CLINICAL REASONING

Mrs Carole Kennedy is a 56-year-old female who has been in your ward for 2 days for
treatment of pneumonia. You are a graduate nurse on the second rotation of your graduate
program and Mrs Kennedy is one of your patients today.
You learn from her notes that Mrs Kennedy lives alone in rented accommodation and has
recently retired on a superannuation pension as her only source of income. Mrs Kennedy’s son
lives in Melbourne and rarely sees him. When you are talking to Mrs Kennedy, she is teary and
tells you she has been feeling down lately. She is worried about going home as her chest pain
has occurred several times recently when she is doing the housework. Mrs Kennedy states that
she hates asking anyone for help.
As documented in the progress notes Mrs Kennedy has a history of ischemic heart disease
(IHD), hypertension and beginning peripheral vascular disease (PVD). She had coronary artery
bypass graft (CABG) surgery six years ago with saphenous vein grafts to her left anterior
descending (LAD) coronary artery and diagonal branch. Two years ago, Mrs Kennedy
underwent a percutaneous transluminal coronary angioplasty (PTCA) with stenting to her right
coronary artery (RCA) and posterior descending artery (PDA).
Mrs Kennedy smoked for 30 pack years, starting at the age of 19 and ceasing at 49 when she
was first diagnosed with coronary artery disease (CAD).
Her weight is charted as 88kg and her height 158cm.
Her observations at 0800 hours were as follows:
Temperature: 37.3ᵒC
Pulse: 74bpm, regular, volume strong
Respiratory rate: 14/min, regular, normal depth
BP: 165/90mmHg (normal for her)
SpO2: 98% on room air
30 minutes later when you are administering Mrs Kennedy’s medications you notice that she is
a little diaphoretic. On questioning she says that she does not feel well, has a mild pressure
sensation in her chest (rated 4/10) that started about 10 minutes ago while she was lying in
bed. She states that it is much the same sort of pain she has had previously. When further
questioned she states that she also has a slight ache in the underside of her upper left arm, and
is feeling a little nauseated.
You assess her vital signs again and they are as follows:
Temperature: 37.2ᵒC
Pulse: 116bpm regular and volume is not as strong as previously
Respiratory Rate: 26/min, regular, a little shallower than previously
BP: 105/70mmHg
SpO2: 92% on room air
She has developed slight shortness of breath. Peripheries are a little cool to touch.

  1. Provide an introduction (approximate 150 words).
    The purpose of the introduction is to give the marker a clear idea of what your essay will
    cover. It should provide some background information on the specific problem or issue
    you are addressing. A few sentences explaining your essay in general terms will give the
    marker an idea of what to expect from the rest of your essay.
  2. Analyse the changes in Mrs Kennedy’s clinical presentation and link these to the
    pathophysiological processes, which are occurring. You will need to explain what could
    be causing the changes in her signs and symptoms (approx. 500 words).
    This question is asking you to analyse the changes in her subjective and objective data
    that has been provided. For example, what causes her heart rate to increase- here you
    are required to explain about pathophysiological changes.
    (Pathophysiological processes mean explanation of mechanisms how the condition
    develops).
  3. Discuss and critically analyse the priorities of care that you have included as part of your
    nursing care. You will need to consider the changes in her condition, giving rationales for
    the priorities of care and specifically the management of her chest discomfort (approx.
    800 words).
    This question is asking you to consider the most important problems that Carole is
    having currently- remember ABC and look at her condition and presentations.
  4. Briefly discuss the psychosocial issues relating to Mrs Kennedy’s current stage of disease
    and her life situation (approx. 200 words).
    This question requires you to look at the psychological factors and her surrounding social
    environment that could have on her physical and mental wellness. There are a number of
    issues that could be addressed however; you are not required to discuss all of them. You
    can choose one or two to discuss.
  5. Provide a conclusion (approx. 150 words).
    The conclusion brings closure to the reader, summing up your points or providing a final
    perspective on your topic. Simply review the main points (being careful not to restate
    them exactly).