ISP: Critical Care Nursing 92473
\nAssessment 1: Case Study – Information
\nName: Bryan Sim
\nMRN: 1234567.UTS
\nAge: 26 years
\nDate of Birth: 02\/02\/1994
\nWeight: ~70kg
\nAllergies: Nil known
\nNext of Kin: Dan (Friend)
\nOther: Non-English Speaking Background (NESB)
\nHistory: Normally fit and well
\nBryan is an international tourist from Korea, studying in Sydney.
\nSetting the Scene:
\nBryan 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.
\n____________________________________________________________________________________
\nAmbulance handover (call via Car 978)
\nI: Bryan Sim, 26 year-old male
\nM: Pulled from the surf at Bondi Beach unresponsive
\nI: Witnessed salt water near drowning with absent respiration and circulation. Submersion time unknown
\nS: Pulseless VT \u00ae
\nCPR & DC shock x 1 ROSC
\nIngested water +++
\nT: C-spine collar insitu
\nLog roll and suction of vomit
\nSpO2 90% in NRB Oxygen 100%,
\nCardiac monitoring \u2013 irregular sinus tachycardia, systolic 90 mmHg
\nConscious, responsive to voice (GCS 13\/15 – E3 V4 M6), speaks minimal English
\n14Fg cannula to right cubital fossa
\nETA approximately 5 minutes
\nFollowing handover, you complete a clinical assessment and collect the following vital signs:
\nStudents 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.
\nYou 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.
\nClinical Reasoning (2000 Words)
\n1. Consider the patient situation 5% (50 words)
\nProvide a relevant and concise description of your observation of the context and situation for Bryan
\n2. Collect cues and\/or information 5% (250 words)
\nReview \/ Gather \/ Recall: Review current information and gather new information. Support this information through the recall of knowledge
\n3. Process Information 25% (500 words)
\nInterpret: Analyse the clinical data and come to understanding of the signs \/ symptoms relevant to Bryan\u2019s presentation
\nDiscriminate: Distinguish the clinical information as either relevant or irrelevant to the current situation
\nRelate & Infer: Identify relationships in the clinical data that match the signs \/ symptoms of Bryan\u2019s presentation
\nPredict: Predict expectations of Bryan\u2019s current situation (if left untreated).
\nMatch: Match Bryan\u2019s current situation to the literature and clinical presentation
\n4. Identify problems \/ issues 15% (350 words)
\nSynthesise facts and interferences to make a definitive nursing diagnosis.
\n5. Establish goals 15% (300 words)
\nUsing the A-G approach, identify three immediate goals for Bryan at this time
\n6. Take Action 15% (200 words)
\nWhat actions will you take as a nurse in response to the goals identified?
\n7. Evaluate 15% (200 words)
\nAfter initiating your interventions, how will you evaluate their effectiveness?
\n8. Reflect 5% (150 words)
\nWhat have you learnt through this process that you will incorporate into your future clinical practice?
\nRADIOMETER ABG800 FLEX
\nABG800 UTSABL 1415 11\/03\/2020
\nSIMULATED PATIENT REPORT Syringe \u2013 S 250uL Sample #13268
\n________________________________________________________
\nIdentifications
\nPatient ID 1234567.UTS
\nPatient Last Name SIM
\nPatient First Name Bryan
\nDate of Birth 02\/02\/1994
\nSample Type Arterial
\nFiO2 100 %
\nT 34.5 oC
\n_________________________________________________________
\nAcid Base Status
\npH 7.28
\npCO2 52 mmHg pO2 62 mmHg sO2 86 %
\ncHCO3-(p)c 16.2 mmol\/L cBase(Ecf)c -3 mmol\/L
\nElectrolyte Values
\ncNa+ 138 mmol\/L cK+ 3.8 mmol\/L cCl- 110 mmol\/L cCa2+ 1.2 mmol\/L
\nMetabolite Values
\ncGlu 9.5 mmol\/L cLac 5.0 mmol\/L
\nOximetry Values
\nctHb 105 g\/L
\nFHHb – %
\nFO2Hb – % FMetHb – % FCOHb – % ctO2G – % BO2G – %
\n\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026
\nNotes
\nC Calculated Value(s)
\n__________________________________________________________
\n__________________________________________________________
\nPrinted 1415 11\/03\/2020
\nUser ID: RN 8457291<\/p>\n","protected":false},"excerpt":{"rendered":"
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