NURS2005 Application of the Clinical Reasoning Cycle in STEMI Nursing Care

Consider the Patient Situation

Collect Cues

Instructions: Review the information about the case scenario provided in this section.

On admission to the Emergency Department (ED), David is diaphoretic and pale. He is alert and orientated but anxious with central chest pain. The doctor examines him and orders a stat dose of IV morphine. Davids ECG is attended and shows ischaemic injury (ST elevation) in the anterior leads. As ST elevation indicates a coronary artery blockage, treatment is aimed at unblocking the vessel.

The doctor asks David if he has any history of head injuries, malignancies, stroke or gastric bleeding to ensure there are no contraindications for thrombolytic treatment. No risk factors are identified, and David is given thrombolytic therapy.

Instructions

Use the space below to complete the following part of the assessment task:

Recall Knowledge: The task here requires you to research and use evidence to explain the pathophysiology of the patients presenting problem in language that shows you and the patient understands what is happening with David (400 words) (20 marks).

Recall Knowledge (type answers here):

Process Information

Instructions: Review the Admission observations.

Admission observations

Temperature = 36.8 ?

Pulse Rate = 108 beats/min

Respiratory Rate = 24 breaths/min

Blood Pressure = 150/90 mmHg

Sp02 = 95% on room air

BGL = 14.1 mmol/L

Pain score = 8

GCS = 15

Co-morbidities

Osteoarthritis

Hypertension

Hyperlipidaemia

Type 2 diabetes mellitus

Use the table below to complete the following part of the assessment task:

Process Information (please circle/highlight you decision in the table provided):

• Interpret review and interpret the observations, identify if this observation is Normal or Abnormal.

• Discriminate from the clues and information you now have, determine if you should be Concerned or Not Concerned.

• Relate it is important to understand and cluster the cues you have collected so far which observations are Cardiac or Non-Cardiac in nature.

• Infer think about clues about Davids condition can any Nursing Intervention occur for each observation, circle Needed or Not Needed.

• Predict During this stage you need to consider the potential outcomes for David which will then guide your actions, identify the observations that could have Consequences or No Consequences for this patient.

Instructions

Use the space below to complete the following part of the assessment task:

Interpret / Discriminate / Relate / Infer / Predict: explain why you considered the following concerns related to the Admission Observations using literature & research to support your discussion (400 words) (5 marks for table)(20 marks for discussion).

Relate and Infer (type answers here):

Identify Problems/Issues

Instructions: Now bring together (synthesise) all the facts form the collecting the clues & reviewing the administration observations to determine nursing diagnoses.

A nursing diagnosis is a problem that becomes apparent following a though and systematic interpretation of subjective and objective data.

Use the space below to complete the following part of the assessment task

Synthesise: Based on your interpretation of the assessment findings, explain in your own words two (2) nursing diagnoses for the person in the scenario (50 words each) (5 marks).

Establish Goals

Instructions

Use the space below to complete the following part of the assessment task:

Describe what you want to happen: Develop two (2) SMART goal for one of your nursing diagnoses that you identified above (200 words) (10 marks).

Describe what you want to happen (Establish Goals) in each subheading:

SMART Goal 1:

Specific:

Measurable

Achievable:

Realistic:

Time:

SMART Goal 2

Specific:

Measurable:

Achievable:

Realistic:

Time:

Take Action

Instructions

Use the space below to complete the following part of the assessment task:

Select a course of action: Identify one (1) nursing intervention for each goal and provide a rationale for each intervention that explains why each intervention is required in this scenario. Interventions may include nursing-initiated interventions or interventions that would be implemented following medical review. Contacting the medical officer is not a suitable intervention. Use evidence to support your rationale and relate this to your specific intervention (400 words)(15 marks).

Select a course of Action:

Evaluate Outcomes

Instructions

Use the space below to complete the following part of the assessment task:

Evaluate: Explain the key steps the registered nurse would take to evaluate the nursing interventions provided (300 words)(10 marks).

Evaluate:

Note references should start on a new page below the body of your work