Page 105 - Critical Care Nursing Demystified

90 CRITICAL CARE NURSING DeMYSTIFIED

Assessment Skills

1 The development of cardiac problems within the individual is very trau-
matic and anxiety provoking. Information pertaining to the cardiovascular
system will enable the critical care nurse to provide the delivery of more thor-
ough and comprehensive nursing care to the patient.
Again, nurse proficiency is required in the mental, emotional, and physical
assessment of the individual suffering from cardiovascular issues. Strength in
assessment skills and techniques will guide patient care, stabilize the patient’s
condition, and prevent additional cardiovascular deterioration.

History and Interview
This portion of assessment should be conducted in a nonthreatening and non-
intimidating manner. The patient’s presenting symptoms and complaints need
to be explored using an organized framework. If the patient is experiencing
active chest pain, the OPQRST organized assessment can be used so the critical
care nurse is consistent and comprehensive (see Table 3–2). The OPQRST is
helpful when the assessment needs to be rapid. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.

TABLE 3–2 OPQRST Pain Assessment
Onset Sudden, sometimes predictable.
Precipitating Stress, exercise, or exertion.
factor
Quality Frequently patientʼs discomfort is heavy, viselike, crushing, or
squeezing. Women, the elderly, and patients with diabetes
may have shortness of breath, mild indigestion. May be
silent.
Radiation Poorly localized but may radiate to neck, jaw, and down arms
Severity Discomfort to agonizing pain. Have the patient rate on a scale
of 1–10.
Timing Comes and ends abruptly. Usually responds to rest, oxygen,
and nitroglycerin. Time of day when it occurs (day/night/after
a heavy meal).

The nurse should ask if the pain is like any other the patient has experienced
and what the patient did to relieve the pain or discomfort. Other associated
symptoms such as dyspnea or shortness of breath going up and down stairs
along with dizziness, extreme sweating, or diaphoresis should be noted. The