Nursing Assignment: Case Study of John Wells and Clinical Reasoning

This nursing assignment presents a comprehensive case study of John Wells, an 82-year-old man admitted to the hospital following a bicycle accident. The assignment meticulously applies the clinical reasoning cycle, beginning with the initial assessment of the patient's situation, which includes behavioral changes, physical injuries, and a history of hypertension. The report then details the collection of cues and information through subjective and objective data, including vital assessments, the Glasgow Coma Scale, and the PERRLA test. The core of the assignment involves processing the collected information, analyzing potential causes for the patient's condition, such as head injury and hypertension, and linking these factors to observed symptoms like fatigue, nausea, confusion, and headache. The report also addresses the processing of test results (CT scan, MRI, cognitive tests) to understand the patient's cognitive abilities and brain function. Ultimately, the assignment demonstrates a clear application of the clinical reasoning cycle to diagnose and plan care for the patient, supported by relevant research and evidence-based practice.

Running assignment: NURSING ASSIGNMENT
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Name of the student:
Name of the university:
Author note:

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Consider the patient situation:
This is the first step of the clinical reasoning cycle, where the clinical situation of the
patient is considered. This assignment focusses on the case study of a 82 year old man john
wells, who has been admitted to the hospital due to behavioral change after an accident. He was
a farmer and resides in the rural areas with his wife. After assessing the Patient, it is found that
while coming from work on his cycle, he became unbalanced and hit his left side of the head
hard on the ground. His wife observed behavior change after his accident and asked his son to
take him to the hospital. He has a tear in his left side of the elbow and abrasion on the left
forearm. Apart from that he has not sustained any physical injury. Though according to the
patient, apart from the physical injury he is all right, his behavior indicates the sign of mental
illness. The patient has a past clinical history of hypertension for which he has not been
prescribed with any antihypertensive medication.
The primary complaints according to John and his son is fatigue, nausea, confusion, loss
of appetite, headache and quiet performance. Though he recently had an accident where his left
side of brain, which is responsible for the cognitive functioning of the body, got hit hard, there is
possibility that, the observed chief complaints is due to internal brain injury (Boyle et al. 2015).
Other possible cause behind his complications is hypertension. As the patient does not take any
antihypertensive medication, there are chances that due to high blood pressure, John became
unbalanced and met an accident (Xie et al. 2016).
Hence from the above it can be stated that there are two risk factors which can be
possible due to his current mental condition, one is hypertension and other is head injury. Due to
this the patient is having the headache followed with nausea and hazy.

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Collection of cues and information:
In this step of the clinical reasoning cycle, information regarding the patient’s medical
conditions is gathered to form an appropriate care plan (Dalton, Gee and Levett-Jones 2015)
To collect all the adequate information required, subjective and objective data of the
patient is collected (Douw et al. 2016). In the objective data the vital assessment of the patient is
conducted. In the vital assessment, blood pressure, pulse rate, respiratory rate, oxygen saturation
and body temperature is assesses. Upon assessing, it is observed that the body temperature of the
patient is optimal (37.6 degree Celsius) and has no signs of complications. The pulse rate (82
beats per minute) and the respiratory rate (17 breaths per minute) of the patient is also optimal
that is within the normal range. Observed oxygen saturation is also within the normal range that
is above 95% (Deschamps et al. 2016). Only the blood pressure of the patient is found to be
elevated enough and has reached 148/84 which is not within the normal range (120/80) (Flynn et
al. 2017). This signs area assessed on regular intervals to monitor the current health condition of
the patient and to observe the recovery process of the patient.
The subjective data of the patient is collected after interviewing the patient that includes
loss of appetite, hazy, headache, nausea, mild confusion, dizziness and low level of
consciousness. To appraise the severity of the subjective data collected, different assessment is
conducted.
Glass coma scale is conducted to assess the level of consciousness, of the patient. This
test is usually performed in the case of patient suffering from any brain injury or illness. The
level of consciousness of the patient is measured by assessing the motor response, verbal
response and eye response of the patient and based on that score is given to the patient. The score

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is assessed on the scale in between 3 to 15. If after assessment, the score of the the patient is less
than 8, the patient is stated to have low level of consciousness and chances of severe brain injury.
If the score is 9-12, the patient is stated to be suffering from moderate level of consciousness and
moderate brain injury and if the score is 13-15, it is considered as normal (Borgialli et al. 2016).
PERRLA test of the patient is also conduct to ensure that the patient had not sustained
any internal brain injury, as there are high chances of such internal injury during accident. In the
PERRLA test, internal cranial injury of the patient is assessed by observing the dilation if pupil
(Hoang et al. 2019)
Apart from that, cognitive test of the patient is also conducted as the patient is
experiencing balance complications. Along with it, CT SCAN, MRI and other test is also
performed to diagnose any other brain abnormality.
Processing the information:
This step of the clinical reasoning cycle aims to process the collected information from
the patient medical assessment. By the information, it is clearly evident that the one of the major
cause behind patient current condition is his age, hypertension and brain injury.
By observing the case of john, it can be stated that according to the patient, he has not
received any brain injury, but by observing the subjective and objective data of the patient, it is
concluded that the current behavioral change of the patient is due to the brain injury.
The patient is suffering from dizziness which is one of the primary symptoms of the brain
concussion. According to the research conducted by Sah et al. (2017) in the case of brain
concussion, balance, concentration, speech and cognitive ability of the patient get affected which

