NRS20002 Clinical Assessment and Diagnostic Reasoning

Assessment Guidelines

NRS20002 is a graded unit, and grades are awarded as detailed in Rule 3.8 of the University's Rules Relating to Awards.

To pass the unit: Students must submit all assessment tasks and obtain at least 50% of the overall assessment marks for the unit.

Part A – Case study 1 & 2: Written Response

This assessment requires you to demonstrate clinical reasoning, submitted in written format, for two different case studies. For each case study, you are required to submit written responses for Part A, as indicated below.

You need to write a written response for each case study addressing the task and submit it by the relevant due date stated above.

The case study information can is located on p. 5 (case study 1) and p.6 (case study 2) of this document.

For each case study, you are expected to apply the Clinical Reasoning Cycle (Levett-Jones, 2013 or 2018). Make sure you respond to the TASK requirements for each case study.

All of the Case study information (for Case 1 and 2) for Part A is contained within this guide.

Part A Case study 1: Written response (John) What you must do:

Read through Case study 1 (John) at the end of this document. Based on the information from case study 1, discuss your initial assessment for John.

Your written response should:

1. Discuss how you would gather new/further information about John’s condition.
2. Identify Johns immediate (next few hours) and short term (next few days) problems.
3. Identify how clinical reasoning has been applied (what stages of the clinical reasoning cycle have you engaged in? And, what *types of reasoning you have used?) *Types of reasoning refers to the theoretical content from the first three weeks of this unit, using the Clinical Reasoning Cycle (Levett-Jones, 2013 or 2018).

Tips:

• Use the 2nd, 3rd and 4th stages of the Clinical Reasoning Cycle
• Use appropriate medical terminology
• Aim to avoid repeating lines of information already provided in the case study (refer to pertinent case facts concisely)

The rubric is available in the Assessment Tasks and Submission tab in Blackboard to help guide you.

Suggested Structure (you can use subheadings for each section):

Paragraph 1:

Methods of gathering further information > 150-175 words •Questions you would ask?

• Any physical assessments?
• Any RN diagnostic tests (BGL, urinalysis?)
• Okay to include other diagnostic tests, however, keep in mind these may require a medical officer order (e.g., x-ray, pathology tests)
• Explain rationale and support with references

Paragraph 2:

John’s immediate and short-term problems > 150-175 words

• Immediate problems are happening now or the next hour or so
• Short term problems are the next few hours to the next day
• Potential problems can be included
• Holistic RN perspective –avoid focusing on medical diagnoses
• Support with scholarly references

Paragraph 3:

How clinical reasoning has been applied > 150-175 words

• How have you applied the Clinical Reasoning Cycle (Levett-Jones, 2013 or 2018) •What type(s) of reasoning have you used? Inductive, deductive, narrative or, collaborative? (explain and support with references)

Part A case Assignment 2: Written response - Grace What you must do:

Read through Case study 2 (Grace) at the end of this document. Based on the information from case study 2, discuss your initial assessment for Grace.

Your written response should:

1. Discuss how you would gather new/further information about Grace’s condition.
2. Identify Grace’s immediate (next few hours) and short-term (next few days) problems.

• Identify how clinical reasoning has been applied (what stages of the clinical reasoning cycle have you engaged in? And, what *types of reasoning have you used?)

* Types of reasoning refers to the theoretical content from the first three weeks of this unit

Tips:

• Use the 2nd, 3rd and 4th stages of the Clinical Reasoning Cycle
• Use appropriate medical terminology
• Aim to avoid repeating lines of information already provided in the case study (refer to pertinent facts concisely)
• A Rubric is also provided in the Assessment Tasks and Submission tab on your Black Board site, to help you identify what is expected

The rubric is available in the Assessment Tasks and Submission tab in Blackboard to help guide you.

Suggested Structure (you can use subheadings for each section) Paragraph 1:

Methods of gathering further information > 150-175 words •Questions you would ask?

