Assessment and Therapeutic Health Care 1

ASSESSMENT AND THERAPEUTIC HEALTH CARE 1 1
Assessment and Therapeutic Health Care 1
Student’s Name
Institutional Affiliation
Professor’s Name
City
Date

ASSESSMENT AND THERAPEUTIC HEALTH CARE 1 2
Complete the following table using information from Mr Cyril Smith’s story
Clinical Reasoning Cycle
Consider the patient situation
In this section, provide a
relevant and concise
description of your observation
of the context and patient
status.
Mr Smith is the patient who is 72 years old and has presented to the
health facility after he had a current colonoscopy which lead to an
examination of bowel cancer. He has been slated for an operation for a
bowel resection the next day. According to GP, he has lost some weight,
reduced appetite and needs motivation with fluid uptake. His oxygen
saturation, temperature, blood sugar level and blood pressure are okay, and
the last voided at 09:00, BNO today. He has a history of type II diabetes
which is diet controlled, osteoarthritis and Chronic Obstructive Pulmonary
Disease. He has been alone since Joy, and Nelson passed away. His
daughter should be in later today in the afternoon.
Collect cues and information
Review / Gather / Recall
Record current information, new
information, knowledge
Review the current information
Mr Smith’s current observations are;
 A pulse rate of 120 bpm
 The oxygen saturation level of 95%
 BGL 7.2 mmol/l
 Temperature 37 C
 Respiratory rate of 22 bpm

ASSESSMENT AND THERAPEUTIC HEALTH CARE 1 3
 Blood pressure 90/50
Mr Smith has a history of type II diabetic which is diet controlled,
osteoarthritis and Chronic Obstructive Pulmonary Disease.
Gather new information
Condition of oral mucosa- dry mouth
Thirst- the patient, requests for a drink.
Skin turgor- skin is dry and flaky
Appetite- Nil
Pain- arthritic pain of a score of 3/10
Cognitive state- Oriented to time and place, pupils are equal and reactive
to light.
Recall knowledge
Being alone considering Joy and Nelson’s demise, his condition
results in a lack of ability to eat because he has no appetite thus lowering
bowel movements.
Process Information
Interpret
Analyze data and come to an
understanding of signs/symptoms
A regular respiratory rate should not go beyond 20 bpm.
Therefore, it is clear that Mr Smith may be suffering from tachypnoea a
condition where a person suffers from faster respirations. Furthermore, his
pulse rate being 120 bpm is high which is familiar to people with a history
of COPD and when a person is dehydrated like Mr Smith who has a dry