Clinical Reasoning Cycle and Vital Signs Measurement

Clinical reasoning
Student Name:
Student Number:
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, provide a
relevant and concise
description of your
observation of the context
and patient situation.
The patient is Sandra Smith, a 33-year-old female who presented with
per vaginal bleeding. She has an IV cannular in her left hand with a
normal saline IV fluid running at 125mls per hour. She has menstrual
pads in situ and has been on bedrest since admission.
Collect cues and/or information
Review
Record current
information (eg handover,
patient history etc,
She is passing 500mls of bleed per hour. She has a past history of
endometriosis, hypotension and childhood asthma. Previous
procedures included laparoscopic incision of endometrial tissue,
colonoscopy, and appendectomy. On assessment important positives
included elevated heart rate at 100 bpm, respiratory rate at 29,
temperature of 38.50Cand a pale diaphoretic appearance with pain of
8/10. She also has not passed urine since admission.
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
This is the measure of a persons
breathing per minute with one
respiration being an inspiration
and a corresponding expiration
(Flenady, Dwyer and
Applegarth, 2016)
Metabolic acidosis due to inadequate
perfusion causes a hyperventilation
as the patient tries to eliminate
excess acid (Mikhail, 2015).
12 -20
breaths/minut
e
Hyperventilation
Hypoventilation
29 breaths per
min
Oxygen
saturations
This is a measure of the amount
of oxygen in blood hence the
level that is delivered to tissues
(Jubran, 2015).
The metabolic acidosis make is hard
to maintain a high oxygen saturation
(Fein, 2014).
97 – 100% Hypoxemia 95 %
Heart rate
(pulse)
This is the measure of the how
fast the heart is beating with one
cycle being diastole plus the
corresponding systole. It is
measured by palpating the radial
artery for radial pulse (Oh, Hong
& Lee, 2016).
Due to blood loss and low perfusion,
there is a sympathetic nervous
system stimulation which causes the
release of catecholamine; adrenaline
and norepinephrine (Kreimeier,
2016). This causes vasoconstriction,
increased heart rate (above 100 bpm)
and increased heart contractility.
With this, there is adequate cardiac
output which increases the tissue
60 -100 bpm Tachycardia
Bradycardia
110 bpm
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
perfusion.
Blood
pressure
His is the measure of the
pumping force of the heart
against the resistance of the
blood vessels (Guyton, 2015)
The blood pressure remains normal
as compensation is occurring. There
is activation of the renin-
angiotensin-aldosterone system that
leads to increased anti-diuretic
production which in turn causes
water retention. However, with
increasing blood loss the pressure
will fall as vasodilation due to
anaerobic respiration occurs (Hinkle
& Cheever, 2013)
130 to 90/85 Hypertension
hypotension
100/60 mmHg
Temperatur
e
This is a measure of the bodies
hotness or coldness and gives an
indication of the bodies core
temperature (Kushimoto et al,
2014)
Brain hypoperfusion due to
haemorrhage resets the core body
temperature imparing normal
thermoregulation (Balk, 2015).
36.5 to 37.20C Hypothermia
Fever
38.50C
Total - 300 word
3