NRS399 : Clinical Reasoning 6 – Planning of Care Case Study

TASK

In this assessment task, you are required to review the below case study and address each of the assessment criteria provided, presenting your findings and insights through an audio-visual presentation.

• Duration: 8 minutes

• Length: Your presentation should include no more than one title page slide, five (5) content slides, and a reference list slide. The total audio time should not exceed 8 minutes for the five slides.

• Creativity and Visual Aids: This is an audio-visual presentation, so feel free to get creative! Incorporate visual aids such as diagrams, charts, multimedia elements, or other engaging tools to enhance your delivery and captivate your audience.

Patient Assessment and Initial Findings

• Conduct an initial assessment using a framework such as the A-G or head-to-toe assessment, considering the patient’s history.

• Identify priority areas for assessment, for example neurological status, cardiovascular health and glucose management etc.

• Analyse findings and discuss immediate concerns, integrating the Clinical Reasoning Cycle to justify these priorities.

Care Planning and Implementation

• Develop a care plan that addresses both the patient’s short-term needs in the hospital and long-term care goals.

• Explain specific interventions for example fall prevention strategies, glucose monitoring, and patient education etc. to enhance their independence with self-management of their health concern.

• Discuss how the care plan will be evaluated and adjusted based on the patient’s response.

Interprofessional Team Collaboration

• Identify essential members of the interprofessional team for the patient’s care.

• Discuss how these professionals contribute to his/her care.

• Outline communication strategies for coordinating with the team, using ISBAR to facilitate accurate, efficient handovers.

Patient Safety and Adverse Event Management

• Identify potential adverse events that could potentially affect the patient, such as falls, hypoglycaemia, infection risk etc.

• Propose interventions to prevent these risks.

• Justify each intervention, explaining how they contribute to optimising the patient’s safety and overall care.

Mindful Communication and Documentation

• Discuss strategies for building a therapeutic relationship with the patient, including mindful communication that respects his/her preferences for holistic care.

• Explain how to involve him/her in their care decisions to promote trust and comfort, using clear, non-technical language.

• Outline documentation practices, ensuring that all assessment findings, interventions, and communications are recorded in line with legal, ethical, and professional standards.

Background:

Ms. Thomas is an Australian-born female with a history of hypertension and hyperlipidaemia. She lives alone in a retirement village, maintains her independence, and is an active member of her local community choir. Evelyn has two daughters, one of whom lives interstate and the other overseas. She identifies as Catholic, and places great value on spiritual support and holistic care.

Presenting Condition

Ms. Thomas was admitted to the emergency department following an episode of acute chest pain radiating to her left arm, accompanied by shortness of breath, diaphoresis, and nausea. ECG and blood tests confirmed a non-ST elevation myocardial infarction (NSTEMI). She is now admitted to the coronary care unit for monitoring and initiation of medical management. She reports feeling frightened and is concerned about her ability to live independently after discharge.

Medical History

• Hypertension

• Hyperlipidaemia

• Osteoarthritis

• Gastroesophageal reflux disease (GORD)

Medications

• Amlodipine

• Atorvastatin

• Aspirin

• Pantoprazole

• Paracetamol (as needed)

Social and Cultural Background

Ms. Thomas is retired and enjoys gardening, walking, and singing in her local choir. She describes herself as spiritual and finds comfort in prayer and church community. Evelyn expresses a strong desire to be involved in decisions about her care and is more receptive to communication that avoids medical jargon. She is particularly anxious about losing her independence and would like to explore rehabilitation options and home-based support services.

Assessment Requirements – Brief Summary

The task required the student to review a detailed case study of Ms. Evelyn Thomas, a 73-year-old patient admitted with a non-ST elevation myocardial infarction (NSTEMI), and present their findings via an audio-visual presentation . The key requirements included:

• Duration & Structure: 8-minute presentation with 1 title slide, 5 content slides, and a reference slide.

• Patient Assessment: Conduct a thorough initial assessment using a structured framework (e.g., A-G or head-to-toe), identifying priority areas such as neurological, cardiovascular, and metabolic status.

• Care Planning: Develop short- and long-term care strategies with evidence-based interventions for patient safety, independence, and self-management.

• Interprofessional Collaboration: Identify team members, explain their contributions, and outline communication strategies (e.g., ISBAR).

• Patient Safety & Risk Management: Identify potential adverse events, propose preventive measures, and justify their importance.

• Mindful Communication & Documentation: Focus on therapeutic communication, patient involvement, and professional documentation in accordance with legal and ethical standards.

• Creativity & Visual Aids: Use diagrams, charts, and multimedia tools to enhance engagement.

Assessment Approach Guided by Academic Mentor

The Academic mentor guided the student in a step-by-step process to meet each requirement:

1. Understanding the Scenario:

   • The mentor encouraged the student to read the case study thoroughly, noting Ms. Thomas’s medical history, current presentation, medications, and social/cultural context.

   • Emphasis was placed on recognizing comorbidities (hypertension, hyperlipidaemia, osteoarthritis, GORD) and psychosocial factors affecting care.

2. Patient Assessment & Initial Findings:

   • Using the A-G assessment framework, the student identified priority areas: cardiovascular status (vital signs, chest pain), neurological function (sensory/motor checks), and overall mobility.

   • The mentor explained the Clinical Reasoning Cycle, helping the student justify why specific findings were prioritized.

3. Care Planning & Implementation:

   • The mentor guided the student to create a care plan addressing immediate needs (NSTEMI monitoring, pain management, fall prevention) and long-term goals (rehabilitation, home support).

   • Evidence-based interventions were linked to Ms. Thomas’s condition, including medication adherence, lifestyle modifications, and patient education on heart health.

4. Interprofessional Team Collaboration:

   • The student identified team members: cardiologist, nurse, physiotherapist, dietitian, and social worker.

   • The mentor explained ISBAR communication to ensure accurate handover and collaboration.

5. Patient Safety & Adverse Event Management:

   • Potential risks were identified: falls, medication errors, infection, or adverse cardiac events.

   • The mentor helped the student justify preventive strategies, linking each intervention to patient safety and improved outcomes.

6. Mindful Communication & Documentation:

   • The mentor emphasized therapeutic communication, ensuring Ms. Thomas’s preferences and independence were respected.

   • Proper documentation practices were outlined, covering assessments, interventions, and patient interactions in line with professional standards.

Outcome and Learning Objectives Achieved

• Outcome:

  • The student successfully created a clear, concise, and engaging audio-visual presentation covering all key areas: assessment, care planning, interprofessional collaboration, safety, and communication.

  • Visual aids such as diagrams, charts, and flowcharts enhanced understanding and audience engagement.

  • The care plan was evidence-based, practical, and tailored to Ms. Thomas’s physical, emotional, and social needs.

• Learning Objectives Covered

  1. Conduct a comprehensive patient assessment using structured frameworks.

  2. Analyse clinical findings and prioritize care using the Clinical Reasoning Cycle.

  3. Develop and implement evidence-based care plans addressing short- and long-term goals.

  4. Collaborate effectively within an interprofessional healthcare team.

  5. Identify risks and implement preventive strategies to enhance patient safety.

  6. Apply mindful communication and documentation practices to support holistic care.

  7. Demonstrate creativity and use of visual aids in professional presentations.

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