Case Study 4 – NGs Online Case Study Nursing Assessment

Case Study 4 – NGs

The health assessment is a systematic way of collecting data and information from the patient which helps to formulate a nursing diagnosis, nursing goal, and implement different strategies to resolve it. Pain assessment is one of the vital signs of patient assessment. Pain can be assessed using the PQRST approach. This case study is based on Mr. Smith who presented to the ED with chest pain and SOB. In this assignment, I would like to discuss the importance of clinical judgment and clinical reasoning as the part of the assessment process and would like to reflect on my experience.

 CASE STUDY:

 Mr. Smith presented to the Emergency Department with Chest pain and Shortness of breath for 1 day with the background history of IHD, HTN and chronic smoker. The patient had all the initial investigations including ECG, full blood counts including Troops was done in Emergency. ECG showed no change to the previous one done 3 months back, Trop level was slightly elevated 28.  There were no significant changes in electrolytes and another blood count.   He was then transferred to our ward (Geriatric assessment unit) for 24-hour telemetry monitoring, serial trop, and ECG.  I assumed the care of the patient @ 1330. I did my initial assessment when I started my shift; His GCS was 15/15, Airway was patent, saturating 95%RA, Nil SOB or any respiratory distress, RR 20. HR and BP were between the flags, Telemetry showing Sinus rhythm. PIVC in right cubital fossa, skin intact, afebrile.  Denied any pain at that moment. After about 2 hours the patient complained that he was having chest pain. I quickly performed pain assessment using the PQRST approach.  On pain assessment using the PQRST approach patient was found to have chest pain on the left side of the chest, crushing in nature. It started from the chest and radiated toward the shoulder and Jaw. I immediately contacted the Team looking after the patient. Performed 12 lead ECG and gave PRN Anginine (GTN) as prescribed in the medication chart, the pain was not relieved by Anginine. Medical Officer (MO) charted morphine. Same given with good effect. MO interpreted ECG. ECG showed ST elevation suggesting Acute Myocardial Infarction. Repeat blood was taken as well. Blood result is taken at that also showed a drastic increase in Trop level

 DISCUSSION:

 Chest pain can be related to varieties of reason, from simple musculoskeletal pain, indigestion to major cardiac reasons like AMI, cardiac arrest. Thus, Chest pain should never be neglected and should be treated as cardiac related and life-threatening causes unless proven otherwise.   According to AIHW, 2017, every day 22 people lose their life due to a heart attack.  Moreover, there were more than 54,000 hospitalizations 2014-2015 due to Heart attack (AIHW, 2015).

 PQRST approach is one of the best approaches to rule out the nature of chest pain ( O’Donovan, 2013). In this approach we look for the location/position and provoking factors of the pain, quality of pain like dullness, sharp, stabbing, crushing, Radiation of the pain severity and timing of the pain.  If the pain is relieved with repositioning it is often referred to as Musculoskeletal and pleuritic pain whereas Cardiac pain is not relieved with repositioning.  Quality of pain also differs according to the cause, Chest pain is often crushing and constricting in nature, although some might be silent.  66% of Cardiac pain is often found to be radiating to the anterior chest, shoulder, and arm (Bucher, Johnson &Rolley, 2015). It can also be present with different symptoms like nausea, diaphoresis, hypotension. The timing of pain like intermittent or continuous should also be taken into account. Anginal pain can be relieved after 2-3min if the precipitating factors are removed, whereas pain related to MI are doesn't get relieved.  Relating to PQRST approach my patient was also complaining of crushing nature pain, not relieved with repositioning, and radiating to jaw and shoulder. The information I could get from Mr. Smith regarding his chest pain was helpful in recognizing the type of pain, and it also gave an idea of when the disease process might have begun.

REFLECTION:

This case study has also taught me the importance of using PQRST approach in pain assessment, Haven’t I used this approach It would be difficult for us to differentiate the type of pain the patient was having.  Appropriate data collection and clinical judgment are the key factors in nursing (Marrey& Anderson, 2017). I was able to find that the patient was in pain and relate it to the Cardiac cause and also could inform the team so they could act upon it on time. Good clinical judgment is helpful in picking up different cues from the health assessment and act upon it fast. Good clinical reasoning skill also helps in interpreting the data correctly and take appropriate action to treat the cause in a timely manner.  Not being able to diagnose and provide appropriate treatment on time properly can also lead to the adverse outcome (Levett-Jones et al. 2010)

 REFERENCES:

Australian Bureau of Statistics 2017, Causes of death 2016, ABS cat.no.3303.0, September;

 Australian Institute of Health and Welfare (AIHW) 2015, Australian hospital statistics 2014-2015.Health services series no.54.Cat.no.HsE145, Canberra: AIHW

 Bucher, L, Johnson, S, &Rolley, J 2015,’Nursing management: Coronary artery disease and acute coronary syndrome’ in  Brown, D, Edwards, H, Seaton, L, Buckley, T, Lewis, SL, Dirksen, SR, Heitkemper, MM & Bucher (eds), Lewis medical-surgical nursing assessment and management of Clinical problems, Elsevier Australia.

Levett-Jones, T, Hoffman, K, Dempsey, J, Jeong, SY, Nobler, D, Norton, CA, Roche, J & Hickey, N 2010, ‘The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients’ Nurse Education Today, vol.30, no.6, pp.515-520.

Massey, D & Anderson V 2017, ‘What factors influence ward nurses’ recognition of and response to patient deterioration?’, Nursing Open, vol.4, no.1, pp.6-23

O’Donovan, K 2013 'Nursing assessment of the causes of chest pain,' British Journal of Cardiac Nursing, Vol 8, no.10, pp 483-488