Flinders University NURS8741: Cardiovascular Assessment Report

This report details a cardiovascular assessment of a 65-year-old female patient presenting with acute chest pain, shortness of breath, and jaw discomfort, indicative of acute myocardial infarction. The assessment utilizes the ISBAR framework, outlining the patient's situation, background, assessment findings (including elevated heart rate, blood pressure, and temperature), and recommendations for immediate transfer to A&E with initial interventions like aspirin and morphine. The report includes an ABCDE assessment, analyzing airway, breathing, circulation, disability, and exposure to determine the patient's unstable condition and system abnormalities. It prioritizes actions to prevent deterioration, such as rapid diagnosis, pain relief, and anxiety management. Furthermore, the report connects the nurse's actions with the ACCCN Practice Standards for Critical Care Nurses, providing specific examples of how the assessment and interventions align with these standards. The author reflects on the learning experience, emphasizing the application of the ABCDE approach, communication skills, and adherence to nursing standards in managing the patient's case.

Running head: ACUTE MYOCARDIAL INFARCTION
ISBAR: Case study
Name of the Student:
Name of the University:
Author Note:

ACUTE MYOCARDIAL INFARCTION 1
Answer 1

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Identity: This is a call from the registered nurse X from the clinic of
GP Y. This call is to inform you about a patient we received
this morning.
Name of the patient: Olive Smith
Age: 65 years
Sex: Female
Situation: Olive presented to this GP branch surgery at 08:30 AM. the GP is
not available at the branch. She reported that she had a pain in the
centre of her chest and shortness of breath, which woke her from
her sleep. She felt pressure discomfort in her jaws. This started at
around 07:00 AM. She also reports of feeling very tired.
Background: She has been a chain smoker for 40 years but has quit smoking for
the past five years. She has a medical history of hypertension.
Assessment: Her current observations include:
HR: 125b/m
BP: 189/112mmHg
RR: 27c/m
SpO2: 95% O/A
Temperature: 102 F
An ABCDE assessment was performed on the patient for
immediate clinical evaluation. Her symptoms and vital signs are
indicative of myocardial infarction.
Response and
rationale:
I would request an immediate transfer of the patient to the
A&E ward for further evaluation. She was given 300 mg
aspirin orally as immediate treatment response and 4-6 mg

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morphine intravenously as analgesics
We will be awaiting emergency help.
Answer 2
The initial assessment of Olive indicates that she is unstable. An ABCDE assessment was
conducted for providing emergency treatment. ABCDE stands for airway, breathing,
circulation, disability and exposure (Norton, 2017). The first step of airway assessment
presented airway clearance as no verbal abnormalities were observed and the response was
normal which concludes that the patient is conscious. The second step of breathing tested her
respiratory rate, which was comparatively higher than the average respiratory rate of 12-20
breaths per minute. The chest was also checked for any underlying deformity causing
increased breaths. No particular chest deformity was observed. The patient, however,
reported an acute pain in the centre of the chest. The inspired oxygen concentration (%) was
also measured which gave the results as 95% O/A. she also exhibited dyspnoea. The
subsequent step was checking the circulation. The patient’s digits were tested for any specific
symptoms. They presented a blue tinge which can be indicative of blockage of blood flow but
was however inconclusive. The blood pressure was observed as 189/112mmHg and her
temperature was recorded as 102F. The blood pressure and body temperature of Olive were
much higher than average values. Disability check for unconsciousness was assessed by
checking her alertness and response to voice and pain (Mayo, 2017). She responded to pain
and voice which demonstrated that she is conscious. The final test of exposure to examine the
patient for external injuries such as bruises, bleeds, rashes, ulcers and IV line wounds were
not observed. The exposure was tested while maintaining the patient’s dignity. This
assessment is indicative of myocardial infarction in Olive.

