ATHC 1 Assessment Three (3) template

ATHC 1 Assessment Three (3) template
Student Name:
Student Number:
Tutor Name:
Patient Name:
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 situation.
Mr smith who is 72 years old male suffering from multiple disorder
such as COPD (chronic obstructive pulmonary disease), type 2
diabetes, excessive weight loss and walking disability has been
admitted to hospital. He stays alone as Mr smith’s wife died two
years ago and their children has moved to their own place. He was
extremely jovial person but due to his family and medical condition
he was socially excluded.
Collect cues and/or information
Review / Gather / Recall
Record current
Mr smith is suffering from chronic obstructive pulmonary disease
(COPD). He also have type 2 diabetes because his body glucose level
1

information, new
information, knowledge
is 7.2 mmol which is more than the normal blood glucose level (less
than 6.9). Instead of that he usually skips his diabetes medicine. Due
to fracture in his ankle which happened around fifteen years ago, he
is suffering from walking disability and hence needs assistance of his
walking aids but then also he manages all his activities of daily living
by himself. He was also diagnosed with bowel cancer and hence
suffering from excessive weight loss and reduced appetite. Airway
path is patent that is no obstruction observed. respiratory rate is 22
beats per minute, pulse rate is 120 beats per minute, oxygen status is
95%, blood pressure is 90/55, patient is oriented to place and time,
and reacts to PEARL (pupils are equal and reactive to light), measured
pain score is 3/10, body temperature is 37 degree Celsius, no wounds or
skin degradation observed, last void recorded at 09.00 and Bowel Gastric
And Intestine also observed. blood glucose level noted as 7.2mmol. His
daughter is going to visit at the afternoon.
Process Information
Interpret
Analyse data and come to
understanding of
signs/symptoms
Tachypnea is observed as his respiratory rate is 22 beats per minute
which is increased than the standard Respiratory Rate (12- 20 beats
per minute) and also has hypotension and his blood pressure is 90/55
due to which he is feeling woozy. Tachycardia is observe as the pulse
rate is 120 beats per minute which is also more than the normal pulse
rate according to his age due to his medical condition. His body
temperature is 37 degree Celsius which is normal. He is suffering
from type 2 diabetes due to which his body glucose level is increased
and is observed as 7.2 mmol and normal body glucose level (less than
2

6.9 mmol). He is also not able to understand the language of the nurse
and hence lacks therapeutic relationship with the nurse.
Discriminate
Distinguish relevant from
irrelevant information
His body temperature is normal and hence there is no need to worry
about that. He has been observed with tachypnea and Tachycardia,
but it is due to his age and medical condition (Koenig et al., 2014).
The main focus is to manage his blood glucose level and blood
pressure due to which he is feeling weak and woozy.
Relate & Infer
Cluster cues, make
deductions or form
opinions
Increase in his respiratory rate is result of his arthritic pain. Due to
the pain, there is an increase in the secretion of hormone responsible
for stress which is directly related in increasing the heart rate of the
individual and due to which the pulse rate of the individual is
increased (Koenig et al., 2014). As he frequently skips his medicine
for diabetes, his BGl is increased which might be one of the reason
for his excessive weight loss (Davies et al., 2015).
Match
Match current situation to
past situations
His current situation both medical and physical has been deteriorated
from the past. Due to his bowel cancer, he is suffering from weight
loss and at the same time loss of appetite (Cozma-Petruţ et al., 2017).
Predict
Predict an outcome
Due to bowel disorder, he is unable to consume solid food and hence
is encouraged to give fluid intake (Cozma-Petruţ et al., 2017).
Identify problems / issues
Synthesise facts and
interferences and make a
definitive nursing
diagnosis
By observing the vital signs and symptoms it can be stated that, due
to diabetes and bowel disorder, he has been suffering from weightless
which leads to weakness and nausea. His arthritic pain should also be
reduced in order to manage his respiratory rate and pulse rate.
3