RS211 Assessment item 3- Clinical Presentation Report
Case Study of ‘Margaret Law’
Use the Task Description and Marking Criteria provided in your Subject Outline to construct your
Clinical Presentation Report.
The following is a guide only. You are required to use the task description and marking criteria
provided in your Subject Outline to construct your paper.
Remember to include:
An introduction (approximately 250 words)
This should orientate the reader to the purpose of the paper and how your paper will be set
out. Remember you are introducing your paper, not repeating the information from the case
study.
The body
The body of your paper should include the following:
Primary Survey (approximately 650 words)
Apply the primary survey assessment framework in order to identify the relevant assessment
data provided in the case study and identify the additional assessments you would need to
conduct in order to complete a comprehensive patient assessment. Your discussion should
include interpretation of abnormal assessment findings in the context of the normal or
expected findings.
You will find the information provided in the case study provides you with some of the
information you need to document a primary survey, in this section, you will need to apply
the Primary Survey systematically, identifying the relevant data provided throughout the case
study. As you progress through the survey, you will need to interpret any abnormal findings
in the context of normal or expected findings. Not all of the information you need has been
provided in the case study, so you will need to clearly outline in your paper what other
assessments you would need to conduct. You do not need to make up any results, you can
simply outline the assessment you would undertake and what you would expect to find in the
context of the patient’s cu
ent condition and what is normal. For example, if the case study
didn’t tell you that the patient’s GCS was 15/15, you could have identified in ‘D’ of the
Primary Survey that you would conduct a neurological assessment using a neurological
assessment tool, and provide a reference.
Remember to provide references that support your discussion throughout this section. For
example, if you write in your paper that the patient’s airway is patent because she is speaking
to you, you would need to provide a reference to support that the ability to speak is an
accurate assessment of a patient’s ability to maintain their own airway. Likewise, if you are
well practiced in the clinical setting and understand that an Sp02 reading of <87% is low and
equires oxygen supplementation, then you would need to provide a cu
ent reference that
supports the numerical figure of <87% as well as a cu
ent reference that supports the
application of supplemental oxygen for this Sp02 reading. This is evidence based practice at
work!
Remember too that this is an academic paper, you will need to construct full sentences when
applying the Primary Survey. Short hand is not acceptable, neither are dot points and
acronyms that haven’t been spelt out initially. For example:
RS211 Assessment item 3- Clinical Presentation Report
Case Study of ‘Margaret Law’
Inco
ect Co
ect
A- The patient’s airway is patent… Assessment of the patient’s airway
demonstrates that it is patent because…
HR 100bpm The patient’s heart rate (HR) is 100 beats per
minute (bpm).
A-
B-
C-
D-
According to (reference) the Primary Survey
commences with the assessment of the
patient’s airway…
Breathing is then assessed. According to
(reference), a thorough assessment of
eathing should include…
Underlying Pathophysiology (approximately 650 words)
Explain in detail at the systemic, tissue and cellular levels the disruptions to normal
physiology that occur with cardiac ischemia, and explain how these disruptions have resulted
in two (2) of the abnormal assessment findings you have identified.
Your learning from BMS192 and BMS291, as well as your Medical-Surgical text books will
e valuable in this section of your paper. Some questions that may help you complete this
section include:
Systemic- What happens to the cardiovascular system and associated organs during Acute
Coronary Syndrome? Explain in detail.
Tissue- What is happening to the Myocardium during Acute Coronary Syndrome? Explain in
detail.
Cellular- What is happening to Cardiomyocytes during Acute Coronary Syndrome? Explain
in detail.
Remember to use the co
ect terminology and to reference throughout your explanation. It
can really help to be able to explain in your own words using the co
ect terminology by
eading pathophysiological explanations from a range of sources. It will also help to have a
thorough understanding of normal cardiac physiology before trying to understand the
disruptions that occur.
Use your explanation of the disruptions above to explain two of the abnormal assessment
findings you identified in the Primary Survey section. Make sure all of your explanations link
in with Margaret’s Case, it can be easy to head off track in this part!
This section demonstrates your ability to link assessment findings to underlying
pathophysiological processes. For example, if you were to identify a high blood pressure in
your Primary Survey, explain how in Acute Coronary Syndrome, the disrupted processes at
the systemic, tissue and cellular levels result in the patient having a high blood. Be sure to
eference your findings!
Nursing Management (approximately 650 words)
RS211 Assessment item 3- Clinical Presentation Report
Case Study of ‘Margaret Law’
Utilise national, state and local best practice guidelines to prioritise and rationalise your
first five nursing interventions. This care should include nurse-initiated interventions and
assessments in addition to any medications that would be prescribed. Each intervention,
assessment or medication should be supported with a rationale that explains how it relates to,
or addresses the underlying pathophysiology of cardiac ischemia.
Hint: It will help to identify your interventions by first researching the best practice
guidelines.
Remember this section asks you to prioritise the first five nursing interventions. Think
about additional and ongoing assessments and nurse initiated medications. For example, you
may consider that the patient should have education around healthy eating to reduce her risk
for cardiovascular disease and complications, however, would this really be one of the first
five interventions you undertake for this patient? Likewise, you may locate a Chest Pain
Pathway that identifies a CXR should be ordered as a priority, is this a nurse initiated
intervention? You could instead discuss your role as a Registered Nurse in advocating for a
CXR to be ordered in accordance with the pathway.
Remember a large part of this section is rationalising your identified nursing intervention. For
example, if one of your interventions is to advocate for analgesia to be prescribed, explain
how this relates to, or addresses the underlying pathophysiology of Acute Coronary
Syndrome. Likewise, if you advocate for a CXR to be ordered, explain why this relates to the
underlying pathophysiology of Acute Coronary Syndrome.
Local pathways are helpful in this section, remember to consider the type of facility and
esources available to you that are outlined in the Case Study. Remember not to limit yourself
to local pathways and procedure guidelines, research
oadly to identify cu
ent evidence
ased practice and utilise primary and secondary sources of information. For example, a chest
pain pathway may direct the clinician to apply supplemental oxygen therapy to all patients
presenting with chest pain. Is this what the cu
ent evidence tells us to do? Look at the
eferences the pathway refers to and conduct your own journal article search to ensure this is
what the best practice guidelines cu
ently advise.
A conclusion
This should summarise the key points made throughout your paper. It is helpful to use the
marking criteria and ask description here to ensure you have addressed all elements of the
assessment.
You must support your paper with a minimum of 15 recent (less than 7 years old) and
credible sources. You should support your paper with a combination of the following
credible sources:
Peer-reviewed journal articles (these are the highest quality sources)
Textbooks (Including, but not limited to your prescribed texts for this subject)
Best practice guidelines
Government documents
Health facility Clinical Practice Guidelines, Pathways, Policies and Protocols (Use
less)
Case Study- Margaret Law XXXXXXXXXXpdf