FACULTY HEALTH & SOCIAL WORK
UNIVERSITY OF PLYMOUTH
ASSESSMENT OF THEORY
2007 – 2008
Assessment of priories, rationale of care of individual experiencing cardiac
chest pain within the general ward environment, focusing on pain as the key
Student Name: ALAN P JACK
University Registration number: 001255
Faculty of Health and Social Work Partnership Site:
CORNWALL (KNOWLEDGE SPA)
Hand in deadline: 18th January 2008
Word count: 2688 Words
Plymouth, PL4 8AA
Tel: 01752-233862 firstname.lastname@example.org
Modular Teacher/Personal Tutor: KIM YOUNG
List of Contents
Front sheet Page 1
List of Contents Page 2
NUR258 Assessment of Theory: Assignment Guidelines Page 4
Assignment Page 6
References Page 16
Appendix 1 : Example of a Modified Early Warning System Chart after Stenhouse,
C. Coates, S. Tivey, M. Allsop, P. and Parker, T. (2000) Prospective evaluation of a
modified Early Warning Score to aid earlier detection of patients developing critical
illness on a general surgical ward. British Journal of Anaesthesia, Vol. 84, (5) 663.
“An NMC Guide for Students of Nursing and Midwifery” (NMC 2002)
“If you want to refer in a written assignment to some real life situation in which
you have been involved, do not provide any information that could identify a
particular patient” (page 5).
This has been complied with in this assignment as all individuals
mentioned have been given pseudonyms
NMC (2002) An NMC Guide for Students of Nursing and Midwifery. London,
NUR258 Assessment of Theory: Assignment Guidelines
September 06 Intake
NUR 258 Adult Nursing 1 – 20 level 2 credits.
Aims of Assessment
In common with other modules that you will study, NUR 258 contains elements of
theory and practice and seeks to integrate these into the modular assessment
The summative assessment for module NUR 258 is in two parts.
Theoretical Assessment: A 2500 word essay
This assignment requires you use a problem solving approach to demonstrate ability
to assess and prioritise care needs for your patient. It must go beyond the purely
descriptive (Please refer to the programme handbook re level two assignment
Choose a patient you have looked after in your current practice area.
Discuss your assessment of the patient & identify the priorities of care, giving
a rationale for your decision.
Identify one key priority and discuss the care needed.
Essay on competent assessment and care planning
Section Content Suggested word limit
Introduction Offer introductory definitions to set 250
the scene. Identify key aspects you
will include in the main body, with
short rationale for choice.
Main body of the Discuss your assessment of the 1000
essay patient and identify & rationalise
Discuss nursing interventionsfor the
key priority for this patient, with 1000
reference to appropriate literature.
Safe and appropriate care and your
accountability must be evident.
Conclusion Summarise the key points of250
learning in this assignment.
2500 word count. + /- 10%
Please refer to your programme handbook for information on the University of
Plymouth’s marking criteria, referencing and correct presentation.
This assignment will discuss nursing assessment, the ramifications of accountability
within the scope of pain and chest pain. It will explore the use of ALERT (Acute Life-
threatening Events Recognition and Treatment) and MEWS (Modified Early Warning
System), pain assessment and tools and nurse biases. Andrew was a 53-year-old
gentleman who was admitted with chest pain and had been found to have an
Anterior Myocardial Infarction (MI) with a past medical history of Coronary Heart
Disease and Unstable Angina Pectoris. He had been admitted to the acute medical
ward on which I was working from the Medical Admissions Unit where this had been
diagnosed. He had been on the ward for three hours when he reported that he had
pain in the centre of his chest. As a result, Oxygen was administered, observations
were taken and recorded and a MEWS score calculated. A doctor not that an
electrocardiogram (ECG) showed no changes compared to older examples.
McCaffrery (1968: 95) states ‘Pain is whatever the experiencing person says it is,
existing whenever the existing whenever the experiencing persons as it does’. More
specifically, Mackway-Jones (2002: 57) defines cardiac pain as ‘Classically, a severe
dull ‘gripping’ or ‘heavy’ pain in the centre of the chest, radiating to the left-arm or to
the neck. May be associated with sweating and nausea’.
Upon assessment, Andrews care priority was reducing his cardiac chest pain.
Recently, having had an MI, thus he needed to rehabilitate safely. His chest pain
took precedence as it was a symptom that, if attended, could have resulted in life
threatening complications, namely a further MI.
