Systematic Assessment and Clinical Reasoning in Patient-Centred Nursing Care NURS4025

Question 1:

Using a systematic assessment method, such as the primary and secondary survey has been advocated in clinical practice, allowing for the collection of both objective and subjective data. The primary survey targets immediate, life-threatening matters and dictates the interventions that must take priority (Hodge & Varndell, 2020). Like in emergencies, when something has gone wrong, identity details completion quickly allows help the critical condition of an unusual problem or a consequence of it.

The secondary survey involves a patient history and reviews of all current symptoms enabling the collection of subjective data. Such a method helps providers to see what exactly the patient is experiencing in terms of pain and complaints and as such helps in designing a treatment plan that meets individual needs (Hodge & Varndell, 2020).

Clinicians can develop a comprehensive picture of the condition of a patient by fusing subjective experiences with objective facts, such as examination results and vital indicators.
Using systematic assessments also improves team member communication in the healthcare setting. A standardised method lowers the possibility of mistakes and missing information by enabling uniform data collection and recordkeeping (Hodge & Varndell, 2020). Because everyone in the team has access to the same baseline information when making decisions, it fosters teamwork.

Question 2:

The Clinical Reasoning Cycle (CRC) is a model that supports nurses in undertaking the process of assessment, planning, implementation and evaluation for patient-centred care through improved clinical decision-making and critical thinking. The individual stages of the cycle hold their own benefits (Bae et al., 2023). When nurses are informed about Rajan's past and current symptoms, which include vomiting and abdominal pain on the right side, they can better understand her context. In addition to vital measures like temperature and heart rate, Sharon also documents subjective information when gathering cue data. This assists in ruling out any problems related to dehydration or pre-existing medical disorders. Rajan's falling oxygen saturation and increased respiratory rate are among the concerning developments the data analysis shows the nurse, underscoring the need for urgent medical attention and prioritizing her treatment.

According to Parreira et al. (2021), identifying problems makes it easier for nurses to create suitable care plans that call for notifying doctors. Rajan's symptoms could point to a dangerous illness like appendicitis. Establishing clear objectives, such as treating Rajan's discomfort and vomiting, ensures that the treatment stays on track and patient centered. It's critical to monitor Rajan's vital signs and use remedies like antiemetics to satisfy her significant wants. In the end, tracking Rajan's condition and regularly assessing the outcomes shows whether Rajan's treatments are effective and what needs to be changed. According to Afriyie (2020), by adhering to the CRC, comprehensive evaluation empowers nurses to improve patient-focused care and clinical decision-making, both of which will ultimately lead to better medical outcomes.

Question 3 a:

In analysing the objective and subjective cues of Rajan Kumar, it's essential to support the assessments with evidence from research studies.

Objective Cues:

1.Heart Rate (HR): Rajan's opening heart rate of 90 beats per minute (bpm) is in the normal range for adult resting heart rates of 60 to 100 beats per minute. Colangelo et al. (2020) also highlights that this heart rate range is relatively consistent and typical, thus indicating the proper functioning of the cardiovascular system. Nurses ought to be aware and evaluate the differentiation of basic heart rates because it could mean something is wrong with the body.

2.Oxygen Saturation (SpO2): With regard to room air, the SpO2 of 95 percent falls within the normal saturation range of 95-100%. According to Herbst et al. (2023), it is evident that values of SpO2 > 95% imply adequacy of blood oxygenation, while < SpO2>

Subjective Cues:

1.Last Meal: Rajans assertion of consuming toast and black tea two days ago suggests that some of the nutrients were assimilated in the body. Yesterday she took small portions of water and had nothing to drink today. As pointed out by Corsello et al. (2020) eating patterns should be comprehended regarding the overall wellness of a patient to diagnose gastrointestinal disorders. Some of these nursing strategies regarding nutrition and hydration might be compatible with this environment.

