University Case Study: Vital Signs Assessment Report, NUR331

This report presents a comprehensive vital signs assessment of Mr. John, a 68-year-old patient admitted to the emergency department following a car accident. The assessment includes analysis of vital signs such as temperature, pulse rate, respiratory rate, blood pressure, oxygen saturation, and pain score, revealing elevated blood pressure and respiratory rate, along with a pain score indicating severe pain. The report also evaluates the patient's Glasgow Coma Scale (GCS) score and weight, highlighting the presence of pneumothorax and overweight status. A respiratory system framework is implemented for further assessment. The report prioritizes care interventions, including monitoring respiratory rate, rhythm, and depth, encouraging deep breathing exercises, and monitoring for pulmonary complications. Evidence-based practices are emphasized throughout the report, with a focus on the crucial role of nurses in ensuring patient recovery and preventing complications. The report concludes with a summary of the assessment and the importance of nurses in providing quality care. References are provided to support the assessment and interventions.

Running head: VITAL SIGNS ASSESSMENT
Vital Signs Assessment
Name of the Student
Name of the University
Author Note

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Introduction
A critical aspect of clinical practice by the advanced practice nurse is to integrate
evidence-based patient assessment. Evidence-based practices are considered to be an
important force in the healthcare sector and healthcare professionals integrate such practices
during the initial assessment to determine the interventions required to treat the patient
(Mackey & Bassendowski 2017). The primary assessment of the vital signs of the patient
gives an overall view of the health status of the patient. However, to provide patient-centered
care, the specific framework of assessment is required to determine specific interventions
(Watkins, Whisman, & Booker 2016). The following sections of the paper will analyse a case
study and determine the current state of the patient and required intervention to recover the
health of the patient.
Patient Assessment
The patient, Mr. John, 68 years old, is admitted to the emergency department after a
car accident. The vital signs show the temperature of 36.5℃, pulse rate of 96 beats per
minute, respiratory rate of 28 breaths per minute, blood pressure of 160/95, oxygen
saturation of 92% and pain score of 9 out of 10. According to Qadir and Maqsood, the body
temperature of the patient is normal and considering the accident of the patient, the elevated
pulsation is justified. The blood pressure of the patient is highly elevated with readings of
160/95, higher than normal levels of 120/80, concluding high blood pressure. The pulse
oximeter readings of 92% indicate a normal oxygen saturation level. However, the pain score
of 9 out of 10 reveals that the patient is suffering from extreme or severe pain and requires
the immediate attention of healthcare professionals (Kannampallil et al. 2016). The normal
respiratory rate of a person at rest is between 15-20 breaths per minute. The patient has a
respiratory rate of 28 breaths per minute, which is abnormally elevated than normal levels,
indicating severe injuries to the lungs occurred due to the accident (Mastan et al. 2017).

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Glasgow Coma Scale (GCS) is used to measure prognosis and severity of brain injury
if any. The scaling measures of the Glasgow Coma Scale are measured on the basis of
patient’s verbal, motor and eye-opening response. The scaling of GCS is limited to 3-15, on
which, a patient with a score of 3 (minimum) has the worst prognosis & is potentially fatal,
with a highly reduced chance of recovery and the score of 15 (maximum) has the best
prognosis. As per the evaluation of the case study, the patient has a GCS score of 15,
indicating that the patient is in good condition and has the best prognosis with higher chances
of recovery (Jain et al. 2019). Moreover, the case study analysis reveals that the patient has
reported no Loss of Consciousness (LOC), which is a good indicator, increasing the chances
of a patient’s recovery.
Another concern found during the patient’s assessment is the weight of the patient.
The patient weighs 130 kilograms, which can be easily determined to be overweight. Upon
calculation of the BMI (Body Mass Index) with average height range, the result comes out to
be above 40 kg/m2, which is high above the normal level of 27.7 as determined by the World
Health Organization. Additional information suggests that Mr. John face difficulties in
performing daily activities due to his overweight status. This issue should be addressed in the
post-operative care plan of the patient.
To conduct further assessment of the patient’s current health status, a respiratory
system framework will be implemented. This is due to the fact that post the car accident, the
patient has suffered severe injuries to the lungs. This is evident with the elevated levels of
blood pressure and respiratory rate, which are abnormally higher than the normal levels of
respective vital signs. Respiratory assessment of the patient will include inspection of
breathing, face, neck, chest percussion and chest auscultation. Experienced nurses can carry
out a full respiratory assessment and document it and this is an essential skill of this
profession. The elements of this type of assessment framework include history taking, initial

3VITAL SIGNS ASSESSMENT
assessment, palpation, inspection, auscultation, percussion and other investigations. With the
help of prompt respiratory assessment, the nurses and other health care professionals can
evaluate the severity of the injury and warrant appropriate treatment interventions. During
breathing assessment, the healthcare professionals including nurses will lookout for laboured
breathing and assess the use of respiratory accessory muscles including sternocleidomastoid,
infrahyoid and platysma. In palpation, the professionals gather information with the help of
touch, in the investigation, the same is done with the help of visual assessment. In percussion,
the professionals strike the chest to determine the condition of the underlying tissue. Finally,
in auscultation, the professionals listen and interpret the sound transmission with the help of a
stethoscope. It is conclusive with the assessment of the vital signs that the patient is having
laboured breathing. Decreased breathing sound can be detected with the inspection of chest
auscultation and is indicative of pneumothorax, COPD, pneumonia, pleural effusion, and
asthma.
Pneumothorax is the collapsed lung and in this condition, the air leaks between the
chest walls and lungs (Taveira-DaSilva et al. 2016). This leaked air is pushed on the outside
of the affected chest and collapses it. The physical findings from the respiratory assessment
that indicate pneumothorax are hyper-resonance, unequal breathing sounds, decreased wall
movement on the affected chest side and percussion over the chest wall. Respiratory distress,
distended neck veins, tracheal deviation are the classic findings indicative of pneumothorax.
Diagnostic testing of pneumothorax includes chest x-ray and chest computed tomography.
Prioritization of Care
The patient, Mr. John, 68 years old, is diagnosed with pneumothorax, with the
collapse of the left lung. The air pressure between the left lung and the chest wall needs to be
removed with the help of a chest cavity made in which a syringe-attached needle is inserted.
A closed chest drainage system needs to be maintained by securing all connections with

