Clinical Reasoning Cycle for Mr. Cyril Smith

ATHC 1 Assessment Three (3) template
Student Name:
Student Number:
Tutor Name:
Patient Name: Mr. Cyril Smith
Complete the following table using information from Mr Cyril Smith’s story
Clinical Reasoning Cycle
Consider the patient situation
In this section, providea
relevant and concise
description of your
observation of the context
and patient situation.
The patient, Mr. Smith is 72 years old has recently been diagnosed with
bowel cancer and has been admitted to the surgical ward of the hospital. He
is scheduled for a bowel resection surgery tomorrow. Mr. Smith was active
and jovial, and he used to enjoy bowling but became lonely since his wife
and youngest child died in an accident. The GP noticed his weight loss,
decreased appetite. Also, the patient needs encouragement for fluid intake.
Mr. Smith feels weird, woozy and his mouth became dry.
Collect cues and/or information
Review / Gather / Recall
Record current information,
new information, knowledge
On the A-H assessment it was found that his airway was patent. His pulse
and respiratory rate is a little high and BP is low. He had a normal arthritic
pain however, his temperature was normal and his blood glucose level was
also under control as the assessment held at 14:00 hours when his meal
was over. He was last voided at 9:00 hours and bowel not opened. His
daughter will visit in the afternoon. Mr. Smith is using Metformin 500mg BD,
paracetamol1gmTDS, ibuprofen 400mg BD and salbutamol 4 puffs PRN as
medicine to control his chronic COPD, osteoarthritis and type II diabetes.
He was a smoker but since last 10 years he is not smoking. He uses
walking stick for mobilising as he had an ankle fracture 15 years ago.
Process Information
Interpret
Analyse data and come to
understanding of
signs/symptoms
On analysing the result found in the assessment it is clear that the normal
pain he is experiencing is due to osteoarthritis. Also, his mouth is becoming
dry as he needs encouragement with fluid intake. According to literature,
bowel cancer requires hydration (Currow et al. 2015). It is also causing
issues like loss of appetite and weight as a consequence.
Discriminate
Distinguish relevant from
irrelevant information
Information regarding the profession of his children is quite irrelevant in the
treatment procedure. Also, as is temperature is normal, it is not required to
consider in the treatment. Information related to the pupil is also irrelevant in
this case.
Relate &Infer
Cluster cues, make
deductions or form opinions
His weight and appetite loss is related to the bowel cancer. The other
symptoms such as shortness of breathing and pain are related to his
chronic health issues.
Match
Match current situation to
past situations
The assessment revealed that his respiratory rate is 22bpm which is more
than normal. However, the O2 saturation is 95% which is almost normal, as
he is taking salbutamol to control his chronic COPD. 15 years ago he had
an ankle fracture and his left leg is weaker due to that. He is taking
paracetamol and ibuprofen to control his pain of chronic osteoarthritis. In
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order to control blood glucose level (BGL), he also takes metformin and
upon assessment after meal his BGL was 7.2mmol which was normal.
Predict
Predict an outcome
His COPD and Blood sugar can cause issue after surgery if left
unmanaged.
Identify problems / issues
Synthesise facts and
interferences and make a
definitive nursing diagnosis
Synthesizing the facts found in the assessment it is clear that oral nutrition
and hydration is essential as his mouth is dry skin is also flaky. It is
important for patients with bowel cancer. His low blood sugar and breathing
issues should also be controlled prior to the surgery. Considering the
chronic diabetes, it is important to suggest proper diet which will be
beneficial for a patient with bowel issues.
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