Person Centered Clinical Reasoning Cycle Assessment

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Person Centred Clinical Reasoning Cycle Assessment

 

 

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1)     Write a short paragraph describing the person’s story and impact of admission for that person, and their perceptions regarding their health and health care.  (approx.400 words)

 

 

The person’s life story is described from their perspective

 

Please make a positive nice life story using this information below:

–       David Smith / 45 years / Male

–       Job: Fisherman

–       Marital status: Separated (10 Months ago)

–       He has a son who is 5 years old

–       David loves his job, and enjoys watching whales while fishing.

 

 

 

 

The impact of admission or illness on the person and their family’s life is discussed.

 

Please sadly explain how the patient misses his son and his daily life routine.

 

 

 

 

The person’s perception regarding their health and health care.

 

Mr Smith has one issue of being in a shared room with 3 others, and he was the youngest as well as the healthiest, which makes him feeling a bit upset and sad.

Please explain how is that can affect badly on the patient’s mental health and SUPPORT THE POINT WITH A REFERENCE.

 

 

 

 

2)     List the patient’s main medical diagnosis and any co-morbidities and then explain the main medical diagnosis and one comorbidity, referring to literature on pathophysiology. (approx. 300 words).

 

Main Medical Diagnosis

 

Meaning – What has the patient been admitted to hospital for?

 

Syncope due to Supraventricular Tachycardia.

 

 

Explanation of main medical diagnosis (refer to literature on pathophysiology)

 

 

Meaning – Explain the diagnosis and link it back to pathophysiology

Please find the link between Syncope and Supraventricular Tachycardia SUPPORT WITH REFERENCES

 

 

Co-morbidities

 

 

Meaning – What other health issues does this patient have?

 

–       Anxiety

–       Depression

 

 

 

Explanation of one co-morbidity (refer to literature on pathophysiology)

 

 

Meaning – Explain one co-morbidity and link it back to pathophysiology

Please choose one of the two above, and link it back to the pathophysiology WITH PROPER REFERENCES.

 

 

3)     List all the patients’ medications, and research the action, indications, side effects and practice points for two medications prescribed for this patient linking to diagnosis or comorbid condition.

using generic name, route, dosage and frequency of prescription.

 

List all the patients medications

 

1-     Quetiapine – Route: Oral / Dosage: 50 mg / Frequency of prescription: Once a day (nocte)

2-     Metoprolol – Route: Oral / Dosage: 50 mg / Frequency of prescription: Twice a day (bd)

3-     Paracetamol – Route: Oral / Dosage: 1 g / Frequency of prescription: Four times a day (qid)

4-     Reboxetine – Route: Oral / Dosage: 4 mg / Frequency of prescription: Twice a day (bd)

Medication One

 

Drug name – Metoprolol

 

Actions of the drug – It is beta-blocker which reduces heart rate, BP and cardiac contractility; also depress sinus node rate and slow conduction through the atrioventricular (AV) node, and prolong atrial refractory periods.

 

Indication of use – Hypertension, Angina, Tachyarrhythmia, MI

 

DosageOral, initially 50–100 mg daily in 1 or 2 doses. Maintenance 50–100 mg once or twice daily.

 

Side effects – bradycardia, hypotension, orthostatic hypotension, nausea, diarrhoea, bronchospasm, dyspnoea.

 

Practice points – Medication must not be ceased suddenly possible rebound hypertension, MI or ventricular arrhythmias (educate pt)

• Monitor renal & hepatic function, and BGL

 

Linkage to diagnosisPLEASE COMPLEATE THIS POINT

 

 

Medication Two

 

Drug nameReboxetine

 

Actions of the drug – Inhibits noradrenaline reuptake; weakly inhibits serotonin reuptake.

 

Indication of use – Major depression

 

DosageOral, 4 mg twice a day; increase if required after 3 weeks to 10 mg daily in divided doses. Maximum 12 mg daily.

 

Side effects – urinary retention, dysuria, urinary frequency, dry mouth, sweating, nausea.

 

Practice points – increased suicidal thoughts and behaviour can occur soon after starting antidepressants, particularly in young people; monitor patients frequently and carefully early in treatment

 

Linkage to diagnosisPLEASE COMPLEATE THIS POINT

 

 

 

4)     Provide a summary of the results of the patient’s vital signs and your fall risk, pressure area risk, nutrition and pain assessments. You need to name the assessment tools, the scores and the significance of these (200 word)

 

 

Patients Vital Signs

Heart rate: 193 bpm

Blood pressure: 129/85  mm Hg

Oxygen saturation: 95%

Respiration rate: 16 per minute

Temperature: 36.6 °C

 

 

Significance of these results – What do these results mean? PLEASE ANSWER

 

 

 

Falls risk assessment

 

Name of tool – FALLS RISK ASSESSMENT AND MANAGEMENT PLAN (FRAMP)

The score for the patient – 9

Significance of the results – What do your results mean? What do you do with these results? PLEASE ANSWER

 

 

Pressure area risk

 

Name of tool – WATERLOW PRESSURE ULCER PREVENTION ASSESSMENT

The score for the patient – 3

Significance of the results – PLEASE COMPLETE

 

 

Nutrition Assessment

 

Name of tool – Mini Nutritional Assessment

The score for the patient – 13

Significance of the results – PLEASE COMPLETE

 

 

Pain Assessment

 

Name of tool – Abbey Pain Scale

The score for the patient – 0

Significance of the results – PLEASE COMPLETE

 

 

 

 

 

 


 

Care Plan

 

4) Nursing care plan

 

Nursing Problems

What is the issue for the patient?

 

Nursing Goals

What do you want to do here for the patient

 

Nursing Actions

What will you do here in the way of care for the patient?

 

Rationales

Why have you chosen the actions you want to do for the patient?

First Nursing Problem

 

 

 

Mr Smith is high risk of falls.

 

One Nursing Goal

 

 

 

Ensure the patient is safe from falls.

First action –

 

Educate the pt to notify nurses if feels dizzy.

Rationale –

 

WITH REFERENCES PLEASE SUPPORT THE ACTION AND SHOW WHY IT’S IMPORTANT

 

 

Second action –

 

Assess the pt’s fall of risks mark daily.

Rationale –

 

WITH REFERENCES PLEASE SUPPORT THE ACTION AND SHOW WHY IT’S IMPORTANT

 

 

Second Nursing Problem

 

 

 

The pt is Tachycardiac

One Nursing Goal

 

 

 

Ensure pt is in normal sinus rhythm.

First action –

 

Monitor HR + rhythm by ECG or monitor

Rationale –

 

WITH REFERENCES PLEASE SUPPORT THE ACTION AND SHOW WHY IT’S IMPORTANT

 

Second action –

 

Administer heart medications carefully as prescribed by the doctor.

Rationale –

 

WITH REFERENCES PLEASE SUPPORT THE ACTION AND SHOW WHY IT’S IMPORTANT

 

 

 

 

 

 

 

5)     Evaluate one outcome of the care provided to the patient or explain what evaluation is needed (approx. 100 words).

 

 

 

Meaning – discuss one outcome from what you did for the patient. Was it good or bad and why?

 

 

SUPPORT WITH REFERENCES PLEASE

 

 

 

 

 

6)      Reflect on what you have learned by undertaking this case study and how you will apply your learning in your future nursing practice (approx. 300 words).    

 

 

 

Meaning –

What have you learnt completing this case study?

How will you use this newly learnt information in your role as a nurse?

 

 

SUPPORT WITH REFERENCES PLEASE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reference List (Please start on a new page)

 

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