Clinical Reasoning and Evidence-Based Care for Mrs. Carol Jansen

Please work through the?Clinical Reasoning Cycle?to state the patient situation, collection of cues, processing with justification for the given issues of:

Risk of recurrent exacerbation of COPD

Risk of falls at home

Then detail goals and provision of evidence-based, person-centred care for your shift of care for preparation for Mrs. Jansens discharge home. Please evaluate your care and reflect on your learning.

2000 words (+/- 10%)- excluding reference list.

Work will only be marked up to the +10% word limit.

Referencing

You will find and read a wide variety of scholarly sources on the topic, integrating a minimum of 8 references. These should be no more than five (5) years old unless of historical significance and/or of specific relevant to the topic (for example, the Ottawa Charter from 1986).

CASE STUDY-

It is 0700 hours, and you are working on an acute respiratory ward in a large metropolitan hospital.

You are caring for Mrs. Carol Jansen, a 72-year-old woman, who was admitted 5 days ago, with an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD). She has been well managed with inhaled and Intravenous corticosteroids, inhaled bronchodilators, Intravenous antibiotics, and oxygen therapy. She has been reviewed by the admitting team, with the recommendation for discharge.

The team have changed her medications to include Fluticasone-vilanterol (Breo Ellipta) 100 25mcg INH daily, Salbutamol 2 puffs PRN, Rulide 150mg BD O, a reducing prednisolone regime 25mg O Daily.

Medical history:

COPD for last 5 years, oxygen dependant for the last 4 months.

Hypertension, hyperlipidaemia, peripheral vascular disease and obesity, no surgical history.

Ex smoker, 30 per day for 30 years, ceased 4 years ago.

Prior to admission her medications included: Salbutamol 2 puffs IHN 4 hourly PRN, Vitamin D3 1000us O daily, Olmesartan 40mg O daily, Atorvastatin 40mg O Nocte.

Nil known allergies.

Social History:

Mrs. Jansen is widowed and lives alone; she has a supportive son who lives close by.

Objective data:

Temp: 36.5 Celsius,?

HR (Heart Rate): 88 beats per minute,

RR (Respiratory Rate): 22 breaths per minute, chest: Good bilateral air entry with fine crackles at bases.

BP (Blood Pressure): 135/85 mmHg,

SaO2 (Saturation): 96% on 2lpm of Intranasal oxygen

BSL: 6.3 mmol/l

GCS 15/15

Pain free

Bowels opened daily.

Subjective Data:

Mrs. Jansen is noted to be unsteady on her feet and sustained a near fall. No injuries occurred, though Mrs. Jansen is fearful, and fatigues quickly. She is forgetful; however, a cognitive screen was identified as normal, she admits to being worried about her new medication.

Introduction (150 words):

Briefly detail what you are going to write about, briefly introducing the patient and the CRC
Patient situation (100 words):

Briefly identify what you know about the patient.
Consider Carols situation describing the person and their context.
Collect cues (350 words):

Review relevant current information.

Document what else you would like to know e.g., history, physical assessment, or other investigations.
Recall what you know about his current health condition (Brief pathophysiology linking Carols health to supporting literature).

Process (500 words):

Identify/Interpret cue to explain abnormal vital signs.
Cluster or group important cues, with patterns of health identified.
Develop inferences/hypotheses of cause of illness/potential problems.
Justify the following two issues:
Risk of recurrent exacerbation of COPD
Risk of falls at home
Relate all information to supporting literature.
Establish goals (100 words):

Identify goals of nursing care related to the nursing problem/issues detailed for Carol.
Remember SMART.
Take action (350 words):

Detail with supporting literature the nursing care for Carol related to your established goal.
Evaluate (150 words):

Evaluate your nursing care strategies with what you expect Carols response will be.
Reflect (150 words):

Reflect on the process of new learning.
What did you learn by completing this case report?
Where do you need to focus your efforts for wider understanding?
Conclusion (150 words):

Briefly describe what you wrote about, as well as a summarising statement.

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