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Assessment is one of the major roles of the registered nurse and is the first step in the nursing process to assist in planning and to facilitate mutually established goals and evaluate outcomes. In reality the nurse is continually assessing and re-assessing the patient throughout the continuity of care. In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice

Identify 3 specific nursing assessments that you would conduct as a priority for Jim’s nursing care that you will undertake on Jim’s admission to your ward.


For each assessment you have identified explain:
Why the assessment is relevant to Jim’s care.
What consequences may occur if this assessment is not completed accurately?

Primary Assessment using the ABCD technique

First and foremost, the registered nurse will have to begin with primary assessment of the patient with the ABCD technique. It is the most common assessment technique and this helps in determination of the dangers that the patient in under as well. The tool begins with airway assessment. For patients with any respiratory disorders, the airway assessment will explore the details of the gas exchange and respiratory rate of the patient. The nurse will assess the secretion, respiratory noises, coughing and airway condition of the patient. The breathing assessment will assess the bilateral air movement, breathing sounds and respiratory rate and rhythm will be assessed, the circulation assessment will check pulse, temperature, skin colour, and capillary refill time. Disability assessment will check activity tolerance and consciousness of the patient using tools like Alert Voice Pain Unconscious score or Gross Motor Function Classification System (Olgers, Dijkstra, Drost-de Klerck & Ter Maaten, 2014).

In the second step the patient will require focused or targeted assessment like the arterial blood gases assessment. Arterial blood gas test assesses the functional capability of the lungs of the patient and the level of gaseous exchange in the patient’s body. This assessment mainly checks the PaO2 levels or the ability of the lungs to move oxygen into blood, PaCO2 levels or the ability of the lungs to remove CO2 from the blood, lactate accumulation levels, and the acid/base status of the arterial blood. As Jim, the patient in case study, had been suffering from influenza infection; this assessment will reveal critical information regarding the lung capacity and burden (Dugas et al., 2012).

The third assessment that will be given to the patient will be another focussed assessment, and it will be focussed checking the palpation of the patient. This assessment will include the bilateral symmetry of chest expansion, skin condition of the patient, capillary refill, fremitus or tactile assessment, and checking for Subcutaneous emphysema. For any respiratory disorder or any infection that causes respiratory distress, there is a significant impact on the lung capacity. Along with that, the excessive mucous production and fluid volume back up, when combined, can have a significant impact on the chest cavity of the patient. This assessment will assess the load of the lungs and respiratory muscles or any chances for excess fluid volume that can lead to bilateral asymmetry of the chest wall and will also provide critical information regarding the infection spread (Ortiz, Rudd, Clark, Jacob & West, 2013). 

Targeted Assessment with Arterial Blood Gas Test

Nursing Care Plan: Jim 

Note:  Dot points recommended in care plan.   Click and type in each cell, click enter in a cell to make it longer. Do not remove text from the template.

A reminder that all rationales must be referenced   

Nursing problem: Risk of spread of infection

Underlying cause or reason: Influenza is a highly contagious virus spread via airborne droplets and direct contact. Immunocompromised patients in the hospital setting are at higher risk of contracting disease resulting in adverse events.

Goal of care

Nursing interventions/actions


Indicators your plan is working

To prevent and control the spread of influenza within the healthcare facility and the community.

Assessment of respiratory status, auscultation of lung fields for wheezing, crackles or any other breathing sounds. Assessment for presence of pallor or cyanosis in the patient (Van Buynder et al., 2013).

Administration of external oxygen therapy followed by pulse oximetry.  

Administration of bronchodilators like albuterol, levalbuterol, formoterol (van Kampen et al., 2013).

Administration of antibiotics like oseltamivir or zanamivir.

Maintaining a vigorous hand hygiene and use of protective equipment. Regular decontamination of patient equipments and diligent monitoring of the patient (Lee & Ison, 2012).

Influenza leads to bronchial swelling and enhanced sputum production due to the tracheobronchial infection and the oversecretion of the goblet cells which narrows down the already inflamed airways adding to respiratory burden. This burden results in higher respiratory rate, and adventitious breathing sounds. This assessment will help in discovering the extent of infection and the impact.  Cyanosis indicates huge loss of airway patency, which is a respiratory emergency (Lee & Ison, 2012).

In case of severe shortness of breath and rhinorrhea, supplemental oxygen will relive the patient and will relive the patent of the respiratory burden. Pulse oxymetry will provide information on oxygen saturation (Dugas et al., 2012).

The bronchodilators will expand the constricted bronchial muscle and will help in reviving the breathing process (Noah & Noah, 2013).  

