Focus: Central Nervous System (CNS)
Shift to shift Handover
Introduction Kaylene McCallum is a 64-year-old female admitted under Dr. Tracy Taylor
Situation Kaylene presented as an inpatient to surgical Ward 6 days ago for a right
knee replacement. Discharge has been delayed due to constipation and an
asthma attack that are now controlled. Kaylene also had an episode of chest
pain yesterday. Kaylene was diagnosed with angina and was treated
successfully with glyceryl trinitrate (GTN). She has had recent episodes of
hypotension. Yesterday afternoon Kaylene experienced a transient
ischaemic attack (TIA) with slurred speech and left arm deficit/weakness.
Symptoms are now resolved.
Background Kaylene has a history of hypertension, asthma and osteoporosis. She lives
alone with her dog Sam. Nil known allergies. Kaylene receives an annual
zoledronic acid infusion for her osteoporosis and she takes irbesartan for
her blood pressure. She uses a Seretide inhaler daily and salbutamol PRN to
manage her asthma. Appendectomy at 12 years of age.
Assessment Vital Observations
Respiratory rate – 16 breaths per minute
Oxygen saturation – 98% on room air
Pulse – 86 bpm, weak and regular
Blood pressure – 115/70 mmHg
Temperature – 37.4°C
Dressing to right knee remains dry and intact.
Pain to right knee – 2/10 at rest increasing to 4/10 on
Recommendations Continue to monitor 1/24 vital observations including neurological
You arrived at clinical placement for an AM shift and Kaylene has been allocated as one of your
patients. Your facilitator asks you to assess Kaylene to assist in the planning of her care.
Explain and use frameworks to assist the
systematic collection of data required for
comprehensive and focused health assessment.
Formulate an assessment for Kaylene using
primary/secondary survey approach and explain
why this approach may be considered