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is also observed in the case of john wells. The patient has also sustained several physical injuries
which is recorded in the pain scale as 4/10, that is the patient is suffering from moderate pain
During vital assessment, only the blood pressure of the patient is observed to be elevated
which is due to brain and other injury as the patient has the past clinical history of hypertension.
The loss of appetite, fatigue and hazy which is observed in the case of John is due to the high
blood pressure. As in the case of high blood pressure, the artery gets narrower and the heart has
to pump faster and hence has to work more to meet the demand of oxygen in the body which
leads to fatigue (Lewis et al. 2019).
The other complaints observed in the case of patient includes, headache which might be
also due to the high blood pressure as in the case if high blood pressure, the blood brain barrier
of the body gets effected posing additional burden in the brain leading to headache.
The other information which is collect during the health assessment of the patient is also
processed. In the above step, glass coma scale of the patient is conducted. Hence if the results of
the test are observed to be below 12, the patient is stated to be in having low level of
consciousness. From the PERRLA test, the cranial part of the brain is assessed and the result is
analyzed. The results obtained from CT scan and MRI is also processed to analyse the brain
function of the patient. The result obtained from the cognitive test of the patient is also observed
to ensure patient’s cognitive ability.
Hence, from the above, it is processed that the current mental and physical health
complication observed in the case of patient is due to the brain injury.

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Reference:
Borgialli, D.A., Mahajan, P., Hoyle Jr, J.D., Powell, E.C., Nadel, F.M., Tunik, M.G., Foerster,
A., Dong, L., Miskin, M., Dayan, P.S. and Holmes, J.F., 2016. Performance of the pediatric
Glasgow Coma Scale score in the evaluation of children with blunt head trauma. Academic
emergency medicine, 23(8), pp.878-884.
Boyle, C.P., Raji, C.A., Erickson, K.I., Lopez, O.L., Becker, J.T., Gach, H.M., Longstreth Jr,
W.T., Teverovskiy, L., Kuller, L.H., Carmichael, O.T. and Thompson, P.M., 2015. Physical
activity, body mass index, and brain atrophy in Alzheimer's disease. Neurobiology of aging, 36,
pp.S194-S202.
Dalton, L., Gee, T. and Levett-Jones, T., 2015. Using clinical reasoning and simulation-based
education to'flip'the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, The,
33(2), p.29.
Deschamps, A., Hall, R., Grocott, H., Mazer, C.D., Choi, P.T., Turgeon, A.F., de Medicis, E.,
Bussières, J.S., Hudson, C., Syed, S. and Seal, D., 2016. Cerebral Oximetry Monitoring to
Maintain Normal Cerebral Oxygen Saturation during High-risk Cardiac SurgeryA Randomized
Controlled Feasibility Trial. Anesthesiology: The Journal of the American Society of
Anesthesiologists, 124(4), pp.826-836.
Douw, G., van Zanten, A.R., van der Hoeven, J.G. and Schoonhoven, L., 2016. Nurses’‘worry’as
predictor of deteriorating surgical ward patients: a prospective cohort study of the Dutch-Early-
Nurse-Worry-Indicator-Score. International journal of nursing studies, 59, pp.134-140.

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Flynn, J.T., Kaelber, D.C., Baker-Smith, C.M., Blowey, D., Carroll, A.E., Daniels, S.R., de
Ferranti, S.D., Dionne, J.M., Falkner, B., Flinn, S.K. and Gidding, S.S., 2017. Clinical practice
guideline for screening and management of high blood pressure in children and adolescents.
Pediatrics, 140(3), p.e20171904.
Hoang, Q.V., 2019. Adult Eye Examination Techniques. In The Columbia Guide to Basic
Elements of Eye Care (pp. 27-36). Springer, Cham.
Lewis, T., 2019. The Heart. Univ of California Press.
Sah, P., 2017. The long-term impact of concussion. Sport Health, 35(1), p.34.
Xie, X., Atkins, E., Lv, J., Bennett, A., Neal, B., Ninomiya, T., Woodward, M., MacMahon, S.,
Turnbull, F., Hillis, G.S. and Chalmers, J., 2016. Effects of intensive blood pressure lowering on
cardiovascular and renal outcomes: updated systematic review and meta-analysis. The Lancet,
387(10017), pp.435-443.