PATIENT ASSESSMENT RECORD

A. Use the following information to complete the form that comes after it.
Read this description of a patient who was admitted to Accident and Emergency (A&E)
when she took an overdose of paracetamol along with alcohol. Then read her A&E
admission form which was completed when she arrived.

When Roberta Blackwood was admitted to A&E, she was sitting up, though she was
little vague and sleepy. She responded to verbal commands and was able to transfer herself
from the ambulance trolley to the casualty trolley.
Roberta’s breath smelt alcohol. However, there were no signs that she had vomited. Base-
line functions were recorded on the admission form thus:

Base-line functions
Breathing Rate Cough
16/min nil
Circulation Pulse rate BP
92/min 105/65 mmHg
Colour Skin Lips
OK pink
Eyes
Pupils react to light OK

Roberta was accompanied in the ambulance by her aunt, Mrs. Judith Smart. The patient
had telephoned her aunt an hour earlier telling her what she had done and asking her to
take care of her baby.
At the time the admission form was completed, Roberta was very withdrawn, avoided
looking at people and would not speak. Later, however, after some counseling by an A&E
staff nurse, she began to talk more openly.
Roberta has a baby. She is unskilled and unqualified and her husband works as laborer.
Roberta often visits a local pub with her aunt, who is her best friend. Her husband is out
most evenings and when he returns, she says, he is usually drunk and often aggressive. She
dreads her husband coming home at night but, though he is fairly rough with her, he has
not beaten her up.
Roberta said she felt unable to cope with the situation at home. She said that the baby
that the baby cried a lot and was very demanding and that she was not getting much sleep.
Roberta is very anxious about the involvement of the Social Services and worries in case
they will take her baby away.
Her parents arrived soon after she did and her father showed he was irritated at his
daughter’s actions. Her husband so far has not visited.
PATIENT ASSESSMENT RECORD MEDICAL INFORMATION
Name: Prefer to be addressed: Relevant medical history
Robbie
Address: Medical diagnosis:
14 Hardcastle Terrace, Chesterton Risk of hepatic failure due to ingestion of 12.5
Other persons important to patient : g paracetamol/risk of respiratory depression
due to drinking unknown amount alcohol.

Whom to contact in emergency: Allergies:

Penicillin

DOB: 20.7.80 Tel: 0112765432 Patient’s feelings and expectations related to

Doctor: Primary Nurse: present illness:
Dr Sullivan RSN Jane Smallweed Patient is aware of dangers & poss. Risks &
Reason for admission: will co-operate with stomach wash-out.
Overdose – 25 paracetamol tabs (approx.) + gin.

Patient’s understanding of admission:

Source of assessment: Nurse’s initial impression (physical and

social):

Family’s understanding of admission:

Drugs taken at home:

Admits to use of cannabis (to help sleep)
 B. Use the following information to complete the form that comes after it.

Mr. John Collingwood is 52 years old. He lives with his wife Mary. He has had chronic
bronchitis since he was 25 and he had pneumonia in childhood. He smokes 30 cigarettes a
day. He has a morning cough and wheeziness as he breathes and gets a lot of chest
infections. He has a high carbohydrate intake and drinks a lot of beer.

Over the past two weeks, Mr. Colingwood has had two severe asthma attacks and
was admitted to hospital when the third attack did not respond to his usual treatment. He
was diagnosed as ‘severe acute asthma’.

On admission the patient had to sit upright in order to be able to breathe and said he
found it difficult to sleep when lying flat. He therefore uses at least two pillows. The patient
is very frightened of dying and needs constant reassurance.

PATIENT ASSESSMENT RECORD

Patient’s name: Medical diagnosis:

Age: Patient’s feelings and expectations related to

present illness:

Form of address: Eating and drinking:

Next of kin: Breathing:

Relevant medical history: Sleeping: