Case Assignment 3
Comprehensive Assessment
Comprehensive assessments are a foundation of high acuity nursing as it allows nurses to establish a baseline for the patient, determine oxygen supply and demand, make sound clinical decisions, and promote personalized care (House-Kokan, 2012). Components of a comprehensive assessment include the patient’s story, a physical assessment, and corroborative diagnostic data (House-Kokan, 2012). A comprehensive assessment for both patients in the case study will be presented.
Patient’s Story
The first patient was not a patient on our assignment for the day. He was a patient we found lying on the floor after we heard a loud thud and crash from across the hall, and we initially knew very little about the patient. We learn from another nurse that the patient is post-op day 2 following an amputation of his right great toe secondary to gangrene and should not have been out of bed. Immediately following the fall the patient was alert and oriented …show more content…
The patient’s vital signs following the fall are BP: 150/70. HR: 82, RR: 32, SaO2: 88% on RA. To properly interpret these vital signs, we would need to look at the patient’s baseline vitals and trends in his vital signs. In acutely ill patients, this is important as we develop an understanding of what these vital signs mean in terms of oxygen supply and demand (House-Kokan, 2012).
Given the patient’s vital signs, we recognize that if this BP is an increase from his baseline, there is a decreased O2 supply due to vasoconstriction and an increased O2 demand as the heart pumps against vasoconstriction (House-Kokan, 2012). With a RR of 32, we suspect an increased O2 supply as minute ventilation increases but also an increased demand of O2 as there is an increase work of breathing (WOB) (House-Kokan, 2012). Given a SaO2 of 88% of RA, we would immediately apply supplemental O2 while awaiting a physician’s order and then titrate O2 to keep his SaO2 >94%, as per the physician’s