Strategies for Collecting Patient Information in Nursing

Collect Cues:

Review the existing documentation;

Social History

Carol Jones is a consultant engineer specializing 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)

Subjective:

The patient skin was pale and she was feeling breathless and nauseated. The patient also had occasional chest pain which goes away on taking rest.

Objective:

Blood pressure: 170/93 mm/Hg

Pulse rate: 160 bpm

Relate & Infer:

• Relate: With Tachycardia the heart rate at resting states becomes too high. Thus the increased pulse rate is also associated with increased blood pressure or hypertension. Due to excessive interstate traveling job, Carol also skips her dietary intake and physical exercise. Most of the time she used to take alcohol or beer in her lunch or dinner. Regular alcohol consumption and mental stress also cause an increased risk of developing tachycardia. The irregular cardiovascular outcomes and respiratory response also influence the skin condition. Thus the pale skin color of the patient also indicates the need for a quick response to manage the breathlessness of the patient.

•     Infer: Carol has been regularly skipping nutritional food and taking high content of alcohol. It enhances the risk factors. The separation from her family extremely busy schedule and intensive traveling also enhance her breathlessness. The job profile of patients demands hectic journeys and thus this can also be one of the reasons for patients to irregular heartbeats. Tachycardia is also related to life-threatening cardiac arrhythmia  (Lee and Cabrera, 2018). The irregular heartbeats also lead to further increase in the blood pressure of the patient. The increase in blood pressure and pulse rate can also cause blood clots or complete heart failure in the patient. Thus it is the first priority for the patient to control or regulate the irregular heartbeats.

•......... Based on your interpretation of all the information/cues presented, form and justify an overall opinion on what may be happening

The mild tachycardia is causing irregular heart rate and breathing shortness. The inadequate ventricular filling is also related to decreased cardiac pit[. The occasional chest pain is also a symptom of a worsening heart condition or further complications related to heart failure or stroke.

Predict: (100 words)

For the safety of the patient, it is necessary to take quick action. Since in tachycardia heart beats too quickly blood flow to the rest of the body as well as to the heart decreases. The increased pulse rate also generates a higher need for oxygen (Edwards, Williams, and Cottee, 2019). The lack of proper treatment can cause oxygen starvation of myocardial cells and thus it can lead to heart attack or even death of a patient as well. If heart rate is not controlled on time then it can also lead to further complications such as increased risk of stroke or blood clot, heart failure, fainting spells as well as sudden death of the patient (Young and Ng, 2018).

Identify the Problem/s

List in order of priority at least two key nursing problems (not included in word count)

Irregular heart rate and breathlessness

Hypertension

Establish Goals & 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.
• 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?).

Evidenced-based skill assessment and reflection

Justify and rationalize your choice of skill (not included in word count)

12 Lead ECG interpretation is chosen as the skill because it will give an accurate diagnosis of the underlying cause of irregular heartbeats and other cardiac activities.

Watch the video of the clinical skill performance that 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 (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 strength of the video is that prior to performing skill the patient was informed about the procedure and its need. Thus the standard of informing patients and involving them in decision making is an effective way to make patients comfortable and fearless. The patient safety was also prioritized in the video and the professional cleaned his hand before starting the process. He also kept the patient in an accurate position so that clear readings could be obtained.

One of the weaknesses identified in the video was that lead placement was done quickly. Thus there are possibility that anatomical precordial lead placement especially lead v1 and v2 at the fourth intercostal space can be inaccurate. It can result in significant differences in diagnosed outcomes of ECG. Further, it was observed that there was a lack of consistency in recording ECG. For the accurate diagnosis, there must be an accurate diagnosis and procedure and results must be documented and recorded. This aspect was neglected in the video and thus it seems to compromise the professional expertise and safety standards of registered nurse 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)

Before starting the procedure health professionals must follow all safety and performance standards. For instance, the infection risk can also significant complications. Thus proper hygiene must be maintained. As a healthcare professional, it is my responsibility to ensure that the patient is comfortable and relaxed so that an accurate diagnosis can be performed  (Patel, Patel, and Patel, 2018). Similar to the video  I will also include this as an essential practice to interact with the patient and to inform them about all possible complications and the purpose of the clinical interventions (Bayrak and Tosun, 2018). For getting ECG readings, ECG gel is applied to the patient so that resistance between skin and electrodes can be reduced and the accuracy of the ECG test can be increased. While performing clinical interventions it is necessary that safety considerations and precise practices are followed. As a professional, I must incorporate practices that best suit the patient's needs and safety. For instance, in the video, the leads were attached randomly without paying focus that where they must be placed (Thirumalai, Duba, and Reddy, 2017). It can result in clinical errors and thus such practices must be avoided. To encourage future learning the experience must be critically reviewed and reflected on the practices to evaluate its strengths as well as weaknesses.

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

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