• Any physical assessments?
• Any RN diagnostic tests (BGL, urinalysis?)
• Okay to include other diagnostic tests however keep in mind these may require a medical officer order (e.g. x-ray, pathology tests)
• Explain rationale and support with references

Paragraph 2:

Grace’s immediate and short-term problems > 150-175 words

• Immediate problems are happening now or the next hour or so
• Short term problems are the next few hours to the next day
• Potential problems can be included
• Holistic RN perspective –avoid focusing on medical diagnoses
• Support with scholarly references

Paragraph 3:

How clinical reasoning has been applied > 150-175 words

• How have you applied the Clinical Reasoning Cycle (Levett-Jones, 2013 or 2018) •What type(s) of reasoning have you used? Inductive, deductive, narrative or collaborative? (explain and support with references)

Format & Submission Details:

• In-text references included in word count
• Use Font size 12, minimal 1.5 spacing
• Use APA 6th referencing and aim for scholarly sources no more than 10 years old
• Submit as Word document
• It is recommended that you use a page header or footer with your name and student ID
• You do not need a separate cover sheet as Turnitin generates a record of your personal submission
• Please submit your assessment under the Turnitin link for Part A Grace in the

Assessment Tasks and submission section (Blackboard)

Case Assignment 1 (John), Part A

John, age 65, weight 78kg

Background

John is a 65 year old man recently diagnosed with cancer of the colon. After noticing increasing episodes of constipation and diarrhoea associated with feeling lethargic, John attended a community health clinic where a nurse provided him with a take home stool specimen collection kit. After receiving the results, John was referred for a colonoscopy by his GP, which revealed a left-sided colon cancer, and a bowel resection was scheduled. John is an ex-smoker and has been diagnosed with early emphysema. His GP also commenced John on some anti-hypertensive medication (Ramipril 2.5mg daily) for moderate hypertension. Context

John is admitted to a small regional hospital for his bowel surgery, which proceeds without any major complications. He returned to the ward at 1700 hours.

It is now Day 1 post-operatively (the next day), and you are allocated to care for John on the morning shift. You listen to the morning report.

Clinical handover (from the night duty RN who appears very tired and keeps yawning)

“In bed 22 we have a 62 year old man who had a partial colectomy and formation of colostomy yesterday. He is under Dr. Barrett’s team and his surgery was uneventful. He has a morphine patient controlled analgesia (PCA) and intravenous (IV) fluids running at 125 mL per hour. During the night, his blood pressure dropped. I told him to cut down on the morphine, but he said the pain was getting bad. He had a clinical review at 0200 hours and we gave him an IV fluid bolus of 250 mL. His indwelling urinary catheter (IDC) urine output has been about 25 mL per hour since 0300 hours. His wound is dry and intact, and his bellovac has drained about 300 mL of heamoserous fluid since yesterday. His stoma looks okay and there has been nothing in his drainage bag. He’s on 6 litres of oxygen via a Hudson mask, and his oxygen saturations are between the flags. There were lots of people visiting last night. I asked them all to leave at 11 pm but I think they will be back this morning.”

The first observations you attend at 0900 hrs reveals the following:

Temperature 37.1ᵒC

Pulse rate 115 (weak/thready)

Respiratory rate 23

Blood pressure 109/50

SpO2 99%

Last hour urine output 20mL

BGL 12.5 mmol/L

Case Assignment 2 (Grace), Part A

Grace, age 74, weight 85kg, & her daughter

Background

Grace, aged 74, lives alone since her husband died three years ago. Prior to this, Grace and her husband (Norm) were “Grey Nomads” touring across Australia to visit their kids. Grace’s interests now include learning to use her new iPad (she is fond of Facebook and has discovered internet banking), doing cryptic crossword puzzles, baking cakes for fundraisers, and tending to her small garden. She has recently joined the local choir, and a friend drives her to/from practice as she does not have a driver’s licence.

