11.14 Clinical Judgment: Case Study

A 34-year-old male client arrives in the emergency department with his partner. The partner is crying, stating the client tried to stand after dinner, and then fell to the floor holding his chest. Upon assessment, the client was experiencing shortness of breath, had a racing heartbeat, voiced slight chest discomfort, and said he felt a fluttering sensation in his chest. He also said he has lower back pain. RR: 28 bpm, HR: regular irregular rhythm 146 bpm, BP: 132/86 mmHg, O2: 97%. The client is diaphoretic and states he feels lightheaded, dizzy, and is afraid he’s going to faint.

After reading the following scenario, perform a primary survey (ABCCS) of the client. The goal is to determine whether urgent interventions are needed and act on signs of clinical deterioration.

What is your priority?

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Nursing Physical Assessment Copyright © 2024 by Barbara Gawron and Meenu James is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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