Posted: September 17th, 2017
Actions for ‘Assessment 2 Case Study: Clinical Reasoning Client Report’
Length: Maximum 1200 words
The Clinical Reasoning Client Report Template may be used as a framework for your discussion.
Please read the case below and apply the first stages of clinical reasoning to Mrs Checketts and her situation
Mrs Checketts is a petite 86 year old woman who has been admitted to your facility for respite after treatment for a fractured wrist sustained during a fall at home.
The first two stages of the clinical reasoning cycle have been applied to Mrs Checketts’ clinical situation. Write a 1200 word client report that addresses the next three stages as per the directions provided:
Consider the patient situation/patient context:
Mrs Checketts is a petite 86 year old woman who has been admitted to your facility for respite after treatment for a fractured wrist sustained during a fall at home
Collect cues/information: You review this initial impression and current information and gather new information/cues you consider relevant
Mrs Checketts lives alone and manages her own activities of daily living. Her son lives interstate and her niece pops in to visit her a few times a week. She is in the early stages of dementia, has paper thin skin and a small pressure injury on her coccyx. She is very unsteady on her feet and tends to pull back on her walking frame. Mrs Checketts’ belongings are kept in a very dirty bag and her clothes smell strongly of cigarette smoke and do not look as if they have been washed in some time.
Her temperature is 36.50C, heart rate regular at 82 beats per minute, Blood pressure 105/60 and respiratory rate 16 breaths per minute. She is 165 cm tall and weighs 50 kilograms
Now for your input…
Process information: Now you have gathered all relevant information, you need to process this data. In this section discuss your interpretation of what is normal or abnormal and distinguish relevant from irrelevant information. Relate or cluster cues together to identify relationships between them and make deductions based on your interpretation of the cues, considering alternatives. Where possible, match this situation to past situations and predict an outcome. You must support your ideas with scholarly literature.
Identify Problems: Consider all of the information that you have collected and processed to identify any patient/client problems or issues. Clearly describe two key issues relevant to Mrs Checketts’ case.
Establish Goals: Describe what you want to happen to Mrs Checketts – a desired outcome for each key issue within a set time frame.
Reference List: A reference list demonstrating wide, relevant reading must be included. Both in-text references and the reference list must adhere to Harvard referencing guidelines
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