Assessment

End of Life

Overview of recent history

Patient Information
Name: Charlie O’Neil
DOB: 01/03/1950 AGED: 71
Hospital number: 00005
Address: 5 Sweet Street, Northampton, NN2 7AL
GP: Dr Baswaz, The Plaine surgery, Northampton
Allergies: No known allergies

Presenting complaint:
• Charlie has been admitted onto the Medical Assessment Unit due to shortness of breath,
and general deterioration of his long-term chronic Heart Failure.
• Charlie has bilateral swollen legs and is struggling to mobilise – refer to PT/OT to provide
suitable ambulatory device
• Charlie is struggling to maintain any diet or fluids due to his excessive shortness of breath
– calculate MUST and input food chart, refer to Dieticians
• Charlie is experiencing chest pain, with a pain score of 7/10 – teach deep breathing
exercises and state will check prescription chart for pain meds
• Charlie states he has not passed urine for over 24 hours – State you will bladder scan
and raise with Doctors

Past Medical History: Chronic heart failure

Social History:
• Charlie is an ex-smoker
• Charlie does not drink any alcohol.
• Charlie is not compliant with his medications, especially the water tablets.
• He lives with his daughter and has a POC X4 to help with ADL’s & meds
• He normally mobilised short distances with assistance of one staff member.
• He is a retired car mechanic.
• He normally manages a healthy diet and hydration, but this has been deteriorating over
the past few months, significant weight loss.

Concerns:
Charlie is very anxious about dying and wants to see the Chaplain

Traps: Hearing aid, water jug, slippers, sweets, newspaper, eyeglasses

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Assessment
Candidate notes
This document is for your use and is not marked by the examiners.
Patient’s details:
Name: Charlie O’Neil
Hospital number: 00005
Address: 5 Sweet Street, Northampton, NN2 7AL
Date of birth: 01/03/1950
Airway
• clear

Breathing
• Shortness of breath
• Respiration, rhythm, depth
• O2 saturation

Circulation
• BP
• Pulse
• Capillary refill

Disability
• chest pain 7/10
• not passed urine over 24 hours
• ex-smoker
• not compliant with meds (water tablets)
• alert, NKA

Exposure – full clinical history

• Long-term chronic heart failure
• Temperature

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Assessment
Candidate notes
This document is for your use and is not marked by the examiners.
Physical
• Bilateral swollen legs
• Difficulty in mobilising, +1 member for assistance

Psychosocial
• Lives with daughter, has POC x4 to help with ADLs and meds

Spiritual
• Anxious about dying, wants to see Chaplain service

Sexual
• No known partner

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Planning

Patient details:
Name: Charlie O’Neil
Hospital number: 00005
Address: 5 Sweet Street, Northampton, NN2 7AL
Date of birth: 01/03/1950
1) Nursing problem/need
___ is experiencing shortness of breath due to progression of chronic health failure
as evidence by a respiratory rate of __ breaths per minute
Aim(s) of care:
___ will verbalise relief from shortness of breath with a respiratory rate of 12-20
breaths per minute and will have a normal breathing pattern and depth
Re-evaluation date:
Today, 11/03/22, hourly, or if any clinical condition changes.
Nursing Interventions
1. Explain plan of care to ___ and gain consent for all nursing interventions.
2. Monitor and record ___’s observations every ___ as per NEWS score of __
and escalate according to NEWS2 policy.
3. Assess ___’s breathing pattern and depth. Monitor for signs of respiratory
distress such as cyanosis and laboured breathing.
4. Teach ___ about the use of deep breathing exercises, diversional activities and
relaxation techniques.
5. Administer to ___ his prescribed oxygen and medications and monitor for their
effectiveness after 30 minutes.
6. Refer ___ to Respiratory Specialist Nurse upon consent as needed.
7. Instruct ___ the use of call bell and place within reach.
8. Document all aspects of care given to ___.

Name (Print): Tarra Mae Ravena

Nurse signature: Date: 11/03/22

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Planning

2) Nursing problem/need
___ is experiencing chest pain due to chronic heart failure with pain scale of _/10.
Aim(s) of care:
___ will verbalise relief from chest pain with pain score between 2-3 out of 10 or
less.
Re-evaluation date:
Today, 11/03/22, hourly, or if any clinical condition changes.
Nursing Interventions
1. Explain plan of care to ___ and gain consent for all nursing interventions.
2. Mo Monitor and record ___’s observations every ___ as per NEWS score of
__ and escalate according to NEWS2 policy.
3. Assess ___’s pain location, radiation and intensity using 0-10 pain scale utilizing
pain assessment tool.
4. Teach ___ alternative pain management such as: diversional activities, deep
breathing exercises, and relaxation techniques
5. Administer to ___ his prescribed medications and monitor for their
effectiveness after 30 minutes.
6. Refer ___ to pain management team upon consent as needed.
7. Instruct ___ the use of call bell and place within reach.
8. Document all aspects of care given to ___.

Name (Print): Tarra Mae Ravena

Nurse signature: Date: 11/03/22

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Planning

3) Nursing problem/need
___ is experiencing general deterioration and is deemed end of life
Aim(s) of care:
___ will have a dignified and peaceful death
Re-evaluation date:
Today, 11/03/22, every 4-hours, or if clinical condition changes.
Nursing Interventions
1. Explain plan of care to ___ and gain consent for all nursing interventions.
2. Monitor and record ___’s observations every ___ as per NEWS score of __
and escalate according to NEWS2 policy.
3. Assess ___ for need of multi-faith chaplain services upon consent as needed.
4. Provide ___ the opportunity to practice his own spiritual belief.
5. Administer to ___ her prescribed medications and monitor for their
effectiveness after 30 minutes.
6. Refer ___ to palliative care team upon consent as needed.
7. Encourage ___ to verbalize feelings and concerns.
8. Instruct ___ the use of call bell and place within reach
9. Document all aspects of care given to ___.