Dougherty and Lister (2004e: p25) explain ‘nursing assessment includes gathering,
validating and organising data, identifying patterns, and reporting and recording
relevant data’. They add that it is a continuous dynamic, used collaboratively by the
nurse to establish clients’ needs so care plans can be. Assessment is the first step
of the nursing process, popularised by Logan, Tierney and Roper (1980), which
comprises assessment, planning, implementation and evaluation of care. With the
communication skill such as active listening and appropriate use of questioning, the
nurse can determine what needs the patient has at present and will have in the
future. If assessment is not at an optimum or a robust enough level, then all other
aspects of the nursing process will not be met, moreover, resultant care could be
both unsafe and inappropriate to the care needs of the client.
There are many reasons for reducing/eliminating pain, these incorporate deontology
and ethics. The Code of Professional Conduct: Standards for Conduct, Performance
and Ethics (Nursing and Midwifery Council (NMC), 2004) explain how due to
contracts of employment, the nurse has a Duty of Care for patients. This involves
having to act continuously beneficently and in a non-maleficent manner. Therefore
as a registered nurse, it is important to acknowledge that you have duty to reduce
pain and prevent deterioration of Andrew’s condition. The code of conduct notes
that registrants on the NMC Register of Nurses, Midwives and Community Public
Health Nurses (NMC, 2008) are accountable for their actions or omissions in a Court
of Law. The implications of this accountability extend to any delegated task given to
other workers whom the nurse must know are competent to do the task.
As a result of a Department of Health (DH) report, “Comprehensive critical care: a
review of adult critical care services” (DH), the ALERT (Acute Life-threatening
Events Recognition and Treatment) course was created (Smith 2003). This course,
based around a manual, was designed to assist acute healthcare professionals to
recognise early signs that patients may be deteriorating. It encourages workers to
predict and prevent and treat deterioration whilst communicating their actions to
both patients and others in the multidisciplinary team. There is an acknowledgement
that workers on non-critical care can find dealing with acute deterioration extremely
stressful. Furthermore, the DH document called for an early warning scoring system
to be introduced for detecting such deterioration.
One of the major tenets of the ALERT course is the use of the ABCDE mnemonic,
which stands for airway, breathing, circulation, disability and exposure. ABCDE is
used to prioritise the assessment of an individual patient. Each of these areas needs
to be attended to and any problems noted dealt with prior to proceeding on to the
next letter. The professional would use a look, listen and feel approach, for example
if an individual has an occluded airway it is imperative it is dealt with prior to dealing
with the patient not breathing. Airway is the first area to be addressed. Andrews’s
airway was patent, which was evident by the fact that he was able to talk in
sentences without any impedance as well as corresponding appropriately to
questioning. Had his airway been compromised, this would not have been possible
and the emergency team would need summoning. Smith (2003) identifies how
opening the airway or use of a jaw thrust would be needed in an emergency to
attempt to gain a patent airway.
Once a patent airway has been established, breathing should be assessed. This
should include how the individual appears such as evidence of cyanosis, evidence of
sweating, depth and rate. Listening to breathing will assist in establishing if there are
any problems such as excessive secretions or wheezing/stidor which may be
indicative of partial airway obstruction (Smith 2003). Moore and Woodrow (2004)
note that respiratory failure is the most common cause of admission to High
The assessment of circulation is primarily concerned with the effectiveness of the
cardiovascular system to perform gaseous/nutrient transfer throughout the body.
This is assessed by assessing capillary refill time (Ahern et al, 2002). Cyanosis is
also indicative of cardiovascular impairment as it can mean that Oxygenation of the
tissues is not occurring adequately (Smith 2003). Blood pressure, pulse and Oxygen
saturations are also measures of cardiovascular function. Andrew had had a MI
which meant that some of his cardiac muscle had died. These necrosic areas could
no longer contract/relax in synergy with the rest of his cardiac muscle thus reducing
the effectiveness of his heart’s pumping action. ECGs can also show the rhythm and
rate of the heart as well as indicating any areas of cardiac insufficiency (Kumar
Within the ABCDE rubric, the presence of disability pertains to the individual’s
neurological state. Smith (2000) advocates the use of AVPU scoring (American
College of Surgeons, 1997). This system is used to assess the alertness of an
individual by classifying her/him as alert, responding to voice or pain or if the
individual is unconscious. It forms part of the MEWS score. It is provides a rapid
assessment of the consciousness of an individual but does not take into account if
an individual is confused which can be indicative of neurological deficit. It is also not
as rigorous as the Glasgow Coma Scale which is widely used for more in depth
neurological assessment (Dougherty and Lister, 2004).