Two days ago, Grace was admitted to hospital following a fall in which she fractured her right neck of femur (#NOF). Grace fell at home in her backyard and was found by her neighbour four hours later, who heard her cries for help. Grace’s only daughter lives 150km away and has been concerned about her mother’s memory and general health for the past 18 months and wants her to move into a nearby aged-care facility. Grace has a history of osteoarthritis and associated hip and wrist pain for which she takes osteo-eze and ibuprofen. Grace was recently diagnosed with cataracts and was awaiting surgery. She broke her glasses during her fall and, the ambulance officer packed an old pair of glasses that belonged to her husband.

Context

Grace was admitted to the orthopaedic ward following an open-reduction and internal fixation (ORIF) for her #NOF.

Grace is now day two post-operative and you are allocated to care for Grace on the morning shift.

Clinical handover (from the night duty RN)

“Grace appeared to sleep intermittently and was stable until this morning. At 0600 hours Grace needed to use her bowels and mobilised to the bathroom on her forearm support frame with assistance. We opted to shower her whilst up, but she became short-of-breath and somewhat confused and mildly agitated. Grace appeared tachypneic, though less so once resting on a chair. Her oxygen saturations ranged from 90%-94% on a Hudson mask though she kept moving her hand and removing her mask, so I don’t know how reliable these readings were. We returned Grace to bed as she was attempting to get out of the chair without her frame. She remained a bit tachycardic around 100 and hypertensive but not so much once resting. She complained of some chest pain but provided a vague description.

We did an electrocardiogram (ECG) which showed sinus tachycardia with no ST changes. Grace was encouraged to use her Fentanyl patient controlled analgesia (PCA) more, and she has since settled down, though she seems to be quite confused. Her vital signs have settled somewhat, but it might be worth requesting a clinical review as her heart rate is still elevated, and her oxygen saturations remain borderline around 93-95% on 8L of oxygen. Oh well, at least she has been showered and used her bowels. Her wound looks good, there’s minimal drain loss, and she’s afebrile. She’s not trying to get out of bed just, but if she does, she might need specialling.”

Part B Case study 1 & 2: Written Response for John and Grace Further information:

• In week 6, you will gain access to further case information about John (Case 1)  In Week 8, you will gain access to further case information about Grace (Case 2).
• *Note: You will need this additional case information prior to responding to Part B.

What you must do:

For each case study (1 and 2), you need to consider and process the new clinical information (provided in weeks 6 and 8). Using the Clinical Reasoning Cycle (Levett-Jones, 2013 or 2018), your discussion should:–

• Identify the problems and issues including the new case study information
• Establish person-centred goals and a nursing plan of care
• Provide a separate reflection for each case study. This reflection should consider what
• you have learnt from responding to both cases 1 & 2, and how you will apply this to the clinical setting (your practice).

The rubric is available in the Assessment Tasks and Submission tab in Blackboard to help guide you.

Suggested Structure - will be provided in week 6 with the case study information

Submission Details:

• Use a heading for each case study (Case Assignment 1: John, Case Assignment 2: Grace)
• In-text references included in word count
• Use Font size 12, minimal 1.5 spacing
• Use APA 6th referencing and aim for scholarly sources no more than ten years old  Word guide 500 words for each case study = 1000 words total +/- 10%.
• Submit as a Word document
• It is recommended that you use a page header or footer with your name and student ID
• Use the Turnitin submission drop box for Part B.
• You do not need a separate cover sheet as Turnitin generates a record of your personal submission.

Assessment 3: Exam (1 hour)

Date: Examination period: End of session: date to be advised.

Weight: 20%

The final examination is scheduled for the end of the study period. Students will be advised during the study period as to when the exam will be held and the format it will take. The exam will be closed book.

• The exam will consist of 40 multiple-choice questions.
• Refer to the Learning Objectives from the Unit Information Guide as a guide to what types of questions to anticipate and prepare for.
• Blackboard practice quizzes will help you prepare for your exam.

Time in your last tutorial will be allocated for exam preparation.

