Initiating the assessment

The nurse telephones Mary to ask if she is willing to meet her, explain what the meeting will entail and to agree a time and date. Before the meeting, the nurse reviews Mary’s health record and health passport, which contains information about Mary’s preferred communication methods and abilities. Based on this information and her prior knowledge of Mary, the nurse decides to use the Calgary-Cambridge model (Kurtz et al 2003) to structure the assessment and the OLDCART mnemonic (Rushforth 2009) to establish the precise nature of Mary’s symptoms and concerns.

The nurse understands that the OLDCART mnemonic does not have to be followed in sequence and plans to be guided by, and respond to, Mary’s cues, questions and replies. The nurse considers how she might frame exploratory questions and explanations in a way that will ensure Mary understands what is being asked, the possible diagnosis and the treatment plan. She also decides to take a range of communication tools with her when she visits Mary, including a visual pain scale, a body chart and images of medical procedures, which she will use if appropriate or required.

Gathering information

When she arrives at the house, the nurse asks Mary if she can undertake the assessment in her bedroom, which is upstairs. On the way up, the nurse notices that Mary stops halfway, appears breathless, holds the front of her chest and says her arm is aching and that she thinks she ‘still has the flu’. When they arrive at the bedroom, the nurse decides to explore this further. Once Mary’s breathing has settled, the nurse asks her if she is happy to continue with the assessment and tells her that she can stop at any time.

The nurse understands that it is important to gather information in a sensitive, reassuring and conversational way that Mary is familiar with, so she starts by asking her about Mary’s holiday at her brother’s house and the nice things she did there, before turning the conversation to her ‘flu’ symptoms and attending to what is concerning Mary the most. Throughout the process the nurse continues to build trust and rapport with Mary, even though they already know each other, and attends to Mary’s non-verbal and verbal cues, which might express any concerns she has about her health.

Mary says she is ‘achy’ and points to her left arm and chest, says she had a chest infection and was ‘on tablets’ and that ‘I am not myself.’ When the nurse asks what she means by this, Mary rubs her abdomen and says that it makes her feel ‘like getting sick’. The nurse observes that Mary has some shortness of breath while she is talking. Mary also says that she is not going for walks anymore, and when the nurse asks why she says it is because the staff walk too fast, she cannot catch up with them and that it makes her ‘feel dizzy’.

Family members who know a person well can contribute to history taking (Martin et al 2012), so having noted that there was nothing in Mary’s health record to indicate she was unwell during her holiday, the nurse telephones Fred, with Mary’s consent and in her presence, to gather more details about this recent illness. Fred says that Mary was breathless and coughing while she was staying with him and that the local GP had prescribed antibiotics. He adds that Mary was not as keen to do activities as she usually was, but he had just put this down to her getting older and ‘being a bit poorly’.

Table 2 gives examples of the communication methods and questions used by the nurse in Mary’s health assessment.

Physical examination

Having gained information about the presenting symptoms, the nurse asks Mary if she is happy to continue with the assessment and explains this will involve taking her blood pressure and listening to her chest but that they can stop at any point. Having again gained Mary’s consent, the nurse continues with the assessment focusing on the presenting symptoms (Table 2) and following Mary’s verbal and non-verbal cues. The nurse takes and records Mary’s temperature, blood pressure, pulse, respiration rate and chest auscultation and weight. All observations are within Mary’s normal range and her chest sounds are clear. Mary’s weight has increased by 3kgs over the last two months.

Explanation and planning

It is important that the nurse provides the type and amount of information that Mary can understand so that she can share in decision-making. The nurse explains to Mary that it does not appear that she has had a chest infection and asks if she has any questions or further concerns about how she is feeling to check her understanding of this.

The nurse then asks Mary if she is happy for her to arrange a visit with her GP to chat about the ache in her arm and chest, which she agrees to. Using pictures, the nurse explains that before the GP visit, she will arrange for Mary to have blood taken and that, depending on the results, the GP may do an electrocardiograph (ECG). Mary has not had an ECG before, so the nurse arranges to bring some easy read information about the procedure and explains that she will go through this with Mary.

Closing the session

The nurse thanks Mary for meeting with her and says that if she thinks of any questions, she can telephone her. The nurse returns the completed health records to Mary’s key worker and updates the key worker on what has been agreed.

Communicating with Mary in a safe, private space, using communication methods that match her expressive and receptive communication, including images and references specific to Mary’s life and needs, enabled the nurse to engage Mary in a focused systematic health assessment. Talking to Mary’s brother during the assessment revealed additional information which enabled the nurse to form a differential diagnosis (anaemia, strained chest muscle or cardiac-related condition) and management plan (physical examination, blood tests and ECG to confirm diagnosis, followed by treatment specific to that diagnosis).