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Assessment CHF

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22 views4 pages

Assessment CHF

Copyright
© © All Rights Reserved
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Available Formats
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Assessment

Candidate briefing

You are a registered adult nurse working in the Medical Assessment Unit who is about to receive
a handover from the Cardiac ED team.

Please conduct a holistic assessment of the patient’s physical, psychosocial, spiritual, and
sexual care needs.

As part of your assessment, please complete an A to E assessment (airway, breathing, circulation,


disability, exposure), and take and record the patient’s vital signs (blood pressure, temperature,
pulse rate, oxygen saturations, respiratory rate) and calculate a national early warning score
(NEWS) score.

Depending on the patient’s circumstances and condition, you may wish to focus on some areas of
assessment in more depth than others.

Please note that there is no need to remove the patient’s clothing to assess exposure. Please ask
the examiner for any additional clinical information you require.

All equipment has been checked, calibrated and is clean.

An observation chart is provided and must be completed within the station.

This document must be completed using a GREEN PEN.

You have 20 minutes to complete this station, including the completion of the following
documentation: NEWS chart.

Assume it is TODAY and it is 10:00 hours.

Clinical Education for Internationally Educated Nurses; Bautista/Garol


Assessment

Overview of recent history


Patient information
Name: Neil Chubbs
Date of birth: 01/01/1950
Hospital number: 223344
Address: Coombe close Frimley, GU16 7ZD
GP: Dr. Ramu, GP Road surgery

Presenting complaint:
• Attended ED 3 weeks ago due to generalise fatigue and chest pain
• Undergone cardiac angiogram 3 weeks ago with no complications post discharge
• Now attending the cardiac ED unit due to left sided chest pain described as heavy and
sharp
• Neil also has bilateral leg swelling in the last 2 weeks
• Seen by the cardiology team with a query diagnosis of new onset of MI vs. Thrombosis
• Neil verbalises that the pain is radiating from his left chest going into his left shoulder
• He is also experiencing loss of appetite since post angiogram
• Feeling emotionally ‘low’ with generalise fatigue
• Walked unaided before angiogram, but finding it more difficult to mobilise due to
oedema and chest pain

Diagnosis: Congestive Heart Failure

Past medical history:


• Myocardial Infarction 10 years ago and 3 weeks ago
• Hypertension since 2005.
• Atrial Fibrillation since 2005

Social history:
• Normally lives with wife with no support or package of care
• Wife is the main carer but is now unable to cope since the recent cardiac angiogram
• Lives in a bungalow house
• Gave up smoking 20 years ago
• Drinks at least two pints of lager every week, sometimes more.
• Daughter or son-in-law visits every other day, bringing meals.

Drug history:
• Digoxin 62.5mcg once a day orally

• Furosemide 25mg twice a day orally

• Clopidogrel 75mg once a day orally

Allergies: Peanuts – Rashes


Plasters - Anaphylaxis
Clinical Education for Internationally Educated Nurses; Bautista/Garol
Assessment
Candidate notes
This documentation is for your use and is not marked by the examiners.
Name: Neil Chubbs
Date of birth: 01/01/1950
Hospital number: 223344
Address: Coombe close Frimley, GU16 7ZD
GP: Dr. Ramu, GP Road surgery

Airway

Breathing

Circulation

Disability

Exposure – full clinical history

Clinical Education for Internationally Educated Nurses; Bautista/Garol


Assessment
Candidate notes
This documentation is for your use and is not marked by the examiners.
Physical

Psychosocial

Spiritual

Sexual

Clinical Education for Internationally Educated Nurses; Bautista/Garol

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