4. Focus your Assessment
What is the worst thing that can happen?
When caring for a patient during acute crisis, it is helpful to consider the
worst case scenario. Mr. Mory is having an acute MI. The worst thing that
could happen to him is he could develop cardiogenic shock. By considering
the “worst-case scenario”, his nurses would be looking for subtle signs and
symptoms of cardiogenic shock and could respond to them early.
What are some early warning signs that this is occurring?
Early signs that Mr. Mory is developing cardiogenic shock include:
tachycardia, narrowing pulse pressure, increasing respiratory rate, and the
presence of an S3 heart sound.
Focus your assessment on those early signs.
Identifying the “worst case scenario” helps the nurse to identify which
assessment parameters to focus on. By focusing on the most likely
symptoms and the most important functions, the nurse can detect problems
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