Once all the above steps have been assessed and dealt with, then a fuller
assessment of the patient is undertaken under the exposure label. This is a head to
toe assessment and is where such areas as temperature blood glucose and pain are
All aspects of the ABCDE are considered within the modified early warning system
score. Subbe et al (2001) devised a score which encompassed systolic blood
pressure, pulse, respiration and temperature. Stenhouse et al (2000) then included
urine output and normal blood pressure so that deviations in temperature would be
less sensitive. This is the scoring system which is used in the ALERT course (Smith,
2003). In a well argued paper, Johnston et al (2007) suggests that although early
warning scoring can be sensitive to deterioration, their potential is not maximised
and the developmental rigour of both critical care outreach teams and MEWS are
both poor. They call for more research into the physiological trigger factor variables
which elicit the calling of outreach teams. The MEWS score is calculated by
allocating the results of clinical observation a score from 0 to 3. If the total score
exceeds 4, the protocol in Appendix 1 is followed.
Chest pain is one of the leading cause of acute hospital admission in the United
Kingdom, accounting for approximately 20-40% of acute medical admissions
(Capewell and McMurray, 2000). These figures appear to be the only ones available
thus more recent research would provide some valuable information. Its origin can
be as diverse as from resulting from a myocardial infarction (MI), angina pectoris,
10nfracted10l/gastic origin, to anxiety (Kessenich, 1999). Melzack and Wall (1996)
argue that it pain, generally, is a multi-factoral concept encompassing both
physiological and psychological factors.
Epstein (2003) reports that MI is the major cause of chest pain on admission to
hospital and can present itself with severe, central crushing (sometimes described as
band-like or severe indigestion) which can persist 15 to 20 minutes, despite rest or
the use of Nitrate preparations. The patient may appear pail and be sweating
perfusely. Hypotension may be present with reduced pulse pressure (difference
between systolic and diastolic readings). This may be due to compromised pumping
potential caused by 11nfracted areas of muscle. The pulse may be irregular with
ectopic beats. He also acknowledges that with elderly patients and individuals with
Diabetes Mellitus symptoms may be present with reduced levels of pain being
reported due to neuropathy.
The cause of chest pain in MI is due to insufficient perfusion to the heart due to an
embolus, travelling blood clot, lodges in one of the coronary arteries. This is the
mechanism by which the administration of high flow (as near as 100%) Oxygen
works. Insufficient oxygen is being perfused to the cardiac muscle thus the heart is
less efficient. This leads to insufficient oxygen perfusion to the rest of the body,
which is detected by chemoreceptors responding to acidosis caused by build up of
Carbon Didoxide in tissue. This, in turn, stimulates tachycardia, thus increasing
strain on the heart. Increasing inhaled Oxygen percentage results in increased
perfusion and strain thus pain reduction. Respiration rate will increase by this
mechanism also which will be stimulated to reduce in the same way (Clancy and
The British National Formulary 54 (BNF) (2007) suggests that Oxygen, Diamorphine
and Nitrates are the used in initial support and for pain relief. High flow (up to 60%)
oxygen can be given (Section 3.6) does not cause extreme risk in Pneumonia or
fibrosing alveoli as lower arterial Oxygen levels are associated with normal or lower
levels of arterial Carbon Dioxide. This is not the case in Asthma where positive
airway pressure may be required to remove excess build up of Carbon Dioxide and
Chronic Obstructive Pulmonary Disease.
Other methods of reducing chest plain include the administration of Glyceryl
Trinitrate (section 2.6.1) which acts as a vasodilator. The stenosed coronary vessels
dilate thus facilitating blood flow thus increasing oxygenation. This medication can
cause hypotension as the lumen of the vessels increases whilst the volume of blood
remains constant thus pressure exerted by the vessels is less. For this reason, its
use is contra-indicated in Aortic Stenosis as the reduced lumen of the aorta, the
primary artery of the body, cannot provide adequate blood flow to not only the heart
but the rest of the body. Glyceryl Dinitrate can be given in intravenous form to
induce vasodilation but regular assessment of blood pressure must be made as
hypotension is a complication.
