Written Assessment 2: Critical Discussion Essay

Instructions

• Prior to commencement, you must register your topic selection with the Nurse Educator.

• Refer to the marking criteria to ensure all required aspects are addressed.

Task

Select a patient you have cared for who is mechanically ventilated and haemodynamically monitored. Identify two major therapeutic nursing or medical interventions and for each intervention address the following:

1. Identify the relevant clinical assessment data and critically analyse your interpretation of this data.

2. Critically analyse the rationale for the patient care intervention and the impact this intervention has had on the patient.

Evidence Requirement

• Support your assignment with at least twenty contemporary (less than five years old) medical and nursing articles.

Assignment Structure

Introduction (~150 words)

1. Brief overview and relevant history of chosen patient.

2. Identify interventions (examples):

• Fluid resuscitation
• Sedation
• Parental nutrition
• Pain management
• Blood glucose control
• ICP management
• Therapeutic hypothermia

Body of Assignment (~1250 words per intervention)

For Example: Fluid Resuscitation

1. Assessment Data

   • urine output, blood pressure, central venous pressure, peripheral circulation, haemoglobin.

   • Analyse: Is assessment data normal/abnormal? What does the data indicate about patient’s condition?

2. Rationale for Intervention

   • Critically analyse rationale from the assessment data (e.g., hypovolemia).

   • Link rationale to intervention choice.

3. Impact of Intervention

   • Critically analyse how the intervention affected the patient.

   • Support with data and literature.

   • Critically analyse both intended outcomes and unintended effects.

Conclusion (~150 words)

• Summarise critique of chosen interventions

Ventilator Settings

• Time: 14:45 – Ventilator initiated

• Mode: SIMV (PRVC) + PS

• Ventilator rate: 18

• TV: 500

• PEEP: 10

• PS: 10

• FiO₂: 50%

ABG on These Settings

• pH: 7.32

• pCO₂: 42

• pO₂: 98

• Oxygen saturation: 97%

• Base excess: -1.9

• Bicarbonate: 21

Adjustment

• FiO₂ reduced to 45%

ABG After Reduction

• pH: 7.37

• pCO₂: 48

• pO₂: 84

• Oxygen saturation: 96%

• Bicarbonate: 27

Fluid Balance

• Total intake: 2137

• Output: 715

• Balance: +1422

PR Word Rounds

Patient Summary

• Severe multilobar CAP with septic pneumonia

• Arterial line placed, intubated

• NGT placed

• CVC planned

• Pleural effusion confirmed on CXR

Patient Condition

• Pt commenced on Piptaz, maintaining SpO₂: 92%

• Admitted at 11:10

Vitals at 13:10

• HR: 95

• BP: 64/50 (MAP 56) → commenced on Noradrenaline 2 mcg

• Albumin resuscitation given

• BP improved to 100/systolic

Nursing Interventions on Sedation

• Fentanyl 20 mcg/hr

• Propofol 20 mcg/hr (continuous infusion)

Infectious Disease (ID) Topic

• Septicemia on sedation

• Sputum & endotracheal aspirate sent for culture

Patient Labs

• Hypokalemia

  • K⁺: 2.31

  • IV fluids with 20 mmol potassium chloride twice

  • Repeated – increased to 3.6

Respiratory Parameters

• RR: 22

• FiO₂: 40%

• SpO₂: 97%

Patient Details

• Name: Mr. X

• Age: 30 years

• Admission Date: 14/9/26 @ 11:00

Problem List

• Extensive multilobar community-acquired pneumonia

• Severe type-1 respiratory failure

History of Presenting Complaint

• 4 days: fever with cough, chest pain, fatigue, body ache

• 2 days: worsening shortness of breath, productive cough with mucoid sputum, pleuritic chest pain

• 1 day: associated with wheezing

• Condition worsened to the point of breathlessness → prompted hospitalization

Past Medical History

• No previous medical/surgical history

Social History

• Smokes marijuana through bong

Clinical Assessment

CNS

• Conscious, oriented

CVS

• HR: 96

• BP: 96/70 (MAP 60) → supported with CET 225, vasopressors used (norad, propofol)

Respiratory

• SpO₂: 88% (on room air)

• Cough with mucoid expectoration

• Not maintaining saturation even on high-flow O₂ (escalated to non-invasive)

• RR: 40/min

• SpO₂: 94–96%

• Temp: 101°F

• PR: 96/min

• BP: 100/70

• FiO₂: 80%

• PaO₂: 55

• HCO₃: 23

• Lactate: 1.2

Chest X-Ray

• Bilateral consolidation (multilobar)

• Suggestive of pneumonia

Provisional Diagnosis

• Extensive multilobar community-acquired pneumonia with severe type-1 respiratory failure

Plan of Management

• Consent obtained

• CVC line placed

• Arterial line placed

• Drugs: Noradrenaline, sedation (propofol, fentanyl)

• IV fluids: crystalloids, albumin

• ABG monitoring

• Culture samples sent (blood, sputum, urine, ET aspirate)

• Antibiotics: Piptaz, Azithromycin

Patient Intubation

• Grade 1 view obtained

• ETT fixed at 21 cm

Ventilator Settings (SIMV PRVC + PS)

• FiO₂: 100% → reduced to 50%

• TV: 500

• PEEP: 10

• RR: 18

• Oxygen saturation: 78%

Key Requirements of the Assessment

The assessment required students to write a 3000-word Critical Discussion Essay based on a patient who is mechanically ventilated and haemodynamically monitored. The main requirements were:

• Select a Patient Case – preferably one personally cared for.

• Identify Two Major Interventions (examples: fluid resuscitation, sedation, pain management, parental nutrition, blood glucose control, ICP management).

• For Each Intervention:

  • Present relevant clinical assessment data and critically analyse its interpretation.

  • Discuss the rationale for the intervention and its selection.

  • Evaluate the impact on the patient , including both intended and unintended effects.

• Use Evidence – support arguments with at least 20 contemporary medical/nursing articles (within 5 years) .

• Follow Structure:

  • Introduction (~150 words) → patient background + identified interventions.

  • Body (~1250 words per intervention) → assessment data, rationale, impact.

  • Conclusion (~150 words) → summarise critique.

Step-by-Step Learning with the Mentor

Step 1: Understanding the Task

The mentor began by carefully going through the problem statement with the student. The focus was on selecting an appropriate patient who was ventilated and haemodynamically monitored, ensuring the case provided enough scope to discuss two major interventions (e.g., sedation and fluid resuscitation).

Step 2: Structuring the Introduction

The mentor guided the student to write a brief 150-word overview of the patient’s background. This included:

• Age, admission details, presenting complaints.

• Clinical history and progression (fever, cough, shortness of breath, chest pain).

• Social history (e.g., smoking marijuana).

• Provisional diagnosis (extensive multilobar CAP with severe type-1 respiratory failure).
  This set the context for the interventions.

Step 3: Identifying Interventions

From the clinical notes, the mentor helped the student narrow down two key interventions that had significant impact:

1. Fluid Resuscitation (e.g., albumin infusion, crystalloids, potassium replacement).

2. Sedation and Ventilator Management (propofol, fentanyl, ventilator settings and adjustments).

Step 4: Analysing Assessment Data

The mentor emphasized using objective clinical data to justify interventions. The student was guided to extract values such as:

• ABG readings: pH, pCO₂, pO₂, bicarbonate, oxygen saturation.

• Hemodynamic parameters: HR, BP, MAP, urine output.

• Respiratory measures: ventilator mode, FiO₂ adjustments, respiratory rate.

• Lab results: potassium levels, lactate.
  The mentor explained how to identify whether the data was normal or abnormal and what it implied (e.g., hypoxemia, hypokalemia, septic shock).

Step 5: Explaining Rationale

For each intervention, the student was taught to critically link the abnormal findings to the treatment given. Examples:

• Fluid resuscitation → low BP and MAP indicated hypovolemia, justifying albumin infusion.

• Sedation/ventilation → patient on SIMV PRVC mode with high FiO₂ requirements; sedation was necessary to synchronise with ventilator and reduce oxygen demand.

Step 6: Evaluating Impact

The mentor guided the student to show both intended benefits and possible unintended consequences , supported by literature:

• Improved hemodynamic stability after fluid resuscitation.

• Better oxygenation and synchrony after sedation.

• Risks such as fluid overload or sedation-related hypotension.

Step 7: Using Evidence

The student was reminded to integrate 20 contemporary sources (within 5 years), such as recent ICU guidelines, peer-reviewed nursing journals, and respiratory/critical care literature.

Step 8: Writing the Conclusion

Finally, the mentor advised keeping the conclusion short (150 words) – summarising the two interventions, highlighting their effectiveness, and reflecting on their impact on patient outcomes.

Learning Outcomes

1. The student successfully structured a comprehensive 3000-word essay addressing the assessment requirements.

2. They demonstrated the ability to:

   • Critically interpret clinical data.

   • Link assessment findings with appropriate interventions.

   • Analyse both positive and negative impacts of interventions.

   • Support arguments with current evidence.

• Learning Objectives Covered:

• Critical thinking in patient case analysis.
• Application of evidence-based practice.
• Integration of theoretical knowledge into clinical decision-making.
• Clear academic writing and structured critique.

Important Note Before You Download

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