Nursing: Assessment, Pathophysiology, and Interventions

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

1NURSING
Introduction
The following report is based on the case study of George who is having certain
cardiac complications. The report will initiate with a detail physical assessment followed by
the description of the detailed pathophysiology of the medication management. At the end,
the paper will highlight the prospective nursing interventions in order to improve patients’
outcome.
Physical Health Assessment
Assessment of the Central Nervous system
The assessment of the central nervous system was done based on the GCS (Glasgow
coma scale) and the reported a score of 15. This is the highest score signifying normal
movement of the eyes, verbal response and motor impulses. The body temperature of George
measured from mouth is 36.5T (normal).
Assessment of the Cardiovascular system
The pulse rate of George is higher than the normal 120 beats per minute (normal 70 to
100), the heart beat is irregular (as per pulse oxymetry), the respiratory rate was 28 beats per
minute (normal 12 to 20) with high level of blood pressure 167/100 mm Hg (normal range:
120/80). George was sweating profusely. There was change in the colour as he was looking
pale (indication of cyanosis) and SpO2 was 88%. The sounds of heart is irregular with
skipping of beats as highlighted in the stethoscope.

2NURSING
Assessment of the Respiratory system
a) Inspection: Increase in the respiratory rate however, significant change in the rise
and fall of chest. SpO2 is 88% which is lower than the normal (97 to 99% is the normal
range). Thus there are chances of developing cyanosis
b) Palpation: Measurement of pain was done with the help of the PQRST method
(provocation, quality, region, severity and time) showed that George is suffering from pain in
his pain in the left posterior shoulder. The pain is radiating in towards his left arm. The pain
increased on exertion with the level of pain score of 9/10. This high level of pain in the back
of the shoulder might be an indication of the acute coronary syndrome (Australian Heart
Foundation, 2016)
c) Percussion: The sounds of the lungs is not prolong
d) Auscultation: auscultation of his chest was clear.
Assessment of the abdominal cavity
a. Inspection: There are no visible scar over the abdomen however, there are
indication of the abdominal distension along with the signs of nausea and vomiting
b. Ausculation: There was no sensation of pain in the abdominal cavity
c. Percussion: There are no indications of the gas sound present that is tympanic
sound.
d. Palpation: There was no pain scare in the abdominal area
4. Assessment of the renal system
There is no past medical history of renal impairment. However, the abdominal
distension significant renal impairment (Mathew et al., 2017)