4VITAL SIGNS ASSESSMENT
adhesive bandages. The suction needs to be regulated with a range of 20-25 cm H2O negative
pressure (Ghazali et al. 2016).
Depending on the respiratory assessment of the patient, the recovery from the
collapsed left lung may take up to 2 weeks post-surgical-intervention. Nurses in charge of the
care of the patient have a crucial role to play in prioritizing the care of the patient. Effective
interventions to be included in the care plan by the nurses include respiration rate, rhythm and
depth monitoring to detect any irregularities such as apneustic, cluster breathing or ataxic.
This action will help to detect any changes or onset of pulmonary complications (Carson‐
Chahhoud et al. 2017). In addition to this, the nurses need to perform regular tests of
auscultation to note adventitious sounds or hypoventilation. The primary goal of the care plan
is to establish or restore the effective respiratory pattern of the patient. To ensure this, the
patient requires to be encouraged to take deep breathing. This action facilitates ventilation
and lung expansion, reduces any risk of airway obstruction (Swearingen & Wright 2019).
Nurses have a crucial role to effectively communicate with the patient and ensure they follow
every instruction provided to them and increase their ability to protect their airway on their
own. The nurses should demonstrate breathing exercises that promote lung expansion for the
speedy recovery of the collapsed lung. These actions will collectively help to restore the
normal breathing rate of the patient and prevent atelectasis. The evaluation and care plan
intervention will be completed partially when the respiratory rate of the patient is restored to
the normal range of 18 breaths per minute and the patient is able to demonstrate deep
breathing exercises on his own.
The role of nurses in restoring the health of the patient who has received treatment of
pneumothorax is critical and very important. The most important role of the nurses is to
ensure any pulmonary complications post the operation. For this, the nurses have to perform

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continuous monitoring of the chest tube units for bubbling, which indicates air leakage
(Swearingen & Wright 2019).
Two main priorities of care that needs to be kept in constant focus by the nurses are
deep breathing exercise of the patient and constant monitoring of respiration rate, depth and
rhythm to note down the onset of any pulmonary complications. These two actions when
place higher in prioritization of care, can help two critical objectives of the care plan. These
objectives are to improve and restore normal and effective respiratory rates and promote lung
expansion.
In addition to these situation-specific care plans, necessary interventions should be
implemented to reduce the weight of the patient.
Conclusion
Evidence-based practices are critical aspects of nursing professionals, which they
imply to ensure the highest standard of quality care is being delivered to the patient. The
above sections of the paper analyse the patient’s health condition and assessment requirement
to prioritize the care options post-treatment of pneumothorax. It can be concluded that the
nurses have a critical role to play in prioritizing the care for the patient to ensure a speedy
recovery.

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References
Carson‐Chahhoud, K.V., Wakai, A., van Agteren, J.E., Smith, B.J., McCabe, G., Brinn, M.P.
and O'Sullivan, R., 2017. Simple aspiration versus intercostal tube drainage for primary
spontaneous pneumothorax in adults. Cochrane Database of Systematic Reviews, (9).
Ghazali, A., Léger, A., Petitpas, F., Guéchi, Y., Boureau-Voultoury, A. and Oriot, D., 2016.
Development and validation of a performance assessment scale for chest tube insertion in
traumatic pneumothorax. J Pulm Respir Med, 6(346), p.2.
Jain, S., Teasdale, G.M. and Iverson, L.M., 2019. Glasgow Coma Scale. In StatPearls
[Internet]. StatPearls Publishing.
Kannampallil, T., Galanter, W.L., Falck, S., Gaunt, M.J., Gibbons, R.D., McNutt, R.,
Odwazny, R., Schiff, G., Vaida, A.J., Wilkie, D.J. and Lambert, B.L., 2016. Characterizing
the pain score trajectories of hospitalized adult medical and surgical patients: a retrospective
cohort study. Pain, 157(12), p.2739.
Mackey, A. and Bassendowski, S., 2017. The history of evidence-based practice in nursing
education and practice. Journal of Professional Nursing, 33(1), pp.51-55.
Mastan, S., Jacob, N., Bavumon, B., Nimisha, K.P. and Rauf, C.P., 2017. Lung Point: A
Warning Sign In Pneumothorax. BMH Medical Journal-ISSN 2348–392X, 4(3), pp.96-99.
Qadir, M.I. and Maqsood, U., 2019. Connection of normal body–temperature with normal
pulse–rate. Adv Cytol Pathol, 4(1), pp.4-5.
Swearingen, P.L. and Wright, J., 2019. All-in-One Nursing Care Planning Resource-E-Book:
Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health. Elsevier Health
Sciences.

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Taveira-DaSilva, A.M., Julien-Williams, P., Jones, A.M. and Moss, J., 2016. Incidence of
pneumothorax in patients with lymphangioleiomyomatosis undergoing pulmonary function
and exercise testing. Chest, 150(1), pp.e5-e8.
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.