1

Running Head: NURSING ASSESSMENT AND DIAGNOSIS: A CASE STUDY

NURSING ASSESSMENT AND DIAGNOSIS: A CASE STUDY

By : ( NAME OF STUDENT.)

Institutional Affiliation:

Dated:
 2
NURSING ASSESSMENT AND DIAGNOSIS: A CASE STUDY

As this is a Case-Study and also as we have been instructed, we have omitted the

generalized introduction and conclusion and go directly to the Case-Solution starting from

Physiology

The heart is divided into four different sections and blood goes from one chamber to

another during the course of a cardiac cycle. In a cardiac cycle, blood flows from the right aorta

to the right ventricle from where it is pushed to the lungs through the pulmonary valve where it

sheds off the waste Carbon Di-oxide, the lungs then rejuvenating the blood with oxygen. The

rich blood first goes into the left aorta and then through the mitral valve to the left ventricle. This

is the strongest part of the heart and from here; a miniature logistics system supplies it to all parts

of the body, including the brain.

A sketch of the

human heart

showing the lobes

and valves.

The cardiac path has four of the valves which work due to differential pressure along their faces

along them aided (when required) with a little muscular physical effort. Although, the blood flow

supposed to be smooth and laminar, at times, it becomes turbulent, due to a host of reasons.

Because of the turbulence, the blood-flow produces certain characteristic sounds which are

collectively referred to as Murmuring of the heart.

 3
NURSING ASSESSMENT AND DIAGNOSIS: A CASE STUDY

The turbulence can occur due to hereditary reasons, the arteries thickening which

increases velocity or decreases flow, slow valve response time due to injury or age, etc.(USC,

n.d)

Assessment

Assessment of the patients medical condition can be tested by comparing the patients

external symptoms to a few conditions which may show identical outer symptoms. Then, from

the ailment with the most matches, the problem can be easily found out. Here, the patient is an

African American 50 years of age who is sweating unnaturally and is under a lot of stress in the

work place. She is moreover obese (in the initial stages), has less physical exercise and is

complaining about sharp chest pains and being fatigued. She is going on sweating, her skin is

warm to the touch, and she suffered from heart murmur when young. She is not only a packet a

day smoker but is a bit obese too. Considering all these, it should not be hard to conclude that the

problem lies in the cardiovascular system.

Three common assessment methods of sound in the precordium and heart area are as

follows.

With the help of a stethoscope and using both bell and diaphragm, the sounds made by the heart

can be heard as a sort of lub-dub. The mistral valve opening corresponds to the dub and it is

easier to find out. Once this is done, the LUB sound takes place. A couple of other sounds can

also be heard depending upon the problem but lub-dub is the most prominent .In fact, it appears

that the lub-dub can be heard even without the facility of stethoscope.
Blood Pressure Measurement is a type of Auscultation too. Now for valve damage the lower

ventricular chamber is a prone area as the BP is high here. For a normal adult, the BP should be

120/80 where 80 mm of Mercury is the pressure at the other low end. When pressure increases,

the valve will have to work more, since the body will demand more blood flow. The BP when
 4
NURSING ASSESSMENT AND DIAGNOSIS: A CASE STUDY

measured with a cuff is a high pitched sound, relatively soft to large and is of high pitch. The

sound is like swooshing or knocking with duration of 60/100 per minute. This sound is an

indication of valve fault. The BP is measured by a contraption having a pressure cuffing ability

with ear-inputs called sphygmomanometer. (Jensen, 2011, pp27)

Extra sounds can also help in a lot of ways. A click sound results from an open valve that moves

during the beginning of systole. Opening snap indicates that the mitral valve is mobile and

snaps during early diastole from high atrial pressure, such as with mitral stenosis. These

sounds are mote discernible if heard right above them i.e. in the aortic area. (Jensen, 2011, pp.

238)

Diagnosis

Both the trained RN and the physician can make diagnoses of the patients condition. The

difference is that the Nurse gathers all the factual information from sources of undeniable

authority whereas the physician gets the information in the form of a report by another

professional. The novels we are reminded of where the jovial and competent physician assisted

by an equally competent nurse who seems to know all the patients by their first names, makes a

round of the ward, was and still is a stereotype. It is the RN who acts as the service provider, who

first assesses the ailment, gathers information from the patient or family enters the data into the

database and tries to correlate the statements so that they emerge as a single, most probable,

hypothesis.

The nursing diagnosis will be age and demographics of the patient and will contain the records of

her heart murmurs as a child. The nurse has the responsibility to collect all the information

wanted by asking either open ended or close ended questions. Once she has the suspicion that the

problem is in the lower mitral area by carrying out sound testing of the heart and carotid vessels.

Nursing diagnosis is upto this level forward and then sideways parallel. From here, the patient
 5
NURSING ASSESSMENT AND DIAGNOSIS: A CASE STUDY

will require attention of a physician as the nurse cannot proceed of his/her own volition. This is

the collaborative diagnosis. It will explain in medical terms as to what the problem exactly is.

The collaboration is between the physician and the nurse and each proceed towards the same

destination.

Nurses focus mainly on monitoring and preventing such problems All collaborative

`problems begin with the diagnostic label Risk for Complication (of RC )

which alerts the service providers that the case calls for a collaborative diagnosis and not a

nursing one. (STUDY GUIDE 1.1,2012, Jan 17th)

http://www2.bakersfieldcollege.edu/cgard/NURS%20B28/STUDY%20GUIDE%201.1%20NCP

%20REVISED.pdf

Planning

I will be using the physical conditions measurements of the patient. I will be stringing

together the murmuring as a child to point out that the patient has a history of that. Although at

that time, no one perhaps advised the child as to what had to be done. Fatigue, Perspiration,

Excessive Stress as the heart is working more. Recorded sounds of the turbulence sounds Lub-

dub and if there, other sounds too. I will be using all these in my diagnosis.

What I anticipate the physician will do first is to get a better idea about the valve seating.

The heart can be X-rayed and kept ready as the physician will be wanting to do that first.

Implementation :

Tests and checks are very important for the patient to know why it is being done. The patient

being treated as if she is not in the room (referred in the third person) is very demeaning. As
 6
NURSING ASSESSMENT AND DIAGNOSIS: A CASE STUDY

much as possible the patients will be complied with. A very important thing will be to know the

possible allergies of the patient. If the patient is a diabetic and other relevant informstion is very

important.

The best thing to do to prepare her is to treat her as your friend ; not as a nurse-patient and tell

her what exacly is ghoing to happen and what she will experience. Honesty with this patient is

mandatory as she is 50 years old.

Evaluation:

As a professional, I will definitely wish that my diagnosis is found accurate but I will prefer the

woman to face the least possible problems and through respirastory eexercises, cure the valve

condition in her heart. As much as possible, I will hope that cardiac surgery does not prove to be

necessary despite the patients obesity.

***************

References
 7
NURSING ASSESSMENT AND DIAGNOSIS: A CASE STUDY

USC. (n.d.). Cardiothoracic Surgery. A Patient's Guide to Heart Surgery Retrieved March 24,

2016, from http://www.cts.usc.edu/hpg-valvesoftheheart-circulationofblood2.html.

Jenson, S. RN. MN.(2011). Pocket Guide for Nursing Health Assessment: A Best Practice .

Approach. Philadelphia, PA 19103: Wolters Kluwer Health / Lippincott Williams &

Wilkins