Clinical Reasoning Cycle for Patient Assessment

ATHC 1 Assessment Two
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Video A.
Clinical Reasoning Cycle
Consider the patient situation
Description of patient
situation.
This case assesses patient Sandra Smith, currently admitted with
heavy bleeding. The patient is weak and fatigued and experiencing
elevated blood pressure, increased heat beat rate and elevating fever.
The patient is experiencing general body weakness and experiences
increased degrees of pain which are hampering his state. The patients
need adequate close monitoring and observation.
Collect cues and/or information
Patient current information The case involves patient Sandra Smith aged 33 years. The patient
has a clinical history of endometriosis, hypotension, and eczema and
childhood asthma. Her vital states indicate;
RR – 29BPM
SpO2- 95%
DR – 110 bpm
Colour- pale and diaphoretic and dizzy
The patient is allergic to codeine and often hypotensive when given
opioids for pain management.
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Video A
Collect cues and/or information continued
Cue
(vital sign)
Definition Factors that may affect this cue Normal range
(adult)
The terminology
used to describe
abnormal cue
Patient’s vital
sign
Respiratory
rate
This refers to the number of
beats being breath per minute.
Respiratory is measured during
rest time and entails counting of
breaths for one minute by the
number of chess rises (Charlton
et al., 2018).
Can be increased with increased
level of fever, illness or other
underlying medical condition
(Karlen, Raman, Asermino &
Dumont, 2013)
12-20 breaths
per minute
Various terminologies
are used; apnea,
dyspnoea,
hyperpnoea,
hypopnoea,
bradypnea
29 beats per
minute
Oxygen
saturation
Oxygen saturation rate refers to
the hemoglobin in the blood.
The ability of the human body is
regulating the key balance of
oxygen in the blood (Collins et
al., 2012).
Health conditions state; underlying
health conditions which have effects
on the organ function (Perea, Al-Ali
and Kiani, 2017).
95-100% Hypoxemia 95% at room
temperature
Heart rate
(pulse)
Heart rate refers to the number
of contractions or beats
occurring in the heart per
minute. The heart rate can vary
depending on body needs
(Mustonen & Pantzar, 2013).
Activities and changes such as
physical exercise, anxiety, stress,
illness can lead to elevated levels
(Aladin et al., 2014)
60-100 bpm Arrhythmia. 110 beats per
minute
Blood
pressure
Blood pressure refers to the
circulating blood located on
blood vessels walls. Most of the
pressure is occasioned by the
Blood pressure is influenced by the
output of the cardiac, total
peripheral resistance and stiffness of
the arterial. Changes in the levels are
120-129/80-84 Hypotension- low
levels
Hypertension – high
100/65
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Collect cues and/or information continued
Cue
(vital sign)
Definition Factors that may affect this cue Normal range
(adult)
The terminology
used to describe
abnormal cue
Patient’s vital
sign
pumping action of the heart in
the circulatory system (Grim &
Grim, 2016).
affected by emotional state, activity
levels, death or disease state (Alpert,
Quinn & Gallick, 2014).
levels
Temperatur
e
Temperature refers to the state
of the body giving an
assessment of thermoregulation
which is normally tightly
regulated. It alters the chemical
reactions and is maintained
through heat balance (Lorenz et
al., 2009)
State of the body dictates the patient
body temperature. Underlying
condition of fever or underlying
health state (Vivekanantham et al.,
2017).
38 °C/100.4 °F Hyperthermia-
elevated levels
Hypothermia-
increased levels
38.5°C
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