CNA155 AT2 Case-study 2020 Zac Smyth is 18-year-old university student who lives on-campus as his parents reside in another state. Zac is studying engineering and enjoys university life. Zac has a...

CNA155 AT2 Case-study 2020
Zac Smyth is 18-year-old university student who lives on-campus as his parents reside in another state. Zac is studying engineering and enjoys university life. Zac has a part-time job working at the local supermarket for 15 hours each week. Zac has no immediate family in the state, but he has a friend of his parents that he sees from time to time. Zac usually goes home to his family during his
eaks but due to his work commitments Zac has not seen his mum, dad, and younger
other for the past 4 months.
Last evening Zac went out to the local pub with a few friends from university. There was a new band playing at the pub and Zac was especially excited to be going. To save money Zac and his friends met up at a friend’s house for ‘pre-drinks’. During this time Zac drank around four full strength beers.
When Zac and his friends a
ived at the pub, they headed straight for the bar to get another beer. Zac and his friends were having a great night, the music was good, and the pub was busy.
Later in the evening Zac started talking to a friendly young woman, shortly after Zac was approached by a man who aggressively accusing Zac of talking to his girlfriend. Zac apologised and returned to his group of friends. Approximately an hour later Zac said goodbye to his friends as he decided to head home.
As Zac was leaving the pub, he was followed out by the man who had earlier confronted him. The man was still ve
ally aggressive and ended up pushing Zac to the ground, resulting in Zac hitting his head on the cement cu
of the road. The security guard saw this incident and intervened. Whilst Zac was not punched, he did sustain a laceration to the back of his head. The security guard noticed quite a bit of bleeding and rang an ambulance.
When the ambulance a
ived, Zac had a GCS of 15 and could recall the whole incident. Zac appeared to have no other injuries. The paramedics undertook vital sign which they stated were ‘normal’ and applied a bandage to Zac’s head wound. The security guard stated that he ‘didn’t think Zac lost consciousness’.
On a
ival to the emergency department, the triage nurse undertook a set of vital signs, GCS and assessed the wound. The triage nurse also took a history from Zac.
Vital signs:
Blood Pressure: 141/88 mmHg
Heart Rate: 90 beats/minute
Respiratory Rate: 17
eaths/minute
Pulse Oximetery: 99% on room ai
Temperature: 36.0 c (tympanic)
GCS:
Eyes 4
Ve
al 4
Motor 6
Head wound:
4cm laceration to the occipital region, small amount of blood oozing from the wound. May require sutures/staples.
Triage:
18-year-old male,
ought in by ambulance following an alleged altercation where patient struck head on road cu
at 2300 hrs. Patient is denies loss of consciousness but unable to recall all events. Pt appears alert but teary. On examination, 4cm laceration noted with slow ooze from wound. Dressing insitu. Vital signs and GCS recorded at 2325 hrs as per chart. No other obvious injuries. Pt denies drug use, states has had approximately ‘five beers since 7pm’. Breath alcohol taken at 2330 hours 0.06%. Pt reports pain to be 5/10 at occipital region, no analgesia taken prior to presentation. Pt states is usually fit and well.
Past medical history:
Childhood asthma, up-to-date with immunisations (last tetanus 12 months ago). Not on any medications and no known allergies.

How to approach this assessment item
Ensure that you answer the questions and avoid simply providing generic information. You must continually link back to the patient and their condition. Do not expect the marking staff to make the connections between the information that you provide. You must make them explicitly yourself so that it is clear that you understand every element of what you have written. Also, don't lose the patient in your answer - their condition and the positive health outcomes that you intend for them need to be the clear focus throughout. 
Please consider yourself to be the registered nurse on duty, and the first nurse to provide care to the patient after he was triaged. Ensure that you remain within your scope of practice as a registered nurse. It is expected that you will identify and describe a minimum of three nursing assessments of greatest priority, and justify your decision by linking the assessments back to the cues and underlying pathophysiology of the patient's presentation. 
Headings and tables may be used in this assignment. If you do utilise tables, remember that the information within the table will need to be discussed in greater detail and linked back to the your patient.
Please ensure you support your statements and assertions with either contemporary (less than ten years since publication) literature or appropriate clinical guidelines. This is important as the references add value to your statements.
We are providing you with a version of the marking ru
ic that will be applied to this assessment item. It provides a
eak-down of the weighting of marks for each criterion and indicates the requirements for each grade. You may wish to use this to assist you in understanding, more fully, the expectations that we have in terms of content and quality. 