NRS20002 Case Assignment Rubric

NRS20002 Determining The Level of Urgency in Clinical Practice

Determining the level of urgency in clinical practice

RN processes to make clinical decisions/judgements

What is meant by the level of urgency? It is learning how to determine the level of urgency, or put another way, learning to determine the degree of risk that vulnerable patients, in your care, may encounter. Determining the level of urgency is part of clinical decision making that you will need to do in your practice as a RN, in order to prioritise the delivery of care. For some situations, such as in Emergency departments, early warning of problem situations has predetermined categorises, for example, Australian Triage Scales (ATS) (Australian College for Emergency Medicine, 2005). In other situations, nurses in consultation with other providers, create styles of practice that include ways of doing things (Benner et al., 2008). The clinicians and academics in this unit have put together a general description to assist you as the novice nurse, to determine the level of risk to your patient. Where possible, research based evidence is used to support the process.

Levels of urgency and associated examples

1. Critical = life threatening, either immediate or imminent, time factor is critically important

Some examples:

• a patient presenting with imminent cardiac arrest
• Airway obstruction
• post-operative haemorrhage that does not diminish with applied pressure, and patient shows signs of deterioration
• Patients meeting Rapid Response criteria are at high risk of becoming critical.

2. Urgent = potentially life threatening or situational urgency

Some examples:

• A patient with post-operative urinary retention, has been ordered IV antibiotics prior to insertion of an Indwelling urinary catheter; assessment or intervention should occur in approximately the next 30 minutes
• A patient presenting with chest pain, most likely cardiac in origin, who requires review or intervention within 10 minutes
• Patients meeting Clinical Review criteria can become urgent if they become unstable.

3. Non-urgent = routine problem for a particular context

Some examples:

• Situations not considered a priority in your working shift, it is more about routine care rather than dealing with a new problem that may have arisen.
• A care plan indicates that a dressing is due on your shift.
• You are conducting a home visit for a client who has a known history of chronic angina, is under the care of cardiologist, who states they did have one episode of chest pain in the previous month, but it was immediately relieved when ½ an anginine was self-administered sublingually. The person has no other current signs and symptoms.

Assessment of a patient problem/need

The level of urgency, the individual patient needs, and the related context, are all variables that will influence your decisions with respect to: the type of assessments and interventions to conduct, their associated order of priority, the speed or time you have to perform them, and whether you need to call for assistance. When providing and co-ordinating care, the Australian and Nursing Midwifery Council (ANMC) (2006) states an RN, is to conduct a systematic and comprehensive approach to assessment. The ANMC (2006) National Competency Standard 5.1 lists the essential characteristics of a systematic approach; some of the main elements to take note of, with respect to assessment, is that assessment should be organised in a structured manner, all relevant resources are to be utilised, the data needs to be confirmed with the patient and members of the healthcare team, and also the RN needs to ensure that the tools and strategies used for assessment are appropriate.

To assist you with this systematic approach to patient assessment, some appropriate strategies and tools are presented below.

A-G algorithm

In NSW acute health care facilities, the A-G algorithm has been promoted by as an early warning system to anticipate and manage deterioration in patients (Jacque et al., 2009). The descriptors of the algorithm are listed below:

• stands for Airway
• stands for Breathing
• stands for Circulation
• stands for Disability
• stands for Exposure
• stands for Fluids
• stands for Glucose (Jacque et al., 2009).

The specific actions you should undertake for each descriptor, and the rationale as to why you should do them, are listed in the chapter entitled ‘When to worry’ in the Detect program (Jacque et al., 2009).

A simulated scenario example, presented in an article by Prescott and Garside (2009) that the authors used for nursing students in England, highlights how the A-G algorithm may be utilised. The initial scenario example, described the data that can be obtained using an A-G algorithm to assess a client. An abridged version follows:

Initial assessment

Simon, a 57 year old has been admitted to a medical ward, with an initial diagnosis of angina; the initial ECG interpretation is normal sinus rhythm. Currently the patient is pain free. An intravenous cannula has been inserted in his right hand; the patient may eat and drink as desired. The initial assessment, by the RN is provided below:

A = Clear, talking in full sentences. Oxygen mask removed in the emergency department B = Respiratory rate 20 breaths per minute; oxygen saturation 96%.

