NUR2204 - Case Study Using Clinical Reasoning Cycle Assignment

Assignment Task

Brief Task Description

Use the Clinical Reasoning Cycle (CRC) to guide your clinical reasoning skills and identify one problem/issue for two (2) out of the five (5) laboratory case study patients. The five (5) case studies are available under the Assessment tab - Clinical Skills Assessment 1 on StudyDesk. You may choose which two (2) patients you focus your assessment on.

You must use the Clinical Reasoning Cycle template provided to complete this assessment.

The Rationale for assessment task

This assessment will build on your increasing ability to think like a nurse by using clinical reasoning to determine the best course of action for the people that you care for.

Course Objectives measured

Course Learning Outcome

1. Apply critical thinking and clinical reasoning skills in the assessment, planning, management, evaluation, and education of individuals experiencing cancer, renal, gastrointestinal, integumentary, reproductive, and neurological dysfunction using a culturally safe, person-centred approach, and for the person receiving palliative care or end of life care.

2. Apply psychomotor clinical skills learnt in the simulated environment using a variety of case studies.

3. Communicate proficiently and in a professional manner as a member of the interdisciplinary health care team.

4. Recognise and respond to the deteriorating patient in the simulated clinical environment.

Task information

Task detail

• You have been provided with a Clinical Reasoning Cycle (CRC) template under Clinical Skills Assessment 1. The template is in a format that allows you to complete the CRC template online. To add an extra page for references, click outside the template at the bottom of the box and click enter. A blank page will appear. Type your references here.
• Choose two (2) patients from the five case studies provided under the Assessment 1 tab on your Study Desk.
• For each patient, work your way through the CRC steps:

Step 1 - Consider the patient situation 

Step 2 - Collect cues/information 

Step 3- Process the information

Step 4 - Identify ONE (1) problem/issue that you believe is a priority during this admission and work through STEPS 5-7 for this ONE (1) problem/issue. (sentence)

Step 5- Establishing goals 

Step 6- Take action 

Step 7- Evaluate outcomes 

Step 8- Reflect on the process and new learning

Task information

Task detail

Students must respond to the case study provided. Please read the case study that relates to the situation to base your assessment from. Using the case study respond to the questions provided using academic writing. Your answer will concentrate on Clare's admission and includes discharge planning.

Case Study:

Introduction

Clare Smith, a 63-year-old female, presented to the Emergency Department (ED) with a 3-day history of urinary issues. Signs and Symptoms: polyuria, dysuria, chills, febrile, nausea and vomiting, and malaise. Diagnosed with Pyelonephritis and admitted to the ward.

Background

Medical History:

• No allergies
• Early onset Dementia (diagnosed 1 year ago)
• T2DM, GORD, recurrent UTI's - urinary incontinence during UTI, chronic pain due to previous fractured ankle.
• Weight 75kg, Height 175cm.

Medications:

• Medications prehospital: Metformin 500mg BD; Esomeprazole 20mg daily, Paracetamol Osteo 1330mg Q8hr daily, Tramadol 100mg PRN, Multi vitamins 1 tablet daily, Fish Oil 2000mg daily.
• Medications on admission: Ampicillin 500mg Q6hr;
• Vancomycin 500mg Q6hr

Psychosocial:

• Clare lives at home with her husband Jim - lives on farm 1hr from town. Son (aged 33 years) - lives in a different state.

Assessment

On admission to the ward:

• Observations: temperature - 38.1°C; heart rate - 112bpm; blood pressure 145/72 mmHg; respiratory rate 22 bpm; Sp02 96% RA; pain - moderate as per Abbey pain scale; BGL 12.2mmoL.
• 18g peripheral intravenous cannula (PIVC) left cubital fossa in situ- VIP score 0, flushing well.
• MSU (mid-stream urine) results include WBC 22, Urea 3.7mmol/L, Creatine 65umol/L, Lactate 1.3mmol/L
• Blood cultures collected - awaiting results.
• Renal USS - no signs of calculi, obstruction, or abscess
• CT scan with contrast-positive for moderate parenchymal involvement.
• Kidney, ureter & bladder X-Ray (KUB) - excludes obstruction.
• On examination: pain lower back and pelvic pain, left flank
  pain on urination.

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