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Case study 1 – CD’s online Case Study Nursing Assessment

Case study 1 – CD’s


Early warning signs of deterioration can be detected through basic observations documented in the Standard Adult General Observation (SAGO) chart.  This is the most common tool we routinely use to assess the overall status or wellness of a patient. In 2010, Between the flags was introduced in New South Wales designed to promote patient safety by responding to early signs of deterioration (Clinical Excellence Commission 2011). Respiratory rate is part of the SAGO chart and an important indication of a serious illness which is often taken for granted (Cretikos et al. 2008). I will discuss the case of one of the patients I cared for whom I have named Simon for anonymity focusing on the respiratory assessment.

Case Presentation:

Simon is a 47 y/o male who presented to our ward from Intensive Care Unit post- percutaneous necrosectomy.  Simon has no past medical histories. He initially came to the hospital with abdominal pain and further tests showed pancreatitis secondary to cholelithiasis. On day two since admission to our ward from the Intensive Care Unit, Simon started coughing and complained of shortness of breath. I have conducted a full set of observations and respiratory assessment. Simon is looking anxious and is nasal flaring. Simon’s blood pressure was 107/ 66 mmHg; his heart rate is 115 bpm; he is febrile with a temperature of is 38.1 degrees Celsius; saturating 89% on room air, only 93% on 4L of oxygen via nasal prongs and 95% on 6L of oxygen via Hudson mask; he is tachypnoeic with a respiratory rate of 25; and his GCS is 15. I have called a clinical review, continued to assess Simon and kept repeating to take his observations. He is alert, orientated, and can still talk in full sentences with no difficulty but complained of chest pain when coughing. He also has crackles on auscultation. I have taken a sputum sample and sent to it pathology for culture. I also took Simon’s ECG to check for any cardiac involvement. Simon was reviewed by a medical officer, an x-ray and a stat dose of Ceftriaxone 1g was ordered.  Chest x-ray results revealed hospital-acquired pneumonia. The use of humidified high oxygen via high flow nasal cannula was recommended. Simon’s condition improved after a few days of intravenous antibiotics, mobilisation, chest physiotherapy, use of spirometry, and deep breathing exercises.


Hospital Acquired Pneumonia (HAP) is one of the leading causes of mortality from hospital-acquired infection, and it usually develops within 48-72 hours of hospitalisation (Lyons and Kollef 2018). Simon being a post-operative patient and having decreased physical activity made him at risk of acquiring pneumonia. Therefore, for patients like him who are at risk, frequent but accurate and reliable measurement of respiratory function is essential to detect early onset of pulmonary compromise that might result in chronic respiratory diseases (Buu 2017).  Results of Simon’s respiratory assessment has shown signs and symptoms of pneumonia. Any obvious symptoms present from visual inspection like a change in skin colour, use of accessory muscles when breathing, and distressed facial expression tells us that something is wrong with the patient and could lead to hypoxia if not treated quickly (Fritz 2015). Simon showing anxiety and exhibiting nasal flaring may be a sign that he is in respiratory distress (Mehta 2010).  I have also assessed his speech as dysarthria is a sign that the airway is compromised (Reier 2004). I have also started Simon on oxygen via the Airvo machine.  Humidified High-flow nasal cannula is a commonly used device in our ward to avoid invasive procedures and ICU admissions. This device works by reducing the work of breathing, therefore improving oxygenation and the humidified oxygen improves patient tolerance and essential for clearing secretions (Vella et al. 2018). I have also encouraged Simon to sit out of bed and mobilise to optimise his lung function and prevent further decline as mobility encourages lung expansion to increase airway clearance (Lyons and Kollef 2018).


Nursing assessment is a challenging skill. This where our clinical judgment begins and creates a huge impact on our decision- making (Cappelletti et al., 2014). This case scenario has made me reflect on my assessment practices in the ward. A thorough respiratory assessment is an important task to screen our patients and identify potential or existing medical problem that needs to be addressed immediately (Fritz 2015). Caring for our patients means we have to undergo a process that starts with the first important stage which is an assessment (McGee 2003) to promote patient safety. A proper assessment will enable us to formulate a nursing diagnosis which will then let us implement an effective individualise plan to let us achieve a positive outcome for our patients (Baid 2006).


Baid, H, 2006, 'Diagnosis. Differential diagnosis in advanced nursing practice.', British Journal of Nursing, 15, 18, 1007-101.1

Buu, MC 2017, 'Respiratory complications, management and treatments for the neuromuscular disease in children,' Current opinion in pediatrics, vol. 29, no. 3, pp.326-333, viewed 27 July 2018 <>.

Cappelletti, A, Engel, JK, Prentice, D, 2014, 'Systemic review of clinical judgment and reasoning in nursing,' Journal of Nursing Education, 53, 453-467.

Clinical Excellence Commission, 2011, Between the flags: Keeping patients safe, pp. 12- 14.

Cretikos, MA,  Bellomo, R,  Hillman, K,  Chen, J,  Finfer, S,  and Flabouris, A, 2008, Respiratory rate: the neglected vital sign, Med J Aust; vol. 188, no. 11, pp. 657-659.

Fritz, D,2015, 'Assessment of the respiratory system,' Home healthcare now, vol. 33, no. 8, pp.414-418.

Lyons, PG&Kollef, MH 2018, 'Prevention of hospital-acquired pneumonia,' Current opinion in critical care, viewed 27 July 2018, <>.

Mandel, JE 2018, 'Recent advances in respiratory monitory in nonoperating room anesthesia,' Current opinion in anaesthesiology, vol. 31, no. 4, pp.448-452, viewed 31 July 2018, <>.

McGee, P, 2003, Advanced health assessment, Advanced nursing practice, Blackwell Pub., Oxford, Chapter 8.

Mehta, M, 2010, 'Performing a respiratory assessment,' Nursing Critical Care, vol. 5, no. 3, pp.45-47.

Reier, CE, 2004, 'Bleeding, dysphagia, dysphonia, dysarthria, severe sore throat, and possible recurrent laryngeal, hypoglossal, and lingual nerve injury associated with routine laryngeal mask airway management: Where is the vigilance?', Anesthesiology, vol. 101, no. 5, pp.1241-1242, viewed 31 July 2018, <>.

Vella, MA, Pascual-Lopez, J, & Kaplan, LJ, 2018, 'High-flow nasal cannula system: Not just another nasal cannula,' JAMA Surgery.

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