CNA152: Health Assessment 1 Assessment Task 2B – Clinical reasoning report

Objective/Criteria Performance Indicators HD DN CR PP NN

1. Consider the patient situation and collect cues/information • Demonstrate a

beginner’s level understanding and application of clinical reasoning cycle.

5 marks

• Forms an initial impression about what might be occurring at the time.

• Correctly determines all cues that are relevant to collect from the patient scenario.

• Differentiates between subjective and objective cues.

• Correctly identifies all subjective and objective cues.

• Forms an initial impression about what might be occurring at the time.

• Determines most cues that are relevant to collect from the patient scenario.

• Correctly identifies most subjective and objective cues.

• Forms an initial impression about what might be occurring at the time.

• Determines many cues which are relevant to collect from the patient scenario.

• Correctly identifies many subjective and objective cues.

• Forms an initial impression about what might be occurring at the time.

• Determines some cues that are relevant to collect from the patient scenario.

• Correctly identifies some subjective and objective cues.

• Does not develop an initial impression of the person in the case.

• Lists cues provided in the case but cannot determine which cues are relevant to collect from the patient scenario.

• Does not identify or incorrectly identifies subjective and objective cues.

2. Process information • Demonstrate a

beginner’s level understanding and application of clinical reasoning cycle, and

• able to apply relevant knowledge to demonstrate a clear understanding of the assessment findings in relation to the patient’s context.

20 marks

• Identifies all relevant normal and abnormal cues.

• Analyses the cues that have been collected.

• Narrows down all the important information about the cues collected.

• Demonstrates an outstanding understanding of the assessment findings and patient’s condition in relation to the principles of anatomy and physiology.

• Compares the current situation to the previous situation including patient’s past history.

• Forms a logical opinion about what the patient is experiencing.

• Identifies all relevant normal and abnormal cues.

• Analyses some of the cues that have been collected.

• Narrows down most of the important information about the cues collected.

• Demonstrates an understanding of the assessment findings and patient’s condition in relation to the principles of anatomy and physiology.

• Compares the current situation to the previous situation.

• Forms a logical opinion about what the patient is experiencing.

• Identifies most normal and abnormal cues.

• Narrows down some important information about the cues collected.

• Demonstrates some understanding of the assessment findings in relation to the principles of anatomy and physiology.

• Compares the current situation to the previous situation.

• Attempts to form a logical opinion about what the patient is experiencing.

• Identifies some normal and abnormal cues.

• Demonstrates a limited understanding of the assessment findings in relation to the principles of anatomy and physiology.

• Some attempt at comparing the current situation to the previous situation.

• Forms a limited logical opinion about what the patient is experiencing.

• Does not identify normal or abnormal cues.

• Narrowing down of important cues has not occurred.

• Does not demonstrate an understanding of the assessment findings in relation to the principles of anatomy and physiology.

• No comparison of the current or previous situation.

• No logical opinion is formed.

CNA152: Health Assessment 1 Assessment Task 2B – Clinical reasoning report

3. Critically reflect, at a beginner’s level, on your skills performance, using scholarly sources to support your reflection. 10 marks

• Demonstrates comprehensive reflection and insight.

• Identifies one strength during the skills assessment and briefly explains why this promotes a positive patient outcome.

• Identifies one aspect of your practice for improvement and explains: a) what you should do differently next time, and b) why this is important for promoting a positive patient outcome.

• Outlines one course of action for improving this aspect of your practice with relevant connections to the current literature.

• Demonstrates solid reflection and insight throughout.

• Identifies one strength during the skills assessment and briefly explains why this promotes a positive patient outcome.

• Identifies one aspect of your practice for improvement and explains: a) what you should do differently next time, and b) why this is important for promoting a positive patient outcome.

• Outlines one course of action for improving this aspect of your practice with some connections to the current literature. Clinical Reasoning Report Discussion

• Demonstrates some reflection and insight throughout.

• Identifies one strength during the skills assessment and briefly explains why this promotes a positive patient outcome.