Name (Print): Tarra Mae Ravena

Nurse signature: Date: 11/03/22

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Planning

4) Nursing problem/need
___ is having reduced mobility as evidenced by bilateral swollen legs due to chronic
heart failure
Aim(s) of care:
___ will safely mobilise with assistance, demonstrate use of assistive devices and
perform ADL’s independently within the limits of his disease
Re-evaluation date:
Today, 11/03/22, every 4-hours, or if clinical condition changes.
Nursing Interventions
1. Explain plan of care to ___ and gain consent for all nursing interventions.
2. Monitor and record ___’s observations every ___ as per NEWS score of __
and escalate according to NEWS2 policy.
3. Assess ___’s ability to mobilize using manual handling tool.
4. Provide ___ a safe and clutter free environment and place all belongings
within reach.
5. Assist ____ with her activities of daily living while avoiding dependency.
6. Administer to ___ his prescribed medications and monitor for their
effectiveness after 30 minutes.
7. Refer ___ to Physiotherapist and Occupational therapist upon consent for
suitable ambulatory device.
8. Instruct ___ the use of call bell and place within reach.
9. Document all aspects of care given to ___.

Name (Print): Tarra Mae Ravena

Nurse signature: Date: 11/03/22

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IMPLEMENTING CARE: SAFE ADMINISTRATION OF MEDICATIONS

OSCE Nursing Field: Adult

Candidate Paperwork and Briefing

Scenario:
Charlie O’Neil has been admitted with breathlessness and is for close observation on the
assessment unit.
Please administer and document his 08:00 medications, safely and in accordance with the
NMC standards.
It is today and it is 08: 00

• Please verbalise what you are doing and why.

• Read out the chart and explain what you are checking/giving/not giving and why.
• Complete all the required drug administration checks.
• Complete the documentation and use the correct codes.
• The correct codes are on the chart and on the drug trolley.
• Check and complete the last page of the chart.
• You have 15 minutes to complete this station, including the required documentation.
• Please proceed to administer and document his 08:00 medications, safely in accordance with
the NMC standards.

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 O’Neil 1.6 meters

Charlie 7 stone (44.4kg)

01/03/1950 17.3

000005
Medical Assessment Unit (MAU) MR Darzi
07:30

Dr. Z Khan 12312321 Dr Z Khan 587

x
Dr Z Khan 587

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 O’Neil 1.6 meters

Charlie 7 stone (44.4kg)

01/03/1950 17.3

000005
Medical Assessment Unit (MAU) MR Darzi
07:30

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 O’Neil 1.6 meters

Charlie 7 stone (44.4kg)

01/03/1950 17.3

000005
Medical Assessment Unit (MAU) MR Darzi
07:30

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 O’Neil 1.6 meters

Charlie 7 stone (44.4kg)

01/03/1950 17.3

000005
Medical Assessment Unit (MAU) MR Darzi
07:30

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 O’Neil 1.6 meters

Charlie 7 stone (44.4kg)

01/03/1950 17.3

000005
Medical Assessment Unit (MAU) MR Darzi
07:30

Furosemide

40 MG OD PO 5 days 08:00 Sija Tomas

Today Treat fluid

retention

+4 days
x

Dr Z Khan 587 Dr. Z Khan

Digoxin

125mcg OD PO 5 days 08:00 Sija Tomas

Today Treat arrhythmias
and control heart
+4 days rate
x

Dr Z Khan 587 Dr. Z Khan

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 O’Neil 1.6 meters

Charlie 7 stone (44.4kg)

01/03/1950 17.3

000005
Medical Assessment Unit (MAU) MR Darzi
07:30

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 O’Neil 1.6 meters

Charlie 7 stone (44.4kg)

01/03/1950 17.3

000005
Medical Assessment Unit (MAU) MR Darzi
07:30

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Evaluation
Candidate notes
This document is for your use and is not marked by the examiners.
Patient details:
Name: Charlie O’Neil
Hospital number: 00005
Address: 5 Sweet Street, Northampton, NN2 7AL
Date of birth: 01/03/1950
Situation
• General deterioration due to long term chronic heart failure
• Complaints of shortness of breath, chest pain and is anxious of dying
• NEWS score of __

Background
• Admitted today due to excessive shortness of breath and pain
• Diagnosis of long-term chronic heart failure
• Alert, No known allergies
• Lives with daughter with POC for ADLs and meds
• Exhausted due to struggling to mobilise related bilateral swollen legs
• Normally manages a healthy diet and hydration, but has been deteriorating
over the past few months resulting significant weight loss
•
Assessment
• Recite VS
• ___ is experiencing shortness of breath due to progression of chronic health
failure as evidence by a respiratory rate of __ breaths per minute
• ___ is experiencing chest pain due to chronic heart failure with pain scale of
_/10.
• ___ is experiencing general deterioration and is deemed end of life
• ___ is having reduced mobility as evidenced by bilateral swollen legs due to
chronic heart failure
• Interventions done and medications given

Recommendation
• NEWS: Escalation type
• Refer to chaplaincy and palliative care team
• Refer to dietician for nutrition if not for end of life
• Encourage to practice spiritual belief and spend time with family

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