Diamorphine is another pain killer which is used widely and effectively with
individuals with chest pain. The BNF (section 4.7.2) states that is does not cause
neither as severe hypotension or nausea as morphine. Intravenous administration
provides the fasted route. If it is only used in emergency situations; the risks of
dependency on the part of the individual are low. However, if an individual has a
propensity for addiction/dependency upon morphine then this may be a problem. As
an opioid, it can suppress the respiratory centre in the brain. Once morphine has
been administered, it is very important that respiratory rate is monitored at regularly.
Assessment of pain can be complicated due to its subjective nature with many tools
used attempting to measure it. Several visual scales are analysed by Duke
(2006).the visual analogue scale consists of a line with no pain at all at one end and
the worst pain possible at the other. The numerical rating scale is similar that has
figures 0 to 10 marked on it. The verbal rating scale is similar to the visual analogue
scale that has increasing description of pain degrees from no pain at all to worst
possible pain. These provide some idea of the patient’s own perception of her/his
pain. She cites Turk (1989) as being one of the first writers to argue that pain may
not be linear and maybe more complex and that the unidirectional approach may
cause distortion to the individual’s pain experience. Also, the individual needs to be
able to understand the concepts involved as well as being able to express her/his
self and be understood for these tools to be effective.
Some pain assessment tools use acronyms an aide-memoir to consider the different
dimensions of pain assessment. “OLD CART” (Onset, Location, Duration,
Characteristics, Accompanying symptoms, Radiation and Treatment) (MacAvoy,
2001) and PQRST (provocation and palliation, quality of pain, region and radiation,
severity on a 0-to-10 scale and timing) (Wentz, 2003) are mnemonic pain
assessment tool. The former is specifically designed for cardiac pain. However, both
tools origin is unknown and little is written about them, moreover its rigour, uses and
limitations. More research in this area could provide some light in these areas.
Much research has been carried out into how Nurse’s biases can influence their
assessment of pain in individuals. This is exemplified by Macfrey et al (2007) who
compare how respondents to 2 vignettes created by Marks and Sachar (1973).
These vignettes, one describing 2 similar 25 year olds who report eight out of ten
pain scores, one smiling and one grimacing, were presented to individuals attending
pain conferences. They were asked what pain score they would record on the
patients pain and if they would give more intravenous morphine. Results showed
that, over time, more nurses reported that they would actually recorded 8/10 pain
scores for both clients and would also give higher levels of morphine. Although this
may give an insight into the attitude of Nurses, there are several flaws. The
respondents are dealing with vignettes, not actual patients so ethnographic validity is
an issue. Also, both patients mentioned are male thus the question of different
responses may have been different if they had been female. Furthermore, on some
occasions, the vignettes were not in their original form so methodology can be
Cardiac chest pain can have serious implications if action is not taken quickly after it
inception. For this reason timely and effective assessment is essential. Nurses are
accountable for their actions/inaction and have a duty to respond if individuals
reporting pain, not only for physiological reasons but for humanitarian ones also.
Pain assessment can be complex. Not only are there issues of measuring the
intangible but also issues of nurse bias. Several tools can be helpful but these
require the client to be able to show understanding as well as appropriate
expression. There are several chemical pain relievers but these all require skilled
nursing assessment. A Nurse making an assessment of pain must be weary of not
allowing her/his own biases to enter proceedings as this may cloud her/his
judgement when making clinical decisions, thus delivering suboptimal care. Much
has been learned during the writing of this piece. This includes much about the
ALERT course and some of the processes involved. The value of incorporating
ALERT into pre-registration Nursing could be considered. This could have
ramifications for Nursing as a whole as individuals would be more aware of signs
that could be indicative of patient deterioration and the steps to take to summon help
where required. Pain, especial when of cardiac in origin, is a very complex concept
requiring specialist assessment part of which can be facilitated by understanding the
nature of pain and being aware of the psychological aspects of it.
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Appendix 1: Example of a Modified Early Warning System Chart after Stenhouse, C.
Coates, S. Tivey, M. Allsop, P. and Parker, T. (2000) Prospective evaluation of a
modified Early Warning Score to aid earlier detection of patients developing critical
illness on a general surgical ward. British Journal of Anaesthesia, 84, (5) 663.