critcareassess1
Clinical reasoning case study
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ISP: Critical Care Nursing 92473
Assessment 1: Case Study – Information
Name: Bryan Sim
MRN: 1234567.UTS
Age: 26 years
Date of Birth: 02/02/1994
Weight: ~70kg
Allergies: Nil known
Next of Kin: Dan (Friend)
Other: Non-English Speaking Background (NESB)
History: Normally fit and well
Bryan is an international tourist from Korea, studying in Sydney.
Setting the Scene:
Bryan Sim is a 26 year old male, pulled from Bondi Beach unresponsive requiring CPR and defibrillation before
having return of spontaneous circulation (ROSC) after approximately 6-8 minutes. Ryan is then transported to
the hospital where you are the receiving nurse. It is Thursday afternoon, 11th March 2020. You are working in
the Emergency Department when you receive the following phone (BAT) Call from the ambulance paramedic
enroute with patient Bryan Sim.
____________________________________________________________________________________
Ambulance handover (call via Car 978)
I: Bryan Sim, 26 year-old male
M: Pulled from the surf at Bondi Beach unresponsive
I: Witnessed salt water near drowning with absent respiration and circulation. Submersion time unknown
S: Pulseless VT ®
CPR & DC shock x 1 > ROSC
Ingested water +++
T: C-spine collar insitu
Log roll and suction of vomit
SpO2 90% in NRB Oxygen 100%,
Cardiac monitoring – irregular sinus tachycardia, systolic 90 mmHg
Conscious, responsive to voice (GCS 13/15 – E3 V4 M6), speaks minimal English
14Fg cannula to right cubital fossa
ETA approximately 5 minutes
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Following handover, you complete a clinical assessment and collect the following vital signs:
Airway
• Clear
• Bryan is mumbling when asked questions by his friend, nil adventitious sounds
Breathing
• Bilaterally equal air entry with bi-basal crackles, decreased at bases, symmetrical
chest movements
• Use of accessory muscles
• Intercostal and subcostal recession
• RR 24 bpm (irregular)
• SpO2 92%
• Non-rebreather mask insitu at 15L/min
Circulation
• Heart Rate 142 bpm
• Blood Pressure 97/54 mmHg
• Pale Pink in colour
• Centrally cool to touch, peripherally cold and mottled
Disability
• Opens eyes spontaneously
• Patient moaning
• Incomprehensible sounds
• Flexion to painful stimuli
• Pupils R/L 5+
Exposure
• Temperature 34.5 degrees (axillar)
• Nil rash, bruises or other concerns noted
• 14fg PIVC insitu to right cubital fossa – VIP Score = 0, dressing dry and intact
• Wet board shorts insitu
Fluids
• 300ml stat dose 0.9% Sodium Chloride administered intravenously
• Infusion insitu however, currently clamped for transfer from Ambulance
stretcher to ED
Glucose
• BGL: 9.5 mmoLs
Social Friend, Dan is present and assisting with interpretation
Students are required to apply the Clinical Reasoning Cycle by Levett-Jones, T. (ed) 2018 to the case study of
Bryan Sim and demonstrate their ability to analyse patient information that supports the provision of best
practice nursing care. Students will need to draw upon their understanding of comprehensive patient
assessment and prioritisation of patient care needs. Students will then describe how they will interact and
deliver the appropriate nursing care to the patient with near drowning.
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You may use this to help you structure your assessment. This is not a formal essay, however, referencing
guidelines still apply. Percentage of marks is applied to each section with suggested word count.
Clinical Reasoning
(2000 Words)
1. Consider the patient situation 5% (50 words)
Provide a relevant and concise description
of your observation of the context and
situation for Bryan
2. Collect cues and/or information 5% (250 words)
Review / Gather / Recall: Review current
information and gather new information.
Support this information through the recall
of knowledge
3. Process Information 25% (500 words)
Interpret: Analyse the clinical data and
come to understanding of the signs /
symptoms relevant to Bryan’s presentation
Discriminate: Distinguish the clinical
information as either relevant or irrelevant
to the current situation
Relate & Infer: Identify relationships in the
clinical data that match the signs /
symptoms of Bryan’s presentation
Predict: Predict expectations of Bryan’s
current situation (if left untreated).
Match: Match Bryan’s current situation to
the literature and clinical presentation
4. Identify problems / issues 15% (350 words)
Synthesise facts and interferences to make
a definitive nursing diagnosis.
5. Establish goals 15% (300 words)
Using the A-G approach, identify three
immediate goals for Bryan at this time
6. Take Action 15% (200 words)
What actions will you take as a nurse in
response to the goals identified?
7. Evaluate 15% (200 words)
After initiating your interventions, how will
you evaluate their effectiveness?
8. Reflect 5% (150 words)
What have you learnt through this process
that you will incorporate into your future
clinical practice?
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RADIOMETER ABG800 FLEX
ABG800 UTSABL 1415 11/03/2020
SIMULATED PATIENT REPORT Syringe – S 250uL Sample #13268
________________________________________________________
Identifications
Patient ID 1234567.UTS
Patient Last Name SIM
Patient First Name Bryan
Date of Birth 02/02/1994
Sample Type Arterial
FiO2 100 %
T 34.5 oC
_________________________________________________________
Acid Base Status
pH 7.28
pCO2 52 mmHg
pO2 62 mmHg
sO2 86 %
cHCO3-(p)c 16.2 mmol/L
cBase(Ecf)c -3 mmol/L
Electrolyte Values
cNa+ 138 mmol/L
cK+ 3.8 mmol/L
cCl- 110 mmol/L
cCa2+ 1.2 mmol/L
Metabolite Values
cGlu 9.5 mmol/L
cLac 5.0 mmol/L
Oximetry Values
ctHb 105 g/L
FHHb – %
FO2Hb – %
FMetHb – %
FCOHb – %
ctO2G – %
BO2G – %
………………………………………………………………………………………………………………
Notes
C Calculated Value(s)
__________________________________________________________
__________________________________________________________
Printed 1415 11/03/2020
User ID: RN 8457291
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