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Answer 3
The primary priority of the nurse to prevent deterioration of the patient with myocardial
infarction is to rapidly diagnose the condition by using the emergency assessment approach
of ABCDE and stratification of risk of the patient presenting an acute chest pain. The history
of the chest pain lasting for over 45 minutes and the pain in the jaw, along with other clinical
presentations such as fatigue or tiredness and dyspnea are conclusive of myocardial infarction
(Reed, Rossi & Cannon, 2017). Secondly, providing immediate relief to the patient while the
emergency service is on their way is essential to prevent deterioration. Pain relief is
significant not only for humanitarian reasons but to reduce the load on the heart as pain is
associated with sympathetic activations and causes vasoconstriction. Intravenous
administration of morphine or diamorphine at a dose of 4-6 mg can help in reducing the pain.
Intravenous administration should be preferred over intramuscular injection. This
administration of morphine or diamorphine is associated with side-effects such as vomiting,
nausea and hypotension (McCarthy et al., 2018). Aspirin can be given to the patient, Olive as
immediate care. Aspirin makes the blood thinner and removes any probable clots in the blood
to ensure the circulation of the blood (Lu et al., 2015). The next priority is providing
reassurance to the patient and the family to reduce anxiety. Anxiety is a natural reaction to
pain and in cases of myocardial infarction. It is essential to control the anxiety of the patient
to prevent excessive disturbance in the patient and relieve the tension to maintain the
condition of the patient.
Answer 4
The assessment of Olive during the ABCDE assessment demonstrated the Standard 13-15 to
collaborate with other nurses and act for the enhancement of professional development. For
example, the ABCDE assessment of Olive was in collaboration with other nurses in the

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critical care unit for the evaluation of Olive and the decisions for immediate relief were taken
in consultation with other nurses as well. The cardiovascular assessment of ABCDE to detect
fluctuations in vital signs, use integrated health assessments and plan goals of immediate care
are in line with the Standards 9 to 12 of the Standards of Practice in immediate evaluation of
Olive for myocardial infarction and providing immediate relief measures of aspirin and
morphine. The nurse’s response in providing reassurance and mental support to the patient,
Olive and her family aligned with the Standards 5-8 of the Standards of Practice. These
Standards lie within the domain of Provision and Coordination of Care, which establishes that
nursing practices must develop and optimize the well-being of the patients and their family
members to prevent complications resulting from anxiety (Acccn.com.au, 2020). The
respiratory and airway assessment of Olive was in line with the nurse’s Standards of Practice
9 to 12 under the domain of critical thinking and analysis. According to the domain, the nurse
successfully applied specialised knowledge of airway and breathing assessments of the
ABCDE tool to evaluate the consciousness, respiratory rate, dyspnoea and other vital signs of
the patient. Moreover, the nurse’s practices in maintaining the dignity of olive while
examining exposure were in line with the professional practice domain, which states to
protect the rights of the patients and provide practices that align with legal implications.
Answer 5
The clinical assessment of Olive was a useful learning experience for me. As the GP was not
available when Olive presented to the clinic, the responsibility of initial assessment and
immediate care of the patient was on the nurses and each nurse played an essential role. It
provided an opportunity to apply the knowledge of the different aspects of the ABCDE
approach of diagnosis to clinical practice. The examination of the patient using each of the
different aspects of ABCDE assessment including airway, breathing, circulation, disability

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and exposure helped in recording the vital signs of Olive and its analysis was useful to
enhance my knowledge of evaluating the vital signs of the patient for confirmatory
conclusions. It also provided another benefit of applying my clinical knowledge of providing
emergency responses. Besides, this case of Olive not only refined my clinical knowledge and
practices but also enhanced my communication skills while I was providing reassurance to
Olive and her family. This practice of providing mental support helped me recognize my
potential strengths and areas of improvement for effective communication and reaching out to
the patient. Moreover, management of Olive’s case also provided an insight into my
alignment of nursing practices with the Standards of Practice required by the nurses to
follow.

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References
Acccn.com.au. (2020). Acccn.com.au. Retrieved 17 April 2020, from
https://www.acccn.com.au/documents/item/934.
Lu, L., Liu, M., Sun, R., Zheng, Y., & Zhang, P. (2015). Myocardial infarction: symptoms
and treatments. Cell biochemistry and biophysics, 72(3), 865-867.
https://doi.org/10.1007/s12013-015-0553-4
Mayo, P. (2017). Undertaking an accurate and comprehensive assessment of the acutely ill
adult. Nursing Standard, 32(8).
McCarthy, C. P., Bhambhani, V., Pomerantsev, E., & Wasfy, J. H. (2018). In‐hospital
outcomes in invasively managed acute myocardial infarction patients who receive
morphine. Journal of interventional cardiology, 31(2), 150-158.
https://doi.org/10.1111/joic.12464
Norton, C. (2017). Acute coronary syndrome: assessment and management. Nursing
Standard, 31(29).
Reed, G. W., Rossi, J. E., & Cannon, C. P. (2017). Acute myocardial infarction. The
Lancet, 389(10065), 197-210. https://doi.org/10.1016/S0140-6736(16)30677-8