CNA155 AT2 2020 Clinical Reasoning Report
Objective/Criteria Performance Indicators
HD 7 – 5.6 marks DN 5.5 – 4.9 marks CR XXXXXXXXXXmarks PP 4.1 – 3.5 marks NN XXXXXXXXXXmarks
Consider the patient: 7 Marks
Explains what is significant about the
patient’s profile i.e. age, health
specific issues, medical history and
isk factors, making links to the
presenting situation.




Views the person against a
ackground of their own age,
health specific issues, medical
history, and risk factors where
applicable. Considers health-
specific issues/medical history.
Makes links to why this is
significant. Forms an initial
impression and makes a basic
assumption about what might be
occu
ing at the time.
Recalls facts about the case
accurately with sensible
interpretation of the significance
of the person’s profile i.e. age,
health specific issues, medical
history and risk factors. Gains an
initial impression and makes a
asic assumption about what
might be unfolding.
Recalls facts about the case
accurately with reasonable
interpretation of the
significance of the person’s
profile i.e. age, health specific
issues, medical history and risk
factors. Gains a good initial
impression of the person in the
case.
Recalls the facts in the
case accurately but with
vague interpretation of
the significance of the
person’s profile i.e. age,
health specific issues,
medical history and risk
factors. Forms a basic
impression of the person
in the case.
Recalls facts within the case
only, with or without
accuracy.
Does not make an
interpretation of the
patients profile i.e. age,
health specific issues,
medical history and risk
factors. Does not develop
an initial impression of the
person in the case.


HD 11 – 8.8 marks DN 8.7 – 7.7 marks CR 7.6 – 6.6 marks PP 6.5 – 5.5 marks NN XXXXXXXXXXmarks
Collect Cues/Information: 11 Marks
Reviews information available.
Demonstrates a clear understanding
of new assessments required for the
situation. Demonstrates clinical
easoning in identifying the most
pertinent new nursing assessments
equired. Links assessments to a clear
understanding of what is going on
with the patient from a functional
and structural perspective within the
ain. Recalls knowledge of the bio
scientific principles underlying the
case.

Reviews all information cu
ently
available. Co
ectly determines
cues that are relevant to collect,
decides on new nursing
assessment data to be collected,
states the assessment
techniques/tools of highest priority
to be used. Can link assessments
and cue collection on knowledge
from a nursing and bioscience
perspective of the patient’s
situation.
Reviews in detail most
information cu
ently available.
Co
ectly determines most of the
cues that are relevant to collect,
decides accurately on most of the
new nursing assessment data to
e collected. States accurately
most techniques and tools of
priority to be used. Cue collection
is accurately based on nursing and
ioscience knowledge relating to
the patients situation
Reviews most information
available. Determines
easonable cues that are
elevant to collect and decides
on reasonable new nursing
assessment data to collect.
States reasonable techniques
and tools for assessment. Cue
collection is based on
easonable nursing and
ioscience knowledge relating
to the patient’s situation.
Reviews some of the
information available.
Determines some cues
that are relevant to
collect. Decides on some
new nursing assessments
data that is relevant to
collect.
States some techniques
or tools of assessment.
Cue collection is based on
some nursing and
ioscience knowledge
elating to the patient’s
situation.
Lists cues provided in the
case, no review. Cannot
determine which cues are
elevant to collect. New
assessments are either not
elevant or not suggested.
Does not state the
techniques or tools to be
used in new cue collection.
No links to the patient’s
situation.





HD 9 – 7.2 marks DN 7.1 – 6.3 marks CR 6.2 – 5.4 marks PP 5.3 – 4.5 marks NN XXXXXXXXXXmarks
Process Information: 9 Marks
Demonstrates understanding of the
most important and relevant cues
elated to the neurological system in
this case. Able to cluster cues in
elation to the suspected problem in
the case. Able to make a suggestion
ased on analysis of the case to make
logical inferences about what the
patient is experiencing.


Na
ows down all the important
information and the relevant cues
in the case. Clusters all cues and
ecognises patterns relating to the
suspected problem underlying the
case. Forms an accurate and
logical opinion about what the
patient is experiencing.
Na
ows down on