Nursing Assessment

The nursing assessment of the acutely ill adult is of significant importance and needs to be carried out using a systematic approach and a range of skills acquired by the nurse. It is vital that a nurse performing assessments on acutely ill patients is adequately equipped to recognise a deteriorating patient and act accordingly (NICE, 2007). During the nurse’s assessment, it is critical to consider all aspects of the patient’s condition and general health and maintain dignity of the patient throughout. The first assessment carried out by the nursing staff is an approach known as the ABCDE approach. This is an ongoing assessment of the patient that analyses the patient’s airway, breathing, circulation, disability and exposure (Pratt, 2006).
ABCDE approach is recommended to avoid missing immediate signs of harm to the patient. However, this approach can lead to misinterpretation. It is important, once it has been established that the patient has a patent airway and has no difficulty with their breathing or circulation, that another assessment tool is used to assess the patient (Harrison et al, 2011).
The most appropriate tool for my patient would be the National Early Warning Score (NEWS). NEWS is a track and trigger system that uses a simple scoring system and physiological parameters to alert staff to deterioration in the acutely ill patient. The Recent National Inquiry into Patient Outcome and Death (NCEPOD, 2005) stated the importance of such tools and their use in early identification of at risk patients. Six simple physiological parameters form the basis of the scoring system. This tool can be used in conjunction with clinical expertise to help aid the patient. These 6 aspects are; Respiratory rate, oxygen saturations, systolic blood pressure, temperature, level of consciousness and pulse rate.
After the ABCDE assessment was carried out on Mr Jones, it was established that he had a patent airway and no difficulty breathing.
However, he displayed an increased respiratory rate, which can be an early sign of deterioration in the patient and must be monitored closely (Resuscitation Council, 2010). The nursing staff decided to reposition Mr Jones to see if this would help. The nurse is also made aware from speaking to Frederick that he is very anxious about being in hospital and believes this may have caused his increased respirations. To help alleviate some of this anxiety, the nurse uses communication as a distraction tool by talking to Frederick about his personal life(Firth and Cornwell, 2009). ABCDE is an approach carried out in order and seeing as Mr Jones’s airway is patent, this assessment is complete. The nurse then began NEWS on Mr. Jones. His vital signs were taken and recorded and Mr. Jones was scoring a 6 on NEWS. This automatically alerted nurses to his deterioration and immediate interventions were necessary to help stabilise Mr Jones. He was placed on half hourly observations and in this time the nurse ordered a set of bloods to be taken to gather further information. During this time, the nursing staff noted his poor urine output and encouraged fluids. However, this did not improve throughout the day. Frederick’s bloods results showed a rapid increase in both serum creatinine and blood urea nitrogen (BUN). This resulted in the nursing staff reassessing Mr Jones and then contacting his surgeon. Throughout the assessment process, it is important to keep the patient informed about what is happening to avoid unnecessary distress. This is turn can help build the patient-nurse relationship and aid the nurse in delivering the best person-centred care
possible.