These antiviral medications will act on controlling the spread of the infection and will help in reducing vulnerability to further deterioration (Van Buynder et al., 2013).

Targeted infection control and diligent monitoring will help in reducing the infection and will evade the chances of secondary infections (van Kampen et al., 2013).

The respiratory rate, auscultation sounds and presence of cyanosis is successfully determined.  

The patient will have slower breathing rate and the oxygen saturation percentage will enhance.

The patient begins to breathe more effectively and the respiratory rate comes back to normal levels.

The patient shows signs of reduced body temperature and the skin pallor comes back to normal.

The patient retains stable vital signs and evades any other infection deterioration.  

Nursing problem: Self care deficit

Underlying cause or reason:

 Influenza with severe infection and associated conditions can lead to various other health care complications that can lead to extreme fatigue and dizziness. The heavy bronchodilators and antiviral antibiotics can also lead to severe headache and malaise. Hence the patient will require the assistance of the nurse for self care deficit and activities of daily living.

Goal of care

Nursing interventions/actions


Indicators your plan is working

The patient will be assisted in all of the activities of daily living and will be able to overcome the impact of self care deficit.

Providing a warm and comfortable environment for the patient. Assisting the patient in bathing, eating, and excretory breaks.

Providing a nutritious antioxidant rich fluid based diet to the patient and encouraging therapeutic and engaging conversation (Lee & Ison, 2012).  

The warm and comfortable environment will help the patient feel secure and cared for and will facilitate overall good health outcomes (Noah & Noah, 2013).

The diet and fluid intake will help in reviving the nutritional status of the patent and will help in reducing the fatigue (Babizhayev & Deyev, 2012). 

The patient is comfortable and is verbalizing his needs.

The patient is able to voice likes and dislikes and can carry out conversations.

Nursing problem: Risk of imbalanced fluid volume

Underlying cause or reason:

Imbalanced fluid volume is a very common concern for Flu infections and it can be attributed due to fever, increased secretion leading of severe rhinorrhea. Along with that the risk of dehydration becomes very high in case of seasonal influenza hence it can be a significant health risk for the patient de to the presence of high nasal secretion.

Goal of care

Nursing interventions/actions


Indicators your plan is working

The patient will not show any signs of fluid volume imbalance and will be relieved from any ion level imbalance

Monitoring and documentation of the vital signs for any orthostatic changes

Monitoring and assessment of the skin integrity and pallor along with urinary output.

Utilization of dehydration bundle and encouraging monitored fluid intake.

It will help in assessing whether the patient is under any risk for postural hypotension (Essen et al., 2014).

Will help in determination of whether the patient is under the risk of severe dehydration (Iwasaki & Pillai, 2014).

Will help reduce the chances of dehydration deterioration and will facilitate fluid balance in the body (van Kampen et al., 2013).

The vital signs remain stable.

The patient does not develop severe dehydration.

The patient reverts back to having normal fluid volume.  

Nursing problem: hyperthermia

Underlying cause or reason:

Influenza infection is heavily related to fever and raised body temperature due to deterioration of the infection and alteration in fluid and electrolyte balance in the body.

Goal of care

Nursing interventions/actions


Indicators your plan is working

The body temperature of the patient will come down to normal levels

Diligent monitoring of vital signs and repeated temperature assessment and documentation.

Administration of antipyretic medication and giving sponge baths to the patient.  

Using cooling blankets if required by the patient.

Will provide a clear understanding the rise of fall of the temperature of the patient (Lee & Ison, 2012).

It will help in reducing the temperature of the patient (Noah & Noah, 2013).

Will help in physically reducing the temperature and provide utmost comfort to the patient (Lee & Ison, 2012).

The patient overcomes hyperthermia.

The body temperature of the patient is visibly reduced.

The patient gradually regains normal body temperature and the patient is comfortable.

Nursing problem: hypertension

Underlying cause or reason:

According to the vital sign assessment of the patient it has been discovered that the patient had 158/86 mmHg blood pressure which can heighten the risk for stroke or TIA of the patient. The patient had already been diagnosed with hypertension before however the patient had not been taking the medicines that have been prescribed to him which only contributed to further deterioration of his hypertension.

Goal of care

Nursing interventions/actions


Indicators your plan is working

The blood pressure of the patient will come back to normal levels

Assessment of lab data such as cardiac markers, complete blood cell count, electrolyte balance, blood urea nitrogen and creatinine and cardiac enzymes (Lionakis, Mendrinos, Sanidas, Favatas & Georgopoulou, 2012).

