Mrs Rhonda Bott is a 68 year old retired receptionist who is bought in by ambulance to the emergency department (ED) of her local hospital. Her son Gareth is with her. Gareth had called the ambulance service earlier stating that his mother woke this morning complaining of a headache and is now unable to lift her right arm and has been having difficulty speaking. On examination Mrs Bott has a BP of 200/110mmHg, pulse rate 78bpm and irregular, respiratory rate 16, SpO2 98%, Glasgow coma scale (GCS) 12/15, & temp 36.8 degrees c. Her blood sugar level is 4.8mmol/L. She also has paralysis of the right arm and right side of the face and nil sensation to touch on the right side of her face and right arm. She appears to understand what is being said to her but cannot respond verbally. Mrs Bott’s history includes depression and lower gastro-intestinal bleeding associated with haemorrhoids. She has no known allergies. Mrs Bott is an