Assessment CHF
Assessment CHF
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.
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.
You have 20 minutes to complete this station, including the completion of the following
documentation: NEWS chart.
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
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
Airway
Breathing
Circulation
Disability
Psychosocial
Spiritual
Sexual