2.Usual Bowel Habits: It is striking what Rajan says about her regular bowel movements. It is needed to define the number of bowel movements a patient had at the beginning controlling any further experience to identify problems as it is essential in cases of abdominal pain suggested by Bharucha & Lacy (2020). Regarding the frequency of defecation, it is assumed that a daily bowel movement is normal and should be considered when determining the overall health of a patient.

These signals are within a normal parameter according to the nurse as they test the function of monitors against normal clinical parameters for adult patients as highlighted by Colangelo et al. (2020). The accepted values, guidelines and references ranges agree with Rajans values.

Rajans own reported history forms the basis for the subjective cues, which shed light on her usual health segments.

Question 3 b:

In analysing Rajan Kumar's case, identifying objective and subjective cues that fall outside the accepted normal range is crucial for effective clinical decision-making.
Objective Cues:

1.Respiratory Rate (RR): Being in the normal adult range of 1220 bpm, Rajan's respiratory rate of 25 bpm, which later rose to 30 bpm, shows tachypnea. Tinawi (2021) states that increased respiratory rates commonly point to respiratory distress or adaptation strategies for diseases including metabolic acidosis. Nurses must recognise tachypnea since it needs quick actions like oxygen therapy or additional respiratory testing.

2.Blood Pressure (B/P): As evidenced by Ranjans bp reading (95/60 mmHg), she has hypotension, which goes under the usual range (120/80 mmHg). Guyette et al. (2021) illustrated that having low bp, coupled with nausea & stomach discomfort, can lead to inadequate perfusion & possibly shock. This requires urgent evaluation to prevent serious issues.

Subjective Cues:

1.Nausea and Vomiting: Rajan feels like puking all night. Research conducted by Broadhurst et al. (2020) reveals that excessive puking can cause imbalances in electrolytes that can eventually lead to dehydration. As a result, nurses need to appraise patients' fluid status and provide the corresponding treatments, like IV fluids and anti-emetics.

2.Pain Description: Rajan illustrated her abdominal pain as dull, but sometimes sharp from last night, especially as it spread to her right shoulder. According to Mehta (2016), this pattern might be reflective of harmful illnesses such as appendicitis or inflammation of the gallbladder. Effective examinations and interventions require nurses to analyse the nature & location of pain.

Importance of Recognizing These Cues:

Noting abnormal signals is important for early intervention, which might reduce complications and improve outcomes for patients (Dresser et al., 2023). For Rajan, spotting tachypnea and hypotension could lead to immediate evaluations for septic diseases or abdominal issues, which would provide timely medical treatment.

Question 4:

Once the subjective & objective cues have been collected from Rajans case, the nurse must follow a systematic approach to ensure comprehensive patient care.

The first task for the nurse is to investigate the collected information to determine and evaluate the intensity of Rajan's condition. The elevated respiratory rate of 30 bpm together with the patient's severe abdominal pain and their low blood pressure of 95/60 mmHg point to a likely acute illness, such as appendicitis or an abdominal infection (Dadeh, 2022). Results indicate that the early recognition of these symptoms could markedly reduce morbidity and achieve better patient outcomes (Dadeh, 2022).

After that, the nurse must concentrate the interventions on the results of the assessment. Our most important focus is to solve Rajan's hypotension along with her respiratory distress. Essential to effective care is the immediate alert to the attending physician about the requirement for additional tests, including imaging studies such as ultrasound or CT scan, along with the implementation of appropriate security measures, such as intravenous fluid resuscitation and pain management (Rud et al., 2019).

The nurse needs to include patient education together with encouragement. To reduce anxiety, it is important to represent the assessment findings clearly and kindly, along with suggested next steps. It is important, too, to record all outputs and appearances for the effective maintenance of an organized medical record. The documentation which provides data on vital signs, subjective complaints, and any begun interventions, helps in patient care today and communication among the healthcare team (Bjerkan et al., 2021). Ultimately, the nurse needs to carefully evaluate Rajan's state, supervising vital signs and symptoms for any changes indicating the need for immediate and effective care for her healthcare requirements. The importance of this method extends to both detailed patient care and raising outcomes (Bjerkan et al., 2021).

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