CNA 252 Assignment 2: Developing a Nursing Care Plan and Reflection

This assignment centers on the development of a nursing care plan for a 45-year-old patient, Carol Jones, presenting with breathlessness, nausea, chest pain, hypertension, and tachycardia, potentially indicating acute coronary syndrome. The assignment requires students to utilize the clinical re...Read More

Scenario 1: Carol Jones
Consider the patient
situation
Carol Jones, 45 years old, is away on an interstate business trip and presented to a GP clinic on the outskirts of the Flinders
Ranges in South Australia. Her main concern is feeling breathless and nauseated. She also complains of occasional chest
pain which goes away when she rests. Her BP is 170/93 mmHg and she is mildly tachycardic. The GP on duty reassures her
and suggests she follow up with her regular GP upon her return home. However, as Carol is leaving the clinic she suddenly
experiences an episode of breathlessness. You, the Practice Nurse on duty, witness this and notice that Carol is pale. When
you check her pulse, it is 160 bpm and irregular.
Collect Cues: Review the existing documentation;
Social History
Carol Jones is a consultant engineer specialising in concrete structures for bridge construction. This requires her to travel
interstate frequently for long periods visiting construction sites. Carol has recently separated and has 5 children ranging from
6 to 18 years of age who reside with their father when Carol is away. Carol’s busy lifestyle precludes her from daily exercise
and much of her dietary intake when she is away is ‘on the run’ takeaway fast-food and alcohol – she states that she has ‘a
beer at lunch and a couple of glasses of wine in the evening to help me relax after a hectic day’. Carol is a non-smoker and
denies any use of recreational drugs.
Recall:
Before you continue with this assignment you should recall and apply your existing knowledge to the above situation to
ensure you have a broad understanding of what is/may be occurring.
Process information Interpret:
In the following table, list the data that you consider to be normal/abnormal (not included in word count)
Normal (Subjective & Objective Data) Abnormal (Subjective & Objective)
Objective Objective
Breathlessness
Nausea

Scenario 1: Carol Jones
Subjective Mild tachycardia
Subjective
Blood Pressure 170/93 mm/Hg (Normal BP: 160/80 mm/Hg)
Pulse rate 160 beats per minute (Normal: 60-100 bpm)
Relate & Infer: (250 words)
 Relate: cluster cues by identifying relationships between them.
• Infer: make deductions as to why a cue, or a cluster of cues may be considered abnormal in this context. Justify by
referring to appropriate anatomy, physiology and pathophysiology.
Refer to Levett-Jones (2018) Clinical Reasoning p7.
•Based on your interpretation of all the information/cues presented, form and justify an overall opinion on what may
be happening
The patient is experiencing sudden episodes of breathlessness and feels nauseated most of the time. She complains of chest
pain, which goes away after she takes rest. According to a study conducted by Simon et al. (2013), episodes of sudden
breathlessness can be an indicator of chronic heart failure or chronic pulmonary disease. Sudden episodes of breathlessness
along with occasional chest pain that goes away while resting can indicate irregular or decreased blood flow in the coronary
arteries. Upon primary inspection of the vital signs, it has been observed that the patient’s blood pressure reading is 173/93
mm/Hg. The normal blood pressure of a human being of 45 years old should be around 120/80 mm/Hg (Currie et al. 2018). As
the systolic pressure of the patient is between 160-180 mm/Hg and diastolic pressure is slightly lower than 100 mm/Hg, it is
evident that the patient is having higher blood pressure, which highly elevated than the normal levels. The blood pressure of
173/93 mm/Hg is indicator of hypertension stage 2. Stage 2 hypertension is more severe form of hypertension, in which the
health care professionals might recommend lifestyle changes to the patient and prescribe medications to address the issue

Scenario 1: Carol Jones
(Yano et al. 2018).
Moreover, the patient has pulse rate of around 160 beats per minute and irregular, which is highly elevated than normal
maximum levels of 100 beats per minute while resting (Hart 2015). The patient is observed to be pale with mild tachycardia.
Analysing all the cues it can be inferred that the patient is suffering from acute coronary syndrome and requires immediate
medical attention.
Predict: (100 words)
Explain what may happen to your patient if no action is taken
Acute coronary syndrome is a life-threatening condition which can prove to be fatal if left untreated. In this condition, the blood
supply to the heart is not sufficient, leading to a condition called tachycardia (Sanchis-Gomar et al. 2016). Tachycardia is the
medical condition where the heart beats goes above 100 beats per minute to meet up the deficit in the heart caused by
interruptions in coronary arteries (Nursing Times 2017). If left untreated, acute coronary syndrome shows several
complications including arrhythmias (electrical dysfunction), mechanical dysfunctions such as heart failure, papillary muscle
dysfunction or myocardial rupture, thrombotic complications and inflammatory complications such as pericarditis (MSD
Manual Professional Edition 2019).
Identify the
Problem/s
List in order of priority at least two key nursing problems (not included in word count)
1. The patient is experiencing anxiety due to increased risk of myocardial infarction or coronary syndrome evident by
episodes of breathlessness, chest pain, and pale face.
2. The patient has increased cardiac output evidenced by hypertension stage 2, mild tachycardia, and chest pain.
Establish Goal &
Take Action
For your (ONE) highest priority nursing problem: (300 words)
 Establish one goal
 List the related FOUR (4) actions you would undertake to achieve that goal. Your actions should include ONE (1) skill
only from the following list; 1) 12 Lead ECG and interpretation, 2) Venipuncture and sample handling, 3) Oxygen
therapy, 4) Pulse oximetry.

Scenario 1: Carol Jones
 Provide a rationale that associates the pathophysiological and psychological principles with each selected nursing action
 Describe how you would evaluate the effectiveness of the care provided (i.e. how will you know that your actions were
beneficial to the patient?).
Problem Goal Related actions Rationale Evaluate outcomes
The patient has
increased cardiac
output evidenced by
hypertension stage 2,
mild tachycardia, and
chest pain.
The patient is
manifesting:
Tachycardia
Chest pain
Nursing Diagnosis:
Acute pain in the chest
and extreme
breathlessness
Fear or anxiety
Expression of worry
.
Relive pain and
distress of the patient
and restore the normal
input values to the
heart with regular
blood flow.
After 8 hours of
nursing intervention,
the patient will feel
relieved of chest pain
with reduced breathing
problems and anxiety.
Heart Rate monitoring
Administering
medications including
aspirin.
Venepuncture or
phlebotomy required
to get blood sampling.
Identify and
acknowledge patient’s
perception of situation
and threat. Encourage
positive expressions
and avoid
confrontations
(Zimmermann et al.
2016).
Answer all the
patient’s queries
factually.
Heart rate monitoring
provides real time
indication of patient’s
heart condition.
Administration of non-
enteric coated
chewable aspirin is
preferred as it helps to
achieve higher
therapeutic levels suer
to rapid absorption into
the blood stream
(Yonetsu et al. 2017).
The cause of anxiety
in the patients is highly
variable and may
include anxious family
members, acute pain
or illness.
Acknowledging
patient’s queries and
answering them
factually increases
patient satisfaction
and decreases
anxiety. Positive
expressions are
Post 8 hours of
nursing intervention,
the nurse will address
the client and assess
the reduction of
anxiety.
With successful
intervention by the
nurses, it can be
expected that the
patient will be
observed with
increased social
interaction (Hatef
Partovi et al. 2018).

Scenario 1: Carol Jones
smoothening.
Unresolved anxiety
increases the
myocardial oxygen
consumption and risks
the patient’s safety
and health outcome,
suffering from acute
coronary syndrome.
Evidenced based
skill assessment
and reflection
Justify and rationalise your choice of skill (not included in word count)
Venepuncture is an important medical procedure performed by the nurses to draw sample of blood or prepare for an
intravenous injection. Venepuncture procedure in acute coronary syndrome requires extreme care as only a vacutainer with a
needle/butterfly or cannula into a rust bottle is recommended to be used (Coventry et al. 2019).
Watch the video of the clinical skill performance which you have chosen from the list provided above. Analyse and critically
reflect on skill performance in the video you have chosen, using the skill checklists in (Tollefson 2019). Discuss 1 (ONE)
strength and 1 (ONE) weakness that you have identified in the skill performance. Discuss in relation to the Registered Nurse
Standards for Practice. (150 words)
Strength Weakness
 The nurse competently identifies indication and
initiates procedure as per the requirement and
instructions from the supervisor. In addition to this, the
nurse provides a clear explanation of the
venepuncture medical procedure to the patient, which
is evident of the therapeutic interaction that the nurse
has been able to establish with the patient (Chan et
 The nurse fails to gather all necessary equipment
required for venepuncture procedure and forgets to
wear gloves during the medical procedure of
venepuncture. It is important that the nurse gathers all
necessary equipment that might be needed while
performing the medical procedure. Moreover, not
wearing gloves while performing the procedure is a

Scenario 1: Carol Jones
al. 2018).Therapeutic relationship is essential in a
nurse and patient interaction as it helps in initiation of
beneficial change in the client. With therapeutic
relationship well established, the nurse and the client
show mutual respect to each and the nurse can
essentially assist with the gratification of patient’s
spiritual, emotional and physical needs.
serious and unprofessional practice by the nurse.
Without gloves in hand, the nurse increases the risk of
patient getting affected by nosocomial infection
(Ghorbani et al. 2016). To eliminate such
complications, it is important that the nurses increases
their hand hygiene compliance and ensure it in clinical
practice.
Reflecting on the video performance, discuss what two (2) actions you will take to address their performance in the promotion
of positive health outcomes. Reflecting on the clinical reasoning cycle, how has this reinforced your professional responsibility
as a beginning level practitioner and informed your future learning? (200 words)
Upon assessing the performance of the nurse in the video, several cues of negligence and inappropriate nursing practice can
be highlighted. The patient is suffering from acute coronary syndrome, which is determined after analysis of patient’s health
symptoms and vital signs. The cues which indicate improper nursing clinical practice includes not wearing gloves during
medical procedure of venepuncture, not gathering all required equipment before the start of the procedure, not removing the
tourniquet post withdrawal of needle, and not cleaning, replacing or disposing the equipment post procedure completion. To
address these issues, it is important that the nurse is made aware of the clinical practice guidelines. Proper education
regarding hand hygiene is extremely important to increase hand hygiene compliance and eliminate any risk of nosocomial
infections in the patient.
Following the clinical reasoning cycle, significant improvement in decision making has been observed. The process is cyclical
and systematic, which helps the nurses to take informed clinical judgements in the emergent, non-routine and unpredictable
situations. Following such practice has helped me to reinforce my professional responsibility of ensuring clinical judgments
during unpredictable situations, which are in the best interest of the patient.

Scenario 1: Carol Jones
Reference: Levett-Jones, T 2018, Clinical reasoning: learning to think like a nurse, 2nd ed, Pearson Australia

Scenario 1: Carol Jones
References
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coronary syndrome patients living at high vs low altitudes in Yemen. Medscape General Medicine, 8(4), p.28.
Chan, E.A., Wong, F., Cheung, M.Y. and Lam, W., 2018. Patients' perceptions of their experiences with nurse-patient communication in oncology settings: A
focused ethnographic study. PloS one, 13(6), p.e0199183.
Coventry, L.L., Jacob, A., Davies, H., Stoneman, L., Keogh, S. and Jacob, E., 2019. Drawing blood from peripheral intravenous cannula compared with
venepuncture: A systematic review and meta analysis.‐ Journal of advanced nursing.
Currie, K.D., Floras, J.S., La Gerche, A. and Goodman, J.M., 2018. Exercise Blood Pressure Guidelines: Time to Re-evaluate What is Normal and
Exaggerated?. Sports Medicine, 48(8), pp.1763-1771.
Ghorbani, A., Sadeghi, L., Shahrokhi, A., Mohammadpour, A., Addo, M. and Khodadadi, E., 2016. Hand hygiene compliance before and after wearing gloves
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Hart, J., 2015. Normal resting pulse rate ranges. J. Nurs. Educ. Pract, 5(8), pp.95-98.
Hatef Partovi, L., Zohari Anboohi, S., Barzabadi Farahani, Z. and Mansouri, S., 2018. Comparison of acute coronary syndrome patients with anxiety regarding
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Available at: https://www.msdmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/complications-of-acute-coronary-syndromes
[Accessed 15 Jan. 2020].
Nursing Times. 2017. Diagnosis, management and nursing care in acute coronary syndrome |. [online] Nursing Times. Available at:
https://www.nursingtimes.net/clinical-archive/cardiovascular-clinical-archive/diagnosis-management-and-nursing-care-in-acute-coronary-syndrome-13-02-
2017/ [Accessed 15 Jan. 2020].
Sanchis-Gomar, F., Perez-Quilis, C., Leischik, R. and Lucia, A., 2016. Epidemiology of coronary heart disease and acute coronary syndrome. Annals of
translational medicine, 4(13).
Simon, S.T., Higginson, I.J., Benalia, H., Gysels, M., Murtagh, F.E., Spicer, J. and Bausewein, C., 2013. Episodes of breathlessness: Types and patterns–a
qualitative study exploring experiences of patients with advanced diseases. Palliative medicine, 27(6), pp.524-532.

Scenario 1: Carol Jones
Yano, Y., Reis, J.P., Colangelo, L.A., Shimbo, D., Viera, A.J., Allen, N.B., Gidding, S.S., Bress, A.P., Greenland, P., Muntner, P. and Lloyd-Jones, D.M., 2018.
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Yonetsu, T., Lee, T., Murai, T., Kanno, Y., Hamaya, R., Ichijo, S., Niida, T., Hada, M., Araki, M., Matsuda, J. and Usui, E., 2017. Association between prior
aspirin use and morphological features of culprit lesions at first presentation of acute coronary syndrome assessed by optical coherence
tomography. Circulation Journal, 81(4), pp.511-519.
Zimmermann, T., Puschmann, E., van den Bussche, H., Wiese, B., Ernst, A., Porzelt, S., Daubmann, A. and Scherer, M., 2016. Collaborative nurse-led self-
management support for primary care patients with anxiety, depressive or somatic symptoms: Cluster-randomised controlled trial (findings of the SMADS
study). International journal of nursing studies, 63, pp.101-111.