Administration of medications such as Thiazide diuretics like diuril, loop diuretics like lasix, and potassium sparing diuretics like spirinolactone (Weber et al., 2014)

These assessment tests will help the health care professionals discover if the patients has any risk for compromised circulation or decreased cardiac output (Cicolini, Gagliardi & Ballone, 2010).

These medications will facilitate diuresis and prevent resorption of sodium and potassium which reduces the blood pressure effectively (Bromfield & Muntner, 2013).

The cardiac marker data was collected and the patient did not show any signs of

Immediate cardiac risk.

The blood pressure of the patient gradually decreases.

It has to be mentioned in this context that the patient in the case study had been going through three particular medications for the suspicion of influenza. First and foremost, the patient had been given oseltamivir 75mg BD oral tablets, now it has to be understood that oseltamivir acts as an inhibitor of the key protein neuraminidase of the influenza virus (Dobson, Whitley, Pocock & Monto, 2015). The mechanism of action of this medication is facilitated by the reaction in the liver. The esterase enzyme in the liver converts this medication into its active state and facilitates its inhibitory action. The second medication that has been prescribed to the patient had been paracetamol 4/24, which has both analgesic and antipyretic effect. This medication was prescribed to the patient to relieve him of his fever, head ache, and his muscle and joint soreness as well (Jefferies et al., 2016). Lastly the patient had been given Fluvax IM stat-dose. It has to be mentioned here that there is enhanced risk for the reoccurrence of Influenza for patients like Jim. Hence, the patient required a Flu shot to ensure that the influenza does not reoccur for the patient o any secondary infection does not occur for the patient.

For administration guidelines and nursing consideration, it has to be mentioned that oseltamivir can have a few side effects in patients aside from any allergy. These side effects include confusion, delirium, hallucinations, or unusual behavior. Hence, the nurse administering this medication will have to be very careful regarding the dosage and interaction. For paracetamol, prolonged usage can cause liver failure and disorders; hence the nurse will have to consider the dosage and any reaction in the patient effectively.  Although, the patient is only allergic to meat and chicken, the Fluvax can cause a few complications like nausea, dizziness and drowsiness, hence the nurse will have to monitor the patient for any adverse reaction to any of the medication.  The patient will need to be monitored for any changes in his skin integrity, consciousness state, or for occurrence of nausea, dizziness and even oedema (Iwasaki & Pillai, 2014).  

For the patient in the case study, Jim had been a homeless man with acute self care deficit, hence there are various health risks that can cause secondary infection or can cause re-occurrence of the infection as well. First and foremost, the patient will need to be included in the care planning procedure for him to get a preliminary understanding of the diseases and its impact. Along with that, it will be the responsibility of the nursing professional to help the patient understand the role of infection control and preventative behaviour in his case. He will also need assistance in understanding the basics of hand hygiene and other related infection control protocols and the basics of how to prevent the influenza infections and the vaccination benefits that he can avail from the government sponsored health difficulties (Babizhayev & Deyev, 2012). Furthermore, the patient smokes whenever he can which can have a significant detrimental effect on his respiratory apparatus and can even deteriorate his hypertension. Hence, the patient will need counselling and education regarding the hazards of smoking. Lastly, Jim is homeless and falls under the radar of extreme poverty which increases his risk for poor nutritional outcomes. Hence the nurse will also have to educate the patient on different community care and social support units where he can get shelter and proper nutrition along with basic needs of life. These patient teaching factors will help the patient evade the risk for any further infection and will help him gain better health and living condition (Essen et al., 2014). 

Targeted Assessment through Palpation

The temperature of the patient is rising and along with that he is showing signs of laboured breathing and shortness of breath at breaths per minute. His heart rate is also high at 125 beats per minute, however his blood pressure is only slightly high at 124/79 mmHg. The oxygen saturation of the patient has also decreased fairly from what the patient admitted to the facility with. From the symptoms it can be mentioned that the patient is undergoing an episode of shortness of breath accompanied by tachycardia. The deterioration of infection must have contributed to obstruction of the airways and ineffective gas exchange, which manifested as labored breathing. And due to deficient oxygen delivery, his heart overcompensated to help manage the oxygen deficiency, which contributed to his tachycardia and resulting palpation. The nurse will have to immediately perform airway clearance and administer bronchodilators to help reduce the labored breathing (Alhamad, Al-Ghonaim, Alfaleh, Cal & Said, 2014). The patient might also need external oxygen along with administration of antipyretics for his fever. 


