Comprehensive Nursing Assessment and Priorities of Care

Running head: NURSING
Nursing
Name of the Student
Name of University
Author’s note

1NURSING
Introduction
The case study below highlights the story of a man who is admitted to hospital with
severe abdominal pain in the upper right quadrant. The paper will initiate with a focus on the
comprehensive nursing assessment followed by highlighting three primary priorities of care and
proper discharge planning under social justice framework for health.
CNS/ CVS/ RESP/ ABDO/ RENAL/ OTHER
1. CNS Assessment
According to the case study, the Glasgow coma scale (GCS) of Smith is 15. This is the
maximum score. This signifies that all the sensory organs (eyes, verbal and the motors) are in
full conscious with no acute chances of brain injury. Since Mr Smith's score is 15, this signifies
that opening of eyes are normal with proper blinking at the base line (Score 4) (GCS 2019). The
moving of the limbs is also occurring as per the commands (Score 6). The body temperature of
Mr Smith is 36.5. T and this is the normal body temperature.
2. CVS Assessment
Pulse rate (PR) of Smith is 102 (normal 70 to 100) and is beating at regular interval,
respiratory rate (RR) is 28 beats per minute (normal range: 12 to 20) and blood pressure is
100/60 mmHg (Normal range: 120/80). Thus blood pressure is below normal. Though the case
study failed to highlight any indication for sweating, but taking into the low pressure into
consideration, it can be stated if the blood pressure drops too low, the body's vital organs fail to
receive enough oxygen and nutrients. Under this stage, the body pass on to shock leading to
generation of excessive sweat, rapid breathing, high pulse and blue skin tone (cyanosis)(Carrick

2NURSING
et al. 2016). Mr Smith’s RR and PP was high and there is no change in skin colour as his SpO2
was not alarmingly low.
3. RESP Assessment
a) Inspection: The respiratory rate is high and with high respiratory rate there occurs
increase rise and fall of chest. The SpO2 is 94% and thus there would be no chances of
cyanosis and he has previous reported cases of pulmonary embolus.
b) Palpation: Measurement of pain can be done accurately by the use of PQRST framework.
 P (provocation) indicates that pain has arisen due to pain in abdomen that is radiating
to back. The pain mainly started after having dinner at 1800 (chops and vegetables).
No reporting of rib fracture was stated at the time of admission however,
 Q (Quality) of the pain includes gnawing in nature indicating extremely distressing
pain.
 Region (R) of pain include right upper quadrant of the abdomen that is travelling to
the back.
 Severity (S) of pain is high as the score is 9/10. The pain was consistent with no
slowing down.
 Time (T) of pain sensation was post dinner (1800 hours) and Smith was admitted at
2000 hours.
c) Percussion: the sound of lungs is not prolong
d) Ausculation: No difference in sound

3NURSING
ABDO Assessment
a. Inspection: There is no visible scar over the abdomen. There are indication of abdominal
distension or signs of nausea and vomiting
b. Auscultation: The pain is in the right upper quadrant of the abdomen and might be
indication of gall stones or other complications in the hepatobiliary system (Cook et al.
2019). No indications were given for hyper or hypo bowel sounds
c. Percussion: There are indication of gas sounds were present (tympanic sound). In case of
abdominal distension there tympanic sounds (Cook et al. 2019)
d. Palpation: The pain score is 9 out of 10
4. RENAL Assessment
There no past medical history of renal complications.
5. Others
The main blood text that must be undertaken in this case is complete blood count (CBC). The
complete blood count test will help in understanding any possible signs of internal infections (it
will be indicated by high levels of neutrophils and macrophages) or haemorrhage in the right
upper quadrant of the stomach (due to rib injury, if any). The signs of haemorrhage will be
indicated by increased level of erythrocyte sedimentation rate. Additional blood test that must be
undertaken include amylase and lipase test that must be undertaken include amylase and lipase
test. Amylase and lipase are the principal digestive enzymes. Amylase helps the body to break-
down starches and lipase helps to digest fats. The digestive organs, pancreas secretes these two
digestive juices. Malfunction in the pancreas leads to decrease in the secretion of these two
digestive juices. Thus amylase and lipase test will leads to poor concentration of both of the