• = Pulse 80 beats per minute, regular (sinus rhythm); blood pressure 148/90mmHg
• = Conscious and alert
• = Nil of note (Prescott & Garside, 2009, p.37)
• = N/A
• = N/A

The subsequent scenario example highlighted the data that can be obtained using an A-G algorithm, to identify a patient problem, when a patient’s condition changes. It does not detail all the nursing actions that you may take in the Assignment of making the assessment, for example, positioning, choosing the appropriate oxygen therapy, alerting staff, or the administration of ordered medications.

Clinical Progression

After an hour, Simon complains of experiencing severe chest pain. When the RN arrives at the bedside he is cold and clammy.

• = Clear
• = Respiratory rate 24 beats per minute; oxygen saturation 90%.
• = Pulse 110 beats per minute, sinus tachycardia; blood pressure 160/100mmHg
• = Alert – complaining of severe chest pain
• = Cold and clammy (Prescott & Garside, 2009, p.37)
• = N/A
• = N/A

It is important to remember, that the A-G algorithm, is presented in order of priority. If your initial assessment of the airway indicates that there is a problem, this problem should be addressed before proceeding to the next level of assessment, the patient’s breathing. Additionally, as these two scenarios indicate, a patient’s condition may change over a Assignment of time, so assessment should not be viewed as a one off event, nor a linear process, but rather as a process which is cyclic in nature.

CNIV Algorithm HOME-O

In some situations, a longer and more detailed assessment of a patient’s presenting problem is required. Wilson and Giddens (2009) divide health assessment into: general health history, past medical and family history, problem based history and examination techniques for each body system. The following systematic process is in part based on the strategy found in Wilson and Giddens (2009). It is particularly useful, for working out the types of questions which would be most relevant to ask the patient with respect to a particular health problem. The descriptors for the HOME-O algorithm are listed below:

H stands for History (subjective data) e.g symptoms, age, risk factors

O stands for Observation of the person, i.e their appearance

M stands for Measurement (objective data) of pertinent physiological data e.g. vital signs, level of consciousness, blood glucose level

E stands for Examination, which may include all of some of these elements: inspection, auscultation, palpation &/or percussion

O stands for Other, and relates to additional data, provided through other relevant sources, for example, diagnostic tests, pathology reports, and X-rays

Further, this systematic approach to assessment is useful when your patient is relatively well, as it allows you time to assess health and wellbeing from a variety of perspectives, including:

physiological, psychological, spiritual, socio-economic and cultural variables.

However, it is worth remembering, that even when the presenting patient problem is more urgent, you will still need to gain specific subjective history (H) from a patient, significant others, or other health workers, to work out the problem. The context determines the type of questions, and the amount of detail.

Department guidelines and levels of evidence

According to Benner et al. (2008), research suggests that patient outcomes are improved through the use of evidence-based guidelines in clinical practice. The Australian and New Zealand guidelines for the management of acute coronary syndrome (ACS) (ACS guidelines working group, 2006) and recently published addendums to these guidelines (Chew et al., 2011), are a case in point. Within the aforementioned documents, grades of recommendations ranging from A-D and levels of evidence 1111 are provided, which clinicians can use to guide practice. For some situations or practice areas, for example, emergency departments, specific triage scales have been formulated to use to determine the level of urgency (Australian College for Emergency Medicine, 2005). Where possible, when making clinical decisions, clinicians should endeavour to use the best level of evidence that is available, as it applies to specific situations and individual patient needs, a practice termed, evidence-based practice (Benner et al., 2008).

A somewhat confusing issue for students is working out how to incorporate broad guidelines, such as those mentioned earlier that relate to ACS (Chew et al. 2011), into their clinical practice. For some aspects of clinical practice, this dilemma is resolved by health departments publishing clinical guidelines. For example, the NSW Department of Health (DOH) (2010) has published rural emergency guidelines to provide clinical support for staff employed to work in a specific context, being rural emergency centres. These particular guidelines provide a systematic approach, for the more common presentations to emergency departments, such as ACS, and are reviewed on a regular basis, at which time new evidence may be incorporated, resulting in a change in clinical practice for these health professionals.

