CNA155 Clinical Reasoning Report Assignment-Tasmania University Australia.

Harvard Australian Refences (8 needed)
Zac Smyth is 18 year old university student who lives on-campus as his parents reside in another state. Zac is studying engineering and enjoys university life. Zac has a part-time job working at the local supermarket for 15 hours each week. Zac has no immediate family in the state but he has a friend of his parents that he sees from time to time. Zac usually goes home to his family during his breaks but due to his work commitments, Zac has not seen his mum, dad and younger brother for the past 4 months.
CNA155 Clinical Reasoning Report Assignment-Tasmania University Australia.

CNA155 Clinical Reasoning Report Assignment-Tasmania University Australia.

Last evening Zac went out to the local pub with a few friends from university. There was a new band playing at the pub and Zac was especially excited to be going. To save money Zac and his friends met up at a friend’s house for ‘pre-drinks’. During this time Zac drank around four full
strength beers.

When Zac and his friends arrived at the pub, they headed straight for the bar to get another beer. Zac and his friends were having a great night, the music was good and the pub was busy.

Later in the evening Zac started talking to a friendly young woman, shortly after Zac was approached by a man who aggressively accusing Zac of talking to his girlfriend. Zac apologised and returned to his group of friends. Approximately an hour later Zac said goodbye to his friends as he decided to head home.

As Zac was leaving the pub he was followed out by the man who had earlier confronted him. The man was still verbally aggressive and ended up pushing Zac to the ground, resulting in Zac hitting his head on the cement curb of the road. The security guard saw this incident and intervened. Whilst Zac was not punched, he did sustain a laceration to the back of his head. The security guard noticed quite a bit of bleeding and rang an ambulance.

CNA155 Clinical Reasoning Report Assignment-Tasmania University Australia.

CNA155 Clinical Reasoning Report Assignment-Tasmania University Australia.

When the ambulance arrived, Zac had a GCS of 15 and could recall the whole incident. Zac appeared to have no other injuries. The paramedics undertook vital sign which they stated were ‘normal’ and applied a bandage to Zac’s head wound. The security guard stated that he ‘didn’t
think Zac lost consciousness’.

18 year old male, brought in by ambulance following an alleged altercation where patient struck head on road curb at 2300 hrs. Patient is denies loss of consciousness but unable to recall all events. Patient appears alert but teary. On examination, 4cm laceration noted with slow ooze from wound. Dressing insitu. Vital signs and GCS recorded at 2325 hrs as per chart. No other obvious injuries. Patient denies drug use, states has hadm approximately ‘five beers since 7pm’.Breath alcohol taken at 2330 hours 0.06%. Patient reports pain to be 5/10 at occipital region, no analgesia taken prior to presentation. Patient states is usually fit and well.

Vital signs
Blood Pressure: 141/88 mmHg
Heart Rate 90 beats/minute
Respiratory Rate 17 breaths/minute
Pulse Oximetery 99% on room air
Temperature 36.0 c (tympanic)

Glasgow Coma Scale
Eyes 4
Verbal 4
Motor 6

Head Wound
4 cm laceration to the occipital region, small amount of blood oozing from the wound. May require sutures/staples.

Past medical history
Childhood asthma, up-to-date with immunisations (last tetanus 12 months ago). Not on any medications and no known allergies.

Clinical Reasoning Report
For this assessment item you will be required to write a clinical reasoning report, demonstrating your understanding of the clinical reasoning cycle by applying the first three components of the cycle to the case of Zac (case study document below). In this report you will be required to:

a) Consider the patient situation:
This requires you to study the patients profile in the case and consider how it shapes your clinical reasoning.

Discuss what is significant about the patient’s age, gender, social situation and medical history, making links to their chief complaint. Also consider what risk factors are present in relation to the chief complaint. Remember that age, gender, social situation and medical history influence the likely health outcome.

b) Collect cues and information:
Review the available information
 The patient’s notes from the emergency department.
 The background information in the case study.
 The subjective and objective data and differentiate normal from abnormal.
 Propose new assessment data/cues to collect and describe the nursing assessments that you will use to collect those cues, as well as the frequency with which those assessments need to be performed.
 Link the nursing assessments to a clear understanding of what is occurring from a functional and structural perspective within the brain. Making these links requires you to recall knowledge of the bio scientific principles underlying the case.

CNA155 Clinical Reasoning Report Assignment-Tasmania University Australia.

CNA155 Clinical Reasoning Report Assignment-Tasmania University Australia.

c) Process the information:
Relate and Infer: Cluster the cues in the case to identify and support the problem that you think might be occurring with the patient. From what you know about the patient’s background, the cues that you have clustered, and the signs and symptoms they are experiencing, explain your interpretation of their condition. In other words, what do you think is going on?

How to approach this assessment iteam
Ensure that you answer the questions and avoid simply providing generic information. You must continually link back to the patient and their condition. Do not expect the marking staff to make the connections between the information that you provide. You must make them explicitly yourself so that it is clear that you understand every element of what you have written. Also, don’t lose the patient in your answer – their condition and the positive health outcomes that you intend for them need to be the clear focus throughout. 

Please consider yourself to be the registered nurse on duty, and the first nurse to provide care to the patient after he was triaged. Ensure that you remain within your scope of practice as a registered nurse. It is expected that you will identify and describe a minimum of three nursing
assessments of greatest priority, and justify your decision by linking the assessments back to the cues and underlying pathophysiology of the patient’s presentation. 

CNA155 Clinical Reasoning Report Assignment-Tasmania University Australia.

CNA155 Clinical Reasoning Report Assignment-Tasmania University Australia.

Headings and tables may be used in this assignment. If you do utilise tables, remember that the information within the table will need to be discussed in greater detail and linked back to the your patient.

Please ensure you support your statements and assertions with either contemporary (less than ten years since publication) literature or appropriate clinical guidelines. This is important as the references add value to your statements.

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