 A 58 year old homeless man named Jim


The patient was admitted with dyspnea, myalgia, fatigue, malaise, rhinorrhea and headache. Assessment discovered to be febrile with a clear nasal discharge, shortness of breath and muscle soreness.


He had high temperature, high heart rate, high respiratory rate, high blood pressure and slightly low oxygen saturation


Jim is a homeless man and he lived on the street. He has a history of smoking with 5 to 10 cigarettes smoked on a daily basis. The patient also had a history of hypertension for which he did not take any medication. The impact of his impoverished living conditions is visible by his reduced body mass and undernourished appurtenance.


The infection of the patient is worsening and the patient is suffering from severe shortness of breath and tachycardia. The patient had been administered bronchodilators and external oxygen therapy for resuscitation.


The patient should be monitored for any further deterioration event and his vital signs should be monitored diligently.  Along with that the impact of the oxygen therapy and bronchodilators should be monitored. In case the tachycardia of the patient does not subside, high dose beta blockers should be administered. The temperature of the patient should also be monitored.


Alhamad, E. H., Al-Ghonaim, M., Alfaleh, H. F., Cal, J. P., & Said, N. (2014). Pulmonary hypertension in end-stage renal disease and post renal transplantation patients. Journal of thoracic disease, 6(6), 606.doi:  10.3978/j.issn.2072-1439.2014.04.29.

Babizhayev, M. A., & Deyev, A. I. (2012). Management of the virulent influenza virus infection by oral formulation of nonhydrolized carnosine and isopeptide of carnosine attenuating proinflammatory cytokine-induced nitric oxide production. American journal of therapeutics, 19(1), e25-e47. doi: 10.1097/MJT.0b013e3181dcf589

Bromfield, S., & Muntner, P. (2013). High blood pressure: the leading global burden of disease risk factor and the need for worldwide prevention programs. Current hypertension reports, 15(3), 134-136. doi:  10.1007/s11906-013-0340-9.

Cicolini, G., Gagliardi, G., & Ballone, E. (2010). Effect of Fowler’s body position on blood pressure measurement. Journal of clinical nursing, 19(23?24), 3581-3583.

Dobson, J., Whitley, R. J., Pocock, S., & Monto, A. S. (2015). Oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials. The Lancet, 385(9979), 1729-1737. S0140-6736(14)62449-1 Doi: 10.1016/j.vaccine.2013.07.059

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Iwasaki, A., & Pillai, P. S. (2014). Innate immunity to influenza virus infection. Nature Reviews Immunology, 14(5), 315. doi:  10.1038/nri3665.

Jefferies, S., Braithwaite, I., Walker, S., Weatherall, M., Jennings, L., Luck, M., ... & Perrin, K. (2016). Randomized controlled trial of the effect of regular paracetamol on influenza infection. Respirology, 21(2), 370-377.

Lee, N., & Ison, M. G. (2012). Diagnosis, management and outcomes of adults hospitalized with influenza. Antiviral therapy, 17(1), 143. doi: 10.3851/IMP2059

Lionakis, N., Mendrinos, D., Sanidas, E., Favatas, G., & Georgopoulou, M. (2012). Hypertension in the elderly. World journal of cardiology, 4(5), 135. doi:  10.4330/wjc.v4.i5.135

Noah, D. L., & Noah, J. W. (2013). Adapting global influenza management strategies to address emerging viruses. American Journal of Physiology-Lung Cellular and Molecular Physiology, 305(2), L108-L117. Doi: 10.1152/ajplung.00105.2013

Olgers, T. J., Dijkstra, R. S., Drost-de Klerck, A. M., & Ter Maaten, J. C. (2017). The ABCDE primary assessment in the emergency department in medically ill patients: an observational pilot study. Red eyes and mucous ulcers; what is your diagnosis?, 106. Retrieved from

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Van Buynder, P. G., Konrad, S., Van Buynder, J. L., Brodkin, E., Krajden, M., Ramler, G., & Bigham, M. (2013). The comparative effectiveness of adjuvanted and unadjuvanted trivalent inactivated influenza vaccine (TIV) in the elderly. Vaccine, 31(51), 6122-6128.  Doi: 10.1016/j.vaccine.2013.07.059

van Kampen, J. J., Bielefeld?Buss, A. J., Ott, A., Maaskant, J., Faber, H. J., Lutisan, J. G., & Boucher, C. A. (2013). Case report: Oseltamivir?induced resistant pandemic influenza A (H1N1) Virus infection in a patient with AIDS and Pneumocystis jirovecii pneumonia. Journal of medical virology, 85(6), 941-943.

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