Person Centred Clinical Reasoning Cycle Assessment
1) Write a short paragraph describing the persons story and impact of admission for that person, and their perceptions regarding their health and health care. (approx.400 words)
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The persons 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 familys life is discussed.
Please sadly explain how the patient misses his son and his daily life routine.
The persons 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 patients mental health and SUPPORT THE POINT WITH A REFERENCE.
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2) List the patients 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).
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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
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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.
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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.
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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) |
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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
Dosage Oral, initially 50100 mg daily in 1 or 2 doses. Maintenance 50100 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 diagnosis PLEASE COMPLEATE THIS POINT
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Medication Two
Drug name Reboxetine
Actions of the drug Inhibits noradrenaline reuptake; weakly inhibits serotonin reuptake.
Indication of use Major depression
Dosage Oral, 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 diagnosis PLEASE COMPLEATE THIS POINT
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4) Provide a summary of the results of the patients 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)
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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
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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
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Pressure area risk
Name of tool WATERLOW PRESSURE ULCER PREVENTION ASSESSMENT The score for the patient 3 Significance of the results PLEASE COMPLETE
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Nutrition Assessment
Name of tool Mini Nutritional Assessment The score for the patient 13 Significance of the results PLEASE COMPLETE
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Pain Assessment
Name of tool Abbey Pain Scale The score for the patient 0 Significance of the results PLEASE COMPLETE
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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.
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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 ITS IMPORTANT
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Second action
Assess the pts fall of risks mark daily. |
Rationale
WITH REFERENCES PLEASE SUPPORT THE ACTION AND SHOW WHY ITS IMPORTANT
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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 ITS IMPORTANT
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Second action
Administer heart medications carefully as prescribed by the doctor. |
Rationale
WITH REFERENCES PLEASE SUPPORT THE ACTION AND SHOW WHY ITS IMPORTANT |
5) Evaluate one outcome of the care provided to the patient or explain what evaluation is needed (approx. 100 words).
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Meaning discuss one outcome from what you did for the patient. Was it good or bad and why?
SUPPORT WITH REFERENCES PLEASE
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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).
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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
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Reference List (Please start on a new page)
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