Case Study
You are a registered nurse (RN) working in a small coastal town hospital with a picturesque view of the ocean. It`s a tranquil day when a woman named Glady’s, in her early fifties, arrives at the emergency department accompanied by her concerned husband. Glady’s is visibly distressed and clutching her chest. She explains that she has been experiencing severe chest pain for the past hour, which began shortly after enjoying a meal at a local seafood restaurant.
Gladys describes the pain as a burning sensation in her chest that radiates to her back. She also mentions that she`s had occasional episodes of heartburn and regurgitation lately, particularly when lying down. She adds that she`s been feeling increasingly short of breath and that her breathing worsens when she takes deep breaths.
Your primary responsibilities include:
Primary Assessment and Monitoring: Assess Glady`s vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation. Continuously monitor her cardiac rhythm through an ECG. Assess her level of consciousness and pain.
Provide Oxygen Therapy: Ensure that Gladys receives adequate oxygen therapy to improve oxygenation and relieve chest pain.
Pain Management: Administer pain relief as ordered by the doctor, which may include antacids to address reflux symptoms.
Differential Diagnosis Consideration: Given the possibility of reflux, a heart attack, and pulmonary embolism as differential diagnoses, assess vital signs and symptoms to differentiate between these conditions.
Emotional Support and Communication: Communicate effectively with Gladys and her husband, addressing their concerns. Keep them informed about the situation.
Collaboration with the Healthcare Team: Collaborate with the medical team to make decisions regarding further assessments and interventions based on the clinical presentation, via an ISBAR tool communication.
Continuous Monitoring and Documentation: Monitor Glady`s condition continuously, document all assessments, interventions, and responses, and communicate effectively with the healthcare team.
Task
This task requires you to write a paper that addresses four (4) stages of the Clinical Reasoning Cycle (CRC): Processing and Interpreting; Establishing Goals; Identifying Issues and Takes Action; and Evaluate Care. For each section, please use the stage of the CRC as your subheading and do the following:
Processing & interpreting: Identifying and interpreting the following assessment findings by circling or highlighting your choice; normal or abnormal parameters, if it raises concerns, if its potential cardiac or non-cardiac relation, the need for nursing intervention, and the predicted outcomes for the patient within the case study. (Referencing where you have interpreted your observations from & copy and paste table from the link below into your written paper).
Establish goals: Establish goals: formulate one SMART goal relevant to the case study based on the nursing assessments (neurological, cardiovascular, respiratory, or endocrine) Make sure you use the SMART goal format subheadings in your response. Support your response with insights from Levett-Jones (2023) and any relevant literature or research.
Identifying issues & takes action: Identify two(2) examples of evidence-based nursing interventions, based on your SMART goals that were created from the following nursing assessments: neurological, cardiovascular, respiratory, or endocrine – that you as the registered nurse could do within this case study. Utilising your clinical knowledge and referring to literature and research to guide your clinical reasoning as you continue to assess the patient’s condition.
Evaluate care: How does the evaluation of outcomes play a crucial role in the clinical reasoning cycle for a nurse? Discuss the significance of re-examining both objective and subjective data to assess the effectiveness of your nursing interventions, integrating research and literature within your response.
You do not need to provide an introduction or a conclusion for this task, however, it must be written using professional and academic language, and be presented in structured paragraphs written in the third person.
Clinical Reasoning Cycle
SMART goal:
The SMART goal is a simplified format to direct and drive goal setting. It stands for Specific, Measurable, Achievable, Relevant and Time-bound.
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