Case Study – Clinical Reasoning Cycle

Case Study – Clinical Reasoning Cycle
CLINICAL REASONING CYLC (CRC) FRAMEWORK GUIDELINE:

1) Consider the person:

Recognising changes in their condition and their present situation –
2) Collect, process & present related health information:

Collect cues and inform
ation – Here you review the patients current medical/surgical history and gather specific information on the present situation.
3) Process information:

This is where you pull all your data and cues together to interpret what is relevant and what is not; to analyse and consider if there is any other information you need about the patient’s current health status. This should include applying relevant information such as the pathophysiology, pharmacology, pathology etc that is relevant. When doing this, try and discriminate between the present health situation that needs immediate intervention (priority), and changes in health that should be considered later in the plan of care.
Once you have processed the information you move to the next stage of the clinical reasoning cycle, to predict an outcome:
4) Identify the problem:

Involves making a clinical decision about an actual or potential health problem that will determine the course of action that needs to be taken.
This is where you will examine the facts, link the information and establish a definitive problem/issue. (For your case study remember you will need to prioritise 3 problems/issues based on the health assessment data that you have identified for the person at the centre of care. What are their immediate needs?).
5) Establishing the goals/s:

Make a plan, this will be specific to each individual patient and focuses on achievable outcomes. For your case study you will need to prioritise care related to the identified problem / issue; a desired outcome, a time frame.
6) Take action:

This is where you follow through with the decided goals and plan. For the case scenario this is where you will discuss the nursing care that would be implemented for your patient, linking this to the assessment data and history.
7) Evaluate outcomes:

This is where you review the patient’s condition to see whether they have improved, and the goals of their plan of care have been met. For the case study remember that you will be evaluating the nursing care strategies to justify the nursing care provided.
8) Reflection:

Consider the interventions implemented, and establish what you have learnt, what went well and what could be improved. For the case study assessment – Reflect on the patient’s outcomes.
NRSG370 Assessment Task 2: Case Study – Medical/Surgical #1

Melody King, 36, Peritonitis following ruptured appendix

Ms. Melody King presented to the Emergency department with 2-3 days of severe Right Lower Quadrant abdominal pain, which required emergency laparoscopic surgery for removal of a ruptured appendix.

She has a past medical history of asthma and depression, with her current prescribed and compliant medications list which includes:

Ventolin
Seretide
Sertraline
Melody’s observations were as follows:

BP 95/45mmHg
HR 120
Temp 38.3°Celcius
RR 22/min and shallow
SpO2 95% on room air
She complained of increasing nausea and centralised abdominal pain 7-8 on a scale of 0 to10. Physical assessment showed a distended abdomen and generalised abdominal guarding. To investigate her condition further, pathology results reveal a raised white blood cell (WBC) count and CRP.

You are the RN caring for Melody post-operatively on the surgical ward.