You are a student nurse working with a school nurse (registered nurse) in a secondary school. You and your mentor are supervising a bubble soccer match this afternoon (26th March) which commenced at 1400 hrs. The match goes for 40 minutes with a 5 minute break in between the two halves. It is a hot and sunny day, the air temperature is 32 oC and the humidity is 45%. Bubble soccer After the match, your mentor asks you to perform a range of health assessments to make sure the students are fit to go home. Jessie Lin is 16 years old and in Year 11. Jessie Lin It is now 1450 hours.
You assess Jessie’s vital signs and record the following results: Temperature (tympanic) 38.5 oC Pulse rate 140 beats/min Respiratory rate (RR) 29 breaths/min Blood pressure (BP) 130/70 mmHg Jessie has flushed skin (see picture above) and her t-shirt is soaked. Her past medical history has not yet been documented in the school record as she is a new student and only enrolled in the school last week after moving from another state. She informs you that her mother is waiting for her in the car park, but she feels very hot and that her heart feels like it is beating very fast. She asks you for a bottle of cold water and a chair.
Jessie’s previous observation records (on a clinical chart) are: Date 23rd March 2020 :BP, Pulse, RR, Temp ,110/60 ,70, 14, 36.8
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24th March 2020: 112/60 74 12 36.6
What you need to do in your clinical reasoning report Provide a concise summary of Jessie’s situation as an introduction to your report (approximately 50 words) – what pertinent information would someone reading your report need to know about who Jessie is and the context of this scenario? List the objective and subjective data (cues) that you have gathered from reviewing the information provided above (approx. 50 words) Analyse and interpret the identified cues and explain the assessment findings in relation to Jessie’s context (approx. 450 words) To do this successfully, you should: categorise the cues and identify what elements are normal or abnormal, and compare the current situation and vital signs with previous health information known about Jessie, and recall and apply knowledge of anatomy and principles of physiology (including concepts of homeostasis and the body’s responses to physical activity) to explain her vital signs and other cues. Then propose what further cues you want to collect and explain why these are relevant and important to the situation (approx. 450 words) To do this successfully, you will need to form a logical opinion about what the further cues should be, when you would undertake the assessments to collect these cues (e.g. after some immediate actions for Jessie) and why these cues should be assessed. Relate your justification to Jessie’s situation AND to the principles of anatomy and normal physiology (focusing on homeostasis). Suggestions for structuring your clinical reasoning report There is no set template for how you have to structure your report as long as the sequence of the information that you present flows logically and the reader can follow your clinical reasoning as it unfolds. The following suggestions are based on answers to frequently asked questions: Section headings can be a helpful signpost for how you have applied the clinical reasoning process. You may choose to use some of the keywords from the phases of the clinical reasoning cycle (e.g. Patient Situation, Cue Collection and Processing Information, Further Cue Collection) or any other headings are also fine. You may use a table to present the objective and subjective cues that you have gathered and which elements are normal or abnormal if you wish. In this particular assignment, information included in a table will contribute to the overall word count. The majority of your report will need to be sentences organised into paragraphs, not just a list of dot points. When explaining something, such as the assessment findings, you need to make the reasons for how they came to be the way they are clear to the reader. Paragraphs will allow you to make the relationships between things evident, whereas a dot point format can sometimes appear as a list of facts without the necessary connections for explaining something. As you are the student nurse in the scenario, you may write your report using ‘first person’ tense. This would be useful in the section of your report where you propose what further cues you want to collect and when you would undertake the assessments e.g. “I would ask Jessie…”. Writing in first person is not mandatory so if you are more comfortable writing objectively in the ‘third person’ (removing personal pronouns from your writing), then you can do so as long as it flows logically! You may use accepted clinical abbreviations in your report, but be sure to introduce all abbreviations the first time that you use them e.g. blood pressure (BP), heart rate (HR), respiratory rate (RR) You are required to use relevant scholarly sources of information (textbooks, journal articles, evidence-based practice guidelines or clinical care standards) to support your analysis of your patient’s health information. A health assessment and/or anatomy and physiology textbook will be useful. The UTAS Library Guide for Health and Medicine is a helpful starting point for how to find other scholarly sources of information. There is no set number of references required, but the references which you use should be of an academic source and used appropriately to support your work. Ensure that you express your writing in your own words to demonstrate your understanding of the patient’s situation and reference all sources of information, both in-text and a reference list at the end of the report, using the Harvard referencing style. Assessment criteria and marking rubric Your clinical reasoning report will be assessed against the following criteria: Apply a beginner’s level of clinical reasoning to assess and interpret health information in relation to the patient’s context. Apply knowledge of anatomy and principles of physiology to explain assessment findings in relation to the patient’s context. Apply a beginner’s level of clinical reasoning to propose and justify further cues that are to be collected in relation to the patient’s context. Communicate using academic writing conventions with references to scholarly sources of information that conform to the Harvard referencing style.