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Assessment Part A
In part A you will collect cues and information regarding your selected patient, process
the information to enable the formulation of hypotheses and then discuss the further
assessments required to negate or validate your hypothesis. – 4 hour time frame
To enable this you are required to
1. Review the documentation of the patient.
2. Gather the data from both the presentation and documentation then hypothesise
what could be happening to your patient.
3. Formulate the probable hypotheses for your patient that are relevant for the next four hours of their hospital stay.
4. Identify the questions you would ask in a patient interview and the focused
physical assessment you would conduct to gather more data to validate or negate
your hypothesis
In your written discussion..
Provide all the hypotheses you have formulated and your rationale for each
hypothesis and include the data you have gathered as evidence of the
hypothesis.
Provide a discussion and examples (where possible) of the questions you would
ask in a patient interview and the focused physical assessment you would conduct
to gather more data to validate or negate your hypothesis. Include in your
discussion a rationale as to why you are asking the questions and conducting the
focused physical assessment. The rationales need to relate to the
pathophysiology of the patient‘s current condition as this discussion which comes
from the literature provides both evidence and explanation of your clinical
reasoning.
PATIENT INFO – digital story and review the documentation of the patient.
Douglas Adams, 51 year old male.
Past history: Type 1 diabetes, Hypertension
Allergies: Penicillin.
Current medications: Humalog Mix 25: 26 units mane and 16 units nocte. Perindopril: 4 mg mane, Aspirin: 100 mg daily.
Social History: Douglas drinks socially 1-2 times a week and consumes 3 standard drinks, he smokes 1 pack of cigarettes a day. He lives in a small apartment by himself and joined a walking group 4 weeks ago with his accounting firm.
Weight :100kg four weeks ago at clinic visit. Height: 185cm.
Presenting complaint: Douglas was admitted with confusion for investigation after a friend visited and found him confused and disorientated at home. He was transported to emergency via ambulance. His Glasgow coma score was 14/15 in emergency.
Current situation: Douglas has been admitted to the ward. When he arrives in the ward the staff completes his weight and height. Weight is 94kg and height 185cm. His Glasgow coma score on admission remained at 14/15. His vital signs are HR –
82bpm, BP – 110/87mmHg, RR-18, T – 36.8. A CT has been planned for Douglas and you inform him that his test will be later this morning. He is having QID Blood Sugar Levels (BSL) and 4/24 neurological obs. His BSL prior to breakfast is 5.2 mmol/L and his mane medications were administered as ordered.
Later that morning, Douglas rings the buzzer to ask what time he will see the doctor and when he will be going for his test. He appears slightly sweaty and has a slight hand tremor. You note that the breakfast was only partly eaten and Douglas says that he’s not really hungry. Douglas appears pale and his speech is slightly slurred. He does not know where he is. His vital signs are: HR – 88bpm, BP –
105/80mmHg, RR-18, T – 36.5.
REFERENCES should include current peer reviewed journal articles (no older than FIVE YEARS OLD)
including nursing journals with minimal text books and no more than two academic websites.
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