NR 557 Week 8 Comprehensive Assessment Paper Example

Comprehensive Assessment Paper: One Home Health Visit, Told in the Order It Happened, Showing How a Counted Respiratory Rate and a Months-Backward Test Turned a Routine Visit Into a Same-Day Referral

Student Name

College of Nursing, Chamberlain University

NR 557: Health Assessment for Professional Nursing Practice

Instructor Name

Month Day, Year

Comprehensive Assessment Paper: One Home Health Visit, Told in the Order It Happened, Showing How a Counted Respiratory Rate and a Months-Backward Test Turned a Routine Visit Into a Same-Day Referral

Before the Door

The visit was a scheduled weekly home health call for a 78-year-old former city bus driver managing chronic obstructive pulmonary disease (COPD), heart failure with reduced ejection fraction and hypertension, discharged from the home health program's heart failure pathway two weeks earlier into routine monitoring. What I knew beforehand came from six weeks of notes: usual oxygen saturation 92% to 93% at rest, respiratory rate recorded as 18 to 20, fully oriented, dry weight 71.0 kg, living alone with daily visits from a daughter. I did not know, until I arrived, that the daughter had dropped in early, worried because the patient had sounded "off" on the phone.

The First Minute

The patient was in the recliner instead of at the kitchen table and told me the problem was getting their wind today. That complaint, and where the patient was sitting, changed the visit before any measurement. The routine plan was a medication review and weight check. The first decision, made at the door, was to take a focused history before anything else, keeping questions short because the patient was pausing mid-sentence.

What was known at that moment: a change in the patient's own words and position. What was not known: whether this was a bad COPD day, a heart failure flare or something new.

The History

The history, taken partly from the daughter because the patient was breathless, gave three days of cough with a change from white to yellow-green sputum, feeling hot and cold since yesterday, breathlessness at rest since yesterday evening, a night in the chair, four uses of the rescue inhaler and, from the daughter, confusion that morning. The patient denied chest pain, coughing blood and calf pain. Weight had not been checked for two days.

The second decision followed: the examination would be targeted to vital signs, the chest comparing both sides, fluid status and mental status. The history alone could not confirm pneumonia; history and examination findings together are needed, and no single finding is decisive (Metlay et al., 1997). The decision to count the respiratory rate for a full minute was deliberate. My own past notes had recorded 18 or 20 at every visit, and I knew those figures had sometimes been glanced rather than counted, a common pattern in recorded respiratory rates (Badawy et al., 2017).

The Examination

After ten minutes' rest: respiratory rate 28, counted for 60 seconds while I held the wrist; oxygen saturation 88% on room air; pulse 104; pressure 128/74; oral temperature 38.3 °C; scale weight 71.8 kg. The right lower chest was dull, with stronger fremitus, bronchial breathing and crackles that did not clear with coughing, with the left base free of crackles. Neck veins flat and ankles no more swollen than usual. Wrong about the day and the month; able to recite only three months backward, compared with full orientation and the complete sequence at every previous visit.

The third decision came during the examination, not after it. When the respiratory rate came back at 28, I extended the examination to a formal mental status check rather than relying on the daughter's report, because a raised rate combined with confusion would change the urgency. The months-backward test turned a report of confusion into a finding.

Interpretation

Against this patient's own baseline, every vital sign except blood pressure was abnormal, and the chest findings were new and one-sided. The findings pointed to right lower lobe consolidation with systemic illness and away from heart failure as the leading cause. Against published thresholds, the patient scored two on the quick sepsis-related organ failure assessment, for respiratory rate of 22 or more and altered mentation (Seymour et al., 2016), and at least two on the CURB-65 pneumonia severity score, for confusion and age (Lim et al., 2003).

The Decision to Refer

The fourth decision was the most contested. The patient said, "I'm fine, I get this," blood pressure was normal and the daughter offered to stay. I weighed those points and set them against the consequences of being wrong: early sepsis left at home could become a much sicker admission or a death, while an unnecessary emergency visit would cost a difficult day. I called the patient's named nurse practitioner at 11:40 and gave a structured handover of situation, background, assessment and recommendation (Haig et al., 2006). The nurse practitioner agreed to emergency evaluation by ambulance.

What was known at the time: counted values, a tested mental status and the patient's baseline. What was not known: the chest radiograph, blood tests and oxygen requirement. The decision rested on what was known and named what was not.

While Waiting

I repeated the measurements at 11:55 and 12:20. The respiratory rate had risen to 30, the saturation was 87% to 88% and the heart rate 106 to 108. The direction was not improving, which confirmed the decision and was passed to the ambulance crew with the patient's usual saturation, so the crew would judge 88% against this patient rather than a general COPD range.

What Happened Next

The chest radiograph in the emergency department confirmed right lower lobe pneumonia. The patient was treated, observed overnight and discharged the next afternoon on oral antibiotics and a short course of steroids, oriented and with a saturation of 92%. At the following home visit, the patient and daughter could repeat the finding and the reason for the antibiotics, and the daughter learned to count breaths for a minute, making the most important return trigger usable at home.

What the Encounter Shows

Three moments made the difference. The first was treating the patient's own words and position as a finding. The second was counting the respiratory rate for a full minute instead of writing the usual 18, a vital sign described as neglected because an abnormal rate is an early warning that is often missed (Cretikos et al., 2008). The third was testing mental status rather than accepting a report. Each decision was made with what was known at the time, and each is recorded where it happened, so the reasoning can be followed and challenged. Had the rate been glanced and recorded as 18, the visit would have ended with a weight check and a patient in a chair, getting worse.

References

Badawy, J., Nguyen, O. K., Clark, C., Halm, E. A., & Makam, A. N. (2017). Is everyone really breathing 20 times a minute? Assessing epidemiology and variation in recorded respiratory rate in hospitalised adults. BMJ Quality & Safety, 26(10), 832-836. https://doi.org/10.1136/bmjqs-2017-006671

Cretikos, M. A., Bellomo, R., Hillman, K., Chen, J., Finfer, S., & Flabouris, A. (2008). Respiratory rate: The neglected vital sign. Medical Journal of Australia, 188(11), 657-659. https://doi.org/10.5694/j.1326-5377.2008.tb01825.x

Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3

Lim, W. S., van der Eerden, M. M., Laing, R., Boersma, W. G., Karalus, N., Town, G. I., Lewis, S. A., & Macfarlane, J. T. (2003). Defining community acquired pneumonia severity on presentation to hospital: An international derivation and validation study. Thorax, 58(5), 377-382. https://doi.org/10.1136/thorax.58.5.377

Metlay, J. P., Kapoor, W. N., & Fine, M. J. (1997). Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA, 278(17), 1440-1445. https://doi.org/10.1001/jama.1997.03550170070035

Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., Rubenfeld, G., Kahn, J. M., Shankar-Hari, M., Singer, M., Deutschman, C. S., Escobar, G. J., & Angus, D. C. (2016). Assessment of clinical criteria for sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 762-774. https://doi.org/10.1001/jama.2016.0288