ATHC 1 Assessment Two (2) Template - Desklib

ATHC 1 Assessment Two (2) template
Student Name: Devika gurung
Student Number: 12858585
Tutor Name:
Complete the following table using information from the assessment resources and Video A.
Clinical Reasoning Cycle
Consider the patient situation
In this section, providea
relevant and concise
description of your
observation of the context
and patient situation.
Sandra Smith, a 33 year old female presented to the emergency with
PV bleeding. HOH assessment is done. The patient is pale, diaphoric,
and dizzy when standing. Sandra is alert and oriented to time, place
and person. She is on best rest after coming to the hospital. She has
an intravenous cannula in her left hand. The site is not inflamed and
the dressing is proper. Menstrual pads are placed in situ and her IV
fluid is normal saline 0.9% 125 mls per hour. She has a PV loss of
500 mls per hour and there has been no bowel movement since the
past two days. Awaiting gynaecologist consultation and possible D
and C.
Collect cues and/or information
Review
Record current information
(eg handover, patient history
etc)
The patient has a history of endometriosis, hypotension, eczema,
childhood asthma. Previous hospital admission was for pain
management, laparoscopic incision of endometrial tissue via
diathermy, colonoscopy and appendectomy. Sandra has a 2 year old
child born PV. The patient is allergic to Codine and develops
hypotensive reaction when administered opioid for pain management.
The patient lives with her partner and child. She had consulted many
gynaecologists for alleviating symptoms of endometriosis. She had
undergone various medication management therapies.
Total - 100 words
1

Complete the following table using information from Video A. Support your answers with references.
Collect cues and/or information continued (150 words
Gather new information - In the video, the nursing student gathers the current vital signs – record this information
Recall knowledge - What do the vital signs measured by the nurse in the video mean
Cue
(vital sign)
Definition
Use your own words supported with
references
Factors that may affect this cue
Use your own words supported with references
Normal
range
(adult)
Terminology used to
describe abnormal
cue
Patient’s vital
sign
Respiratory
rate
Respiratory rate is the rate at
which breathing occurs.
Formally, it is the number of
movements indicative of
inspiration and expiration per
unit time (Holley et al. 2016).
Asthma, anxiety, pneumonia congestive
heart failure, use of narcotic, lung disease,
drug overdose, fever (Tavernie and
Jeanne, 2014).
12-20
breaths
per
minute
(bpm)
Bradypnea (low
respiratory rate) and
Tachypnea (high
respiratory rate)
29 bpm
Oxygen
saturations
Oxygen saturation is the fraction
of oxygen-saturated hemoglobin
relative to total hemoglobin
(unsaturated + saturated) in
the blood (Butcher et al. 2018)
Chronic obstructive pulmonary disorder,
smoking, pulmonary circulation,
emphysema,
95-
100%
Hypoxemia 95%
Heart rate
(pulse)
Pulse rate is the number of times
the heart beats in a minute
(Schroeder and Voss 2017).
Infection, stress, dehydration, thyroid
disorder, anaemia, shock and heart
conditions.
60-80
beats
per
minute
(bpm)
Arrhythmia 110 bpm
Blood
pressure
Blood pressure is the
measurement of the pressure or
force of blood against the
mercury. It is the measured by
Smoking, stress, cold temperature,
exercise, full bladder, caffeine, weight loss
or gain, salt intake (Chow et al. 2015)
120/80
mmHg
Hypotension (low
blood pressure) and
hypertension (high
blood pressure)
100/60
2

Collect cues and/or information continued (150 words
Gather new information - In the video, the nursing student gathers the current vital signs – record this information
Recall knowledge - What do the vital signs measured by the nurse in the video mean
Cue
(vital sign)
Definition
Use your own words supported with
references
Factors that may affect this cue
Use your own words supported with references
Normal
range
(adult)
Terminology used to
describe abnormal
cue
Patient’s vital
sign
systolic pressure and diastolic
pressure (Peng et al. 2017).
Temperature Body temperature is the
temperature of the body as
measured by placing the
thermometer in the anus, mouth
or under the armpit (Butcher et
al. 2018).
Dehydration, stress, exercise, thyroid
disorder (Knobel-Dail et al. 2017).
37
degree
Celsius
Hypothermia (low
body temperature) and
hyperthermia (high
body temperature)
38.5 C
Total - 300 words
3