• Identifies one aspect of your practice for improvement and explains what you should do differently next time.

• Outlines one course of action for improving this aspect of your practice with limited connections to the current literature.

• The reflection is mostly a description of the learning experience but some attempt to provide justification for events or actions which have happened.

• Identifies one strength during the skills assessment and briefly explains why this promotes a positive patient outcome.

• Identifies one aspect of your practice for improvement and briefly explains what you should do differently next time.

• Outlines one course of action for improving this aspect of your practice.

• The reflection provides a description of the skills performance only.

• The reflection does not identify any actions or identifies irrelevant actions to improve the situation (the practical skills).

4. Writes in a structured, succinct and well informed manner with references to appropriate academic literature, current research and evidence- based clinical practice guidelines. Using correct Harvard referencing style 5 marks

• A high level of academic writing with strong evidence of planning.

• The paper is exceptionally logical, insightful and balanced and is consistently expressed in a clear and fluent manner.

• Accurately references all sources using the Harvard style.

• Academic writing with strong evidence of planning.

• The paper is logical and balanced and expressed in a clear and fluent manner.

• Accurately references the majority sources using the Harvard style

• Academic writing with clear evidence of planning with a logical flow.

• Discussion is generally expressed in a clear and fluent manner.

• Accurately references the majority sources using the Harvard style.

• Academic writing using coherent and partly cohesive expression.

• Semi-structured using some academic literature to support the paper.

• Accurately references most sources using the Harvard style.

• Multiple punctuation, sentence structure and formatting errors which impact on readability.

• Non-academic sources are utilised. • Inaccurate referencing style or

does not use the Harvard style. • Uses few or no references to

support work.

CNA152 Assessment Task 2B: Clinical Reasoning Report

Patient 2 Miss Lucy Wu, 20 years old, presented to a medical centre with pneumonia. Her skin looks very dry and pale. You have been assigned to look after her with a registered nurse this morning. At 0700 hrs, you received a handover from the night duty staff. Patient profile A 20-year-old Chinese female Chief complaint ‘I feel very tired and have chest pain when I cough. I don’t feel

like eating and drinking.’ Present health Patient states she is usually well. She has a history of

hypertension and is on medication. Her normal blood pressure (BP) is 140/80mmHg (on medical treatment). She returned to Launceston from Shanghai, China a few days ago. She started to feel generally unwell and fatigued since she returned to Launceston. She reported she had a few episodes of vomiting and shaking chills overnight. At 0400 hours, she felt the urge to use the bathroom. She said she felt generally unwell and shaking chills as soon as she got out of bed. She reported she felt very sick in her stomach and vomited a large volume of greenish-yellow fluid in the bathroom. Her flatmate called 000 and took her to the emergency department. Clinical Reasoning Report Discussion

Past medical history Medical history Hypertension for 2 years (on medication and under control),

tuberculosis 10 years ago and hay fever. Allergies She states she is allergic to aspirin and she comes out in hives. Social history Alcohol use Enjoys 1 to 2 standard drinks every night, usually drinks white

wine. Tobacco use Has never smoked. Domestic and intimate partner

She is single and an overseas student. She has a cousin who is also an overseas student in Sydney. Her parents live in Shanghai, China.

Work environment She is a second-year Bachelor of Business student in the University of Tasmania.

Home environment She lives in the Inveresk apartments. Religion Nil

CNA152 Assessment Task 2B: Clinical Reasoning Report

Patient 2 At 0600hrs, Miss Wu’s vital signs in the emergency department were: Blood Pressure 130/80 mmHg Pulse 110 beats/minute Temperature 39ºC Respiratory rate 24 breaths/minute

Now, the time is 0730 hours. Your mentor (the registered nurse) asks you to take a set of Miss Wu’s vital signs and the results are: Blood Pressure 140/70 mmHg Pulse 70 beats/minute Temperature 37.5ºC Respiratory rate 16 breaths/minute

Before you leave her room, Miss Wu tells you her T-shirt is soaked in sweat.