NURBN 3030 Assessment Task 1
Part A
Written plan of care for a clinically deteriorating patient scenario addressing steps 1 5 of the Clinical Reasoning Cycle.
Group Number: AT1 1 Bed 3
Student Names and ID Numbers: Deborah Welsh 30300842, Bailey Fleming 30411450
Campus: Gippsland
Unit Coordinator: Maryam G
Word count:
Patient Name: Antonio Cabrini
Address: 45 Willow Crescent, FEDVALLEY, 3000
URN: 11223340
Patient Gender: Male
Scenario Details:
Mr Antonio has been readmitted to the ward following an episode of chest pain last evening. He
was assessed in the ED and pathology review indicated elevated Troponin levels. He has been diagnosed with a non-ST-elevation Myocardial Infarction (NSTEMI). He has been accepted for transfer to a tertiary facility and an Angiogram has been scheduled within 24 hours. He will stay in the ED while awaiting ambulance transfer. He requires serial Troponin levels and ECGs. Any chest pain must be reported.
His past history includes asthma and COPD, and his medications include:
Fluticasone Accuhaler 500mcg twice daily,
Salbutamol MDI 2 puffs twice daily and up to 8 10 puffs PRN during acute exacerbations of his COPD
Ipratroprium Bromide MDI 2 puffs 4 times daily and up to 4 puffs during acute exacerbations of his COPD.
Antonio has a documented allergy to Penicillin.
It is the morning shift, and you are just entering the room post-handover to introduce yourself. You notice that Mr Antonio appears uncomfortable. You ask how he is, and he reports he has developed some chest pain following a walk to the toilet.
In your allocated group initiate assessment and implement the plan of care that you formulated for AT1A, applying the final three steps of the clinical reasoning cycle. Your management for this patient must include the following:
Systematic assessment of the Antonio
Provide appropriate and prioritised nursing care: including administration of medication.
Problem solving abilities incorporating clinical reasoning skills.
Effective teamwork: each person allocated a designated role/s.
Display effective communication between team members.
Display therapeutic communication with Antonio.
Accurate documentation
Consider the Patients Situation
Collect Cues/Information
Process the Information
Upon monitoring Mr Cabrini staff have noted significant change after he attended the toilet. He has complained to staff that he is having chest pain which is to be reported immediately as per charting. His respiratory rate at present is within range which is 12 to 18 BPM for an adult (ref) but his blood pressure, heart rate and oxygen levels have all decreased. The ECG, in all leads, is showing an increase in the ST level which is a significant sign (ref). The main concerns are the heart rate and rhythm which are signs of ventricular fibrillation. (ref).
Although Mr Cabrini has been diagnosed with non-ST-elevation Myocardial infarction his current ECG is showing an elevation in the ST rhythm.
Identify Problems/Issues
Establish Goals
References