However, in other areas, such as medical or surgical wards, scales or procedural guidelines are not always available. In this instance, clinicians must make decisions based on their theoretical and technological understanding, prior experience in managing this situation, and apply this knowledge to the patient’s specific problem and context. In these situations, algorithms provide a decision support structure, and can improve accuracy, when making clinical judgements about an individual patient (Benner et al., 2008), with respect to level of urgency and problem identification.

Concluding remarks

In summary, this document has been put together for undergraduate bachelor of nursing students, to provide some underpinning knowledge as to how clinical decisions are made by RNs in practice, with respect to determining the level of urgency and identifying a patient’s problem. Students can apply and test their understanding of this decision making process by working out the level of urgency, and the patient’s problem provided in the Formation- Based Learning Units. During laboratory sessions, discussions by individual students as to their estimation of the level of urgency and the assessments needed to identify the patient problem, will allow peers and tutors to evaluate, and determine the appropriateness of these decisions. In turn, this may give you, the student more confidence in making these types of clinical decisions during your viva/simulation exams. The information provided in this document should not be interpreted as comprehensive discussion regarding clinical decision making in practice by a RN, as this concept is complex (Benner et al., 2008). In addition, students need to be aware that clinicians in speciality areas, such as mental health or paediatrics, may use alternative frameworks to determine the level of urgency.

So, in conclusion, make mistakes, learn, and work towards making clinical decisions that are rational, evidence based and systematic, as your patient’s safety depends on you, the health professional.

References

Acute coronary syndrome guidelines working group. (2006). Guidelines for the management of acute coronary artery syndromes. Medical Journal of Australia, 184 (8 Suppl), S1-32. Retrieved from http://www.mja.com.au/public/issues/184_08_170406/suppl_170406_fm.html

Australasian College of Emergency Medicine. (2005). G24 Guidelines on the implementation of the Austalian Triage Scale in emergency departments. Victoria, Melbourne: Australasian College of Emergency Medicine.

Australian Nursing and Midwifery Council. (2006). National Competency Standards for the Registered Nurse - 4th Edition (new format). Retrieved from

http://www.nursingmidwiferyboard.gov.au/Codes-and-Guidelines.aspx

Benner, P., Hughes, R., & Sutphen, M. (2008). Clinical reasoning, decisionmaking, and action: Thinking critically and clinically. In Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert Wood Johnson Foundation). Rockville,

MD: Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/QUAL/nurseshdbk/

Berman, A., Kozier, B., & Erb, G. L. (Eds.). (2010). Kozier and Erb’s Fundamentals of Nursing (1st Australian edition ed.). Frenchs Forest: Pearson Australia.

Chew, D., Aroney, C., Aylward, P., Kelly, A., White, H., Tideman, P., & et al. (2011). 2011 Addendum to the National Heart Foundation of Australia/Cardiac Society for the management of acute coronary syndromes (ACS) 2006 [In press], 1-16. doi: 10.1016/j.hlc.2011.03.008

Jacque, T., Fisher, M., Hillman, K., Berry, M., Hughes, C., Lamm, D., et al. (2009). Detect manual: When to worry (2nd ed.). Retrieved from http://nswhealth.moodle.com.au/

NSW Department of Health. (2010). Rural adult emergency clinical guidelines - 3rd edition

[GL2010_003]. Retrieved from http://www.health.nsw.gov.au/policies/GL/2010/GL2010_003.html

Prescott, S., & Garside, J. (2009). An evaluation of simulated clinical practice for adult branch students. Nursing Standard, 23(22), 35-40.

Wilson, S., & Giddens, J. (2009). Health assessment for nursing practice (4th ed.). St. Louis, Missouri: Mosby Elsevier.