[SOLVED] Clinical reasoning skills

 

Purpose clinical reasoning skills: The purpose of this assignment is to: 1) test student’s ability to apply concepts to advance patient care in the acute care setting, 2) demonstrate clinical reasoning skills at the advanced beginner level, 3) demonstrate competent clinical judgement skills, and 4) demonstrate knowledge and correct use of APA formatting.
Format: An individual written assignment as per your instructor’s guidelines. Clinical judgment on a nursing unit is strengthened by a team approach with positive collaboration. Clinical reasoning and clinical judgement are inherently “thinking” activities and coherent articulation of the outcomes of these activities are paramount for safe patient care. Electronically submitted via myClass drop box in in WORD ONLY – No PDFs, No Google Docs.
This assignment allows you some choices on the assignment you will write. In the following sections, you will choose a patient, select their major medical issue / disease process, select a comorbid health condition that will impact their major medical issue, and select a drug allergy that will need to be considered in planning their care. In this assignment, you will walk through the steps of the nursing process and articulate how you are thinking about this patient and planning their care based on the case study narrative you create.

Part 1 – Assignment Preparation
Assignment Preparation Step 1: Choose your patient!
From the list below, select one of the following four patients to be the focus of your care:
Hospitalized 69 year old female, single, living alone in an apartment in Grande Prairie.
Hospitalized 87 year old male, single, living in an assisted living setting in Grande Prairie.
Hospitalized 74 year old male, married, living with his partner in a single detached home in Grande Prairie.
Hospitalized 17 year old female, single, lives with her parents and two siblings (aged 6y and 10y) in a house in Grande Prairie.

Assignment Preparation Step 2: Choose the patient’s MAJOR pathophysiology!
From the list below, select 1 MAJOR medical issue or disease process (i.e. primary reason for hospitalization):
Acute exacerbation of COPD (Concept: Gas Exchange)
Attributes: 3 exacerbations per year with 1 previous hospitalization. Quit smoking 3 years ago (has smoked since age 16y)
SPO2 measure 83% on room air
Chest X-ray (PA/LAT): no pleural effusions or area of consolidation
Prescribed Drugs:
Ipratropium bromide 20mcg/inhalation: Take 2 inhalations every 6 hours
Salbutamol 100mcg/inhalation: Take 2 inhalations every 4 hours as needed
Prednisone 50 mg PO daily for 5 days
Amoxicillin 1 gram PO three times daily for 7 days

 

Congestive Heart Failure (Concept: Perfusion and Gas exchange)
Attributes: Left ventricular ejection fraction of 35%. Smoker 1 pack daily since age 16y. BMI 34.
SPO2 measure 87% on room air. BP on admission 100/60.
Chest x-ray (PA/LAT): small bilateral pleural effusions and cardiomegaly.
Prescribed Drugs:
Ramipril 5mg PO daily
Metoprolol 12.5mg PO twice daily
Furosemide 60mg PO each morning and noon
Hydrochlorothiazide 50mg PO each morning

Urosepsis (Concepts: Fluid and Electrolytes and Infection)
Attributes: Drinks four large glasses of wine daily. Non-smoker.
BP on admission 80/40. Reduced attention and confusion, new to the patient.
Urine: Urinalysis – 3+ blood, 3+ leukocytes. Culture: e-coli 10^8, sensitivity pending.
Drugs:
Piperacillin-Tazobactam 3.375 grams IV every 6 hours
Normal Saline (0.9% NaCl) IV infusion: 1 liter over 1 hour then 250ml hourly for 8 hours then reassess.
Thiamine 100mg IM or PO daily
Lorazepam 2 mg PO each 6 hours for 4 doses then 1mg PO each 6 hours for 8 doses then stop.

Acute gastrointestinal bleed secondary to peptic ulcer (Concepts: Perfusion and Infection)
Attributes: Had endoscopy with epinephrine and hemoclips. Drinks 6-8 ounces of alcohol most days. Smoker 1 pack per day.
BP on admission to medical unit 90/42, heart rate 110 beats per minute.
Drugs:
Pantoprazole 40mg IV every 12 hours
Octreotide 100mcg bolus then infuse at 25mcg per hour for 72 hours
2 units of Packed Red Blood Cells
Furosemide 20mg IV after each unit of packed red blood cells.

Acute exacerbation of Ulcerative Colitis (Concepts: Inflammation and Infection)
Attributes: 12-16 bloody stools daily. No alcohol, nicotine or other drug use.
Temperature 38.8 Celsius, heart rate 110 beats per minute, BP 110/80. Stool culture is negative.
Drugs:
Mesalamine (Pentasa) 1 gram 4 times daily.
Methylprednisolone 20mg IV every 8 hours
Ciprofloxacin 400mg IV every 12 hours
Metronidazole 500mg IV every 8 hours

Assignment Preparation Step 3: Choose the patient’s COMORBID pathophysiology!
From the list below, select ONE COMORBID medical issue or disease process (i.e. chronic condition, not necessarily why they are in the hospital):
Type 2 diabetes
Stable
Prescribed Drugs:
Insulin glargine 18 units SC each night

Atrial fibrillation
Stable
Prescribed Drugs:
Rivaroxaban 20 mg PO each supper

Moderate liver cirrhosis
Stable
Prescribed Drugs:
Spironolactone 25mg PO daily

Hypertension
Stable
Prescribed Drugs:
Amlodipine 10mg PO daily

Stage 2 chronic renal failure
Stable
Prescribed Drugs:
500 mg ferrous sulfate (100 mg elemental iron) PO twice a day
Ramipril 2.5mg PO daily

Epilepsy: General Onset, tonic-clonic seizure disorder
Stable with daily medication
Prescribed Drugs:
Tegretol XR 400mg twice a day

Asthma (moderate)
Stable with daily medication
Prescribed Drugs:
Symbicort Turbohaler 200/6mcg, 2 inh twice a day
Ventolin inhaler with spacer, 2-4 puffs Q3h PRN Wheezing or shortness of breath

Assignment Preparation Step 4: Select ONE drug allergy for your patient that you will need to note in your care plan:
Penicillin
Ramipril
Sulpha-based drugs

Part 2 – Components of the Assignment

Assignment Components: Once you have selected your desired patient characteristics from the lists above, write your assignment following the section descriptions provided below. For the Health History and Physical Examination, please use the template at the end of this instruction document.
Section 1: Health History and Physical (H&P) (begin with this, but it will be an appendix of your assignment)
Using the template found at the end of this document – complete the Health History and Physical Exam database (chart) using the available information from your selected case parameters.
For sections of the H&P that you do not have information from the case selections for, you are expected to create the finding based on your knowledge of the presenting conditions of your patient. Apply your knowledge of anatomy, physiology, pathophysiology, & pharmacology to create a narrative of your patient’s case.
Do NOT add any new pathology or comorbid problems to the scenario.
Include the H&P chart (use the provided template) at the end of your assignment as an Appendix. Adding the chart as an Appendix means it is not counted in your WORD or PAGE Maximum limits for the assignment.

Section 2: Pathophysiology (Maximum 750 words)
The student will focus on the two disease processes that they have chosen: ONE major (i.e. primary reason for hospital admission) and ONE comorbid condition.
Provide a relevant and concise summary of the selected MAJOR disease process (Maximum 250 words).
Provide a relevant and concise summary of the selected COMORBID disease process (Maximum 250 words).
Briefly describe how the COMORBID condition (or its treatment) potentially complicates the treatment of the MAJOR disease process. (Maximum 250 words).

Section 3: Assessment Data including Health History, Physical and Holistic Examination of Data (Clinical Reasoning) (Maximum of 500 words):
Identify the 3 most relevant pieces of health history and holistic examination data that are provided or will be required to inform your nursing care. If priority assessment data is not provided in the scenario you selected, you should create / devise the data that makes sense for the condition or situation (i.e. make it up but make sure it makes sense for the patient scenario). The intent of this section is for you to highlight the 3 most relevant things a nurse wants to know about the patient given the diagnoses they were admitted with. This section focuses on the inter-related concepts as well as the major concept. Provide rationales using evidence of why that assessment data is important and why it would manifest with the patho you have selected. DO NOT add new pathology or problems to the scenario (e.g. do not suddenly give your patient lung cancer in addition to their asthma).

Section 4: Problem Identification and Prioritization (Clinical Judgement) (Maximum 500 words).
Identify the 3 most important problems/priorities your patient is experiencing in your scenario. List them according to priority with the top priority being first in the list. Base your priorities on your ASSESSMENT FINDINGS and ensure they are consistent with the patient’s history, disease and comorbidities. Briefly explain your rationale for selecting your top 3 problems/priorities.

Section 5: Interventions: Independent and Collaborative (Maximum 250 words)
List 5 interventions. Include both independent nursing interventions, those that are based on nursing knowledge and within the scope of practice of the RN to implement independently, as well as collaborative interventions, those that require collaboration with a physician, nurse practitioner, or allied health professional etc.
Be sure to focus on CORE Interventions – those that absolutely MUST happen to maintain and improve the health of your client.
Interventions may be listed in a table or bullet points. Be sure to include the rationale for the
intervention.

6. Section 6: Laboratory and Diagnostic Tests (Maximum 250 words):
List laboratory and diagnostic tests that you anticipate being ordered or might have already been ordered as part of the admission work up that occurred prior to your care of the patient.
Provide your rationales using evidence. Think about why a certain test might be used in diagnosing or
monitoring this disease or condition. Also, how does this information influence your clinical decision-making as a registered nurse? Use your pharmacology textbook and resources!
Labs and Diagnostics may be listed in a table or bullet points. Provide rationale for each test.
d. Use your Mosby’s Canadian Manual of Diagnostic and Laboratory Tests.

7. Section 7: Evaluation of Interventions (Max. 250 words)
When nurses are caring for their patients in an active treatment area (as described in this assignment), the
nursing care plan process might be completed and re-initiated multiple times during a shift. The evaluation phase does not wait until the end of shift but happens immediately after the interventions are completed and the care planning process repeats.
a. For this section, summarize how you would evaluate your 5 interventions
b. You may provide data that suggests whether the patient has improved or requires on-going care and continuation of the nursing care planning process. How will you know if the patient is improving or deteriorating?
8. Section 8: Potential Challenges to Care and Anticipating Undesirable Outcomes (Maximum 250 words)
List 2-3 challenges that may present as a result of the patient’s condition, history or as a result of the care provided to them. This is asking you to think deeper/broader and begin to anticipate any negative or undesirable consequences of care that occur every day.
Anticipate issues or undesirable outcomes that might arise as a result of the patient’s condition and treatments. While death of the patient might be considered the worst-case scenario, there are other undesirable outcomes that we need to be aware of and monitor for.

 

9. Section 9: Scholarly Writing and APA formatting.
The majority of this assignment will be presented in proper sentence form with proper grammar and syntax, correct spelling, and appropriate citations and references using APA 7th Edition.
Your ideas need to be well thought out and clearly communicated. You may use common, lay language, but when describing medical and nursing activities, it is expected that you will use appropriate language and terminology.
Please use the template provided for the Health History and Holistic Examination section. Attach it to the assignment as an Appendix.
The assignment must be submitted as a WORD Document. No other formats will be accepted.
Please follow the organization provided in this assignment description for the remainder of the assignment.
Use this link to go to the UAlberta Library APA Style page and the Quick Reference Guides provided there. This link takes you to the page on in-text citation and quotation.
Minimum expectations of APA formatting required for this assignment include:
Student Title Page
Pagination beginning on page 1 in the top right corner
Title of assignment on first page along with the names of the group members.
Appropriate use and formatting of levels of headings
Correct in-text citations
Correct citation of all quoted material
Correct formatting of references on reference page, including correct referencing of chapters in an edited textbook as well as for non-edited textbooks, websites, and other sources.
It is expected that you will use 3-5 sources as references. You may use your med surg, patho, pharmacology, anatomy and physiology textbooks, etc.
You do NOT cite the APA Manual in your reference list.
Double spaced with 1-inch margins (note the change if using a quote greater than 40 words)
Times or Times New Roman 12-point font throughout
Word limits for each section have been provided to help guide you in knowing how much emphasis each section should have or how concise or comprehensive your discussion should be. APA allows for a 10% variance on word limits. The maximum word count is 2750– NOT including your Title Page, Reference Page, or any appendices.

Use the following H&P table for your assignment. Copy and paste it into your document at the end as an appendix.

Health History and Physical Examination Data
Identifying data:
Chief concern:
History of Present illness:
Medications: Psychoactive Substance Use: Allergies:
Past history:
Childhood:
Adult illnesses:
Medical:
Surgical:
Psychiatric:
Obstetrical/Gynecological:
Health Maintenance:
Screening Tests:
Family history:
Personal and social history:
Review of Systems and Physical Exam:
General survey:

 

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