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Systematic Nursing Assessment Case Study

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Systematic Nursing Assessment Case Study
Clinical Case Study

Nursing is a complex and ever expanding profession. Nursing care mainly focuses on the patient’s physical care, which allows nurses to be with their patients for much longer than many other health professionals. Systematic patient assessment is an integral part of a nurse’s job as it permits patient care to be prioritized according to severity of condition, and also molds the basis of care plans (Anderson, 1998). Through early detection of a deteriorating patient, appropriate treatment can be elicited, which could prevent adverse events and potentially save a patient’s life.

Patient assessment is an ongoing process that is conducted throughout the patients stay, with the frequency dependent on the patient’s overall status (Stoy, 2001). If assessment is not conducted thoroughly, vital information may be missed which may impact on the patients overall progress. A detailed systematic assessment is comprised of a primary survey: which aims to identify and treat life threatening conditions, and a secondary survey: which includes a detailed health history and a head to toe assessment (Wardrope & Mackenzie, 2004).

This paper relates systematic patient assessment to a clinical case study: Mr. Brown, a 72-year-old male is admitted to ED with increasing SOB on exertion. Throughout the paper Mr. Brown’s symptoms will be coupled to appropriate nursing interventions, as outlined by the appropriate literature.

The first assessment to be conducted is the primary survey, which involves the identification of immediately life threatening conditions, coupled with appropriate nursing interventions (Allen, 2004). It should be commenced immediately upon contact with the patient, as well as any subsequent interactions. The primary survey is an objective assessment, and follows the pneumonic DRsABCDE (BetterHealth, 2013).

The primary survey begins with “D” and involves the health care provider assessing for dangers to self, the patient, or



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