educational plan for the patient and family.

- Promote expression of feelings and fears. Let patient/SO know these are normal reactions.