Comprehensive Nursing Assessment Report: Cardiac Patient with NSTEMI

This report presents a comprehensive nursing assessment of a 50-year-old male factory worker admitted to the cardiac unit with NSTEMI. The assessment encompasses the patient's unstable condition, abnormal heart rhythm, and relevant vital signs. It details a systematic approach to cardiac, central nervous system, abdominal, respiratory, and renal system assessments, including inspection, palpation, auscultation, and percussion. The report emphasizes the importance of patient history, social background, and nutritional assessment. Prioritized nursing needs include cardiac monitoring, nutritional support, and patient education. The report highlights the significance of continuous cardiac monitoring, dietary intake review, and patient education on lifestyle modifications, including smoking cessation and alcohol reduction. The report references key nursing interventions and assessment tools, such as the PCAM, to ensure optimal patient outcomes. References are provided for further study.

1Running head: NURSING
Nursing
Name of student:
Name of university:
Author note:

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The patient in the present case study analysis is Mr Paul Peters who had been
admitted to the cardiac unit with the NSTEMI (Non-ST segment elevation myocardial
infarction). From the assessment of his current condition, it is noted that he is in unstable
condition and the ECG shows abnormality in heart rhythm. The correct vital statistics are
T36.5, HR 88, RR 18, BP 110/70, while the oxygen saturation is 96%. His age is 50 and
weighs 88 kgs. He is a factory worker and a regular smoker, with a sedentary lifestyle. His
level is education is low. The present section would detail the assessments to be taken for the
patient.
Assessment of the cardiac system of the patient would be most crucial since the
patient has abnormal heart rhythm and he is in unstable condition. The cardiac examination
would follow the stages of inspection, palpation and auscultation. The patient would need to
be positioned in the supine position and torso and neck would be exposed completely. The
general inspection would include his status of comfort, an abnormal movement like head
bobbing. The hands are to be inspected for skin turgor and temperature. It is imperative that a
nurse is as objective as possible while collecting patient data. Reporting the findings is very
much essential, and the charting of the results in a clear manner is also needed (Donahue
2011).
The second assessment would be a central nervous system that would involve the
assessment of the motor and the sensory responses of the patient. The purpose would be the
determination of impairment of nervous system. The examination to be conducted is Mental
Status Examination. This would involve the assessment of consciousness using the Glasgow
Coma Scale. A Mini Mental State (MMSE) examination would be pivotal. Muscle strength is
to be examined through the MRC (Medical Research Council) scale. The patient is to be
assessed for muscle tone and rigidity. Any abnormal movement, such as seizures and

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fasciculations are to be assessed along with the above mentioned assessments (Watkins,
Whisman and Booker 2016).
The consecutive assessments would be of the abdomen, respiratory system and the
renal system. Abdomen assessment would involve inspection, auscultation, palpation and
percussion of the abdomen. The inspection would include an examination of the shape of the
abdomen, abdominal masses, skin abnormalities, and abdomen wall movement with
respiration. Auscultation would detect altered bowel sounds, vascular bruits or rubs.
Atherosclerosis is the common cause of alteration of arterial blood flow. Palpation refers to
the abdomen examination for crepitus of the abdominal wall, for any abdominal masses or
abdominal tenderness (Lewis et al. 2016) . Assessment of the renal system, that is, kidneys
and bladder are commonly performed in combination with an abdominal assessment.
Auscultation is performed before percussion and palpation because these activities can lead to
vague abdominal vascular sounds and enhanced bowel sounds. Assessment elements would
include frequent urination, difficulty in urination and hematuria. A urine specimen is to be
checked for infection, and odour and colour. The bladder is to be palpated for any signs of
distention of the bladder. Assessment of the respiratory system would mainly focus on the
evaluation of respiratory distress. Major evidence of distress are a cough and audible
wheezing. Body temperature and respiratory rate are to be checked regularly (Considine and
Currey 2015).
Since the patient is a regular smoker and drinker, his social background is also to be
assessed before outlining the care plan. The regular nutritional diet of the patient is to be
assessed. It is important to know whether the patient had suffered loss or increase in weight
in the recent past. The Patient Centered Assessment Method (PCAM) can be the appropriate
tool for assessing the complexity of the patient through examination of the health
determinants. The tool assesses the lifestyle behaviour of the patient, the mental well being

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and the health literacy. The social environment is also to be assessed. The members of the
family who can provide in depth information about the patient is to be ascertained.
Intellectual function, depression and mental impairment are to be accurately highlighted. The
rationale is that thee behavioural and mental stare of the patient plays a key role in achieving
ultimate patient outcomes after the administration of medical interventions (Forbes and Watt
2015).
The prioritization of nursing needs enlists the main areas of focus to be cardiac
monitoring, nutritional needs and patient education. Since the patient has abnormal heart
rhythm, this would be the centre of nursing care for the patient. Cardiac monitoring refers to
the continual monitoring of the patient’s heart condition with the help of probes placed on the
skin of the patient’s body. The method would be noninvasive and painless. While such
monitoring is done, the nurse would play a crucial role in preparing the patient and ensuring
that the test is being done accurately. The monitor is to be observed correctly, and accurate
results are to be reported.
It has been found that the patient is obese, weighing 88 kgs. A review of the dietary
intake of the patient is needed. This would include calorie intake, eating habits and type of
food consumed. This step would provide the chance of focusing on the importance of
balanced diet as per the body needs. An eating plan is to be formulated that would be based
upon the patient specifications. A diet would include food items from all basic groups and
help in maintaining optimal body functioning. A suitable environment is to be created that
would foster the positive eating habit of the patient. Activity level of the patient would also
be assessed simultaneously. The patient would be required to carry out physical activity in
some form to maintain appropriate body weight (Butcher et al. 2013).

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The last nursing care aspect would be patient education. It is important that the patient
is encouraged to quit smoking and drinking. The nurse to refer the patient to a counsellor who
would aid in encouraging the patient to quit these two habits. The role of the nurse in this
regard would be to provide emotional support and educate the patient about the adverse
impact of alcohol and tobacco on health. Since the literacy level of the patient is low, it is
advisable that the nurse communicates in a language that is understandable to laymen. The
communication between the two needs to be clear and transparent (Morton et al. 2017).

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References
Butcher, H.K., Bulechek, G.M., Dochterman, J.M.M. and Wagner, C., 2013. Nursing
Interventions Classification (NIC)-E-Book. Elsevier Health Sciences. p. 178-180.
Considine, J. and Currey, J., 2015. Ensuring a proactive, evidence‐based, patient safety
approach to patient assessment. Journal of clinical nursing, 24(1-2), pp.300-307.
Donahue, M.P., 2011. Nursing, the finest art: An illustrated history. Mosby. pp. 258-259.
Forbes, H. and Watt, E., 2015. Jarvis's Physical Examination and Health Assessment.
Elsevier Health Sciences. p. 327.
Lewis, S.L., Bucher, L., Heitkemper, M.M., Harding, M.M., Kwong, J. and Roberts, D.,
2016. Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems,
Single Volume. Elsevier Health Sciences.
Morton, P.G., Fontaine, D., Hudak, C.M. and Gallo, B.M., 2017. Critical care nursing: a
holistic approach. Lippincott Williams & Wilkins. pp. 25-27.
Watkins, T., Whisman, L. and Booker, P., 2016. Nursing assessment of continuous vital sign
surveillance to improve patient safety on the medical/surgical unit. Journal of clinical
nursing, 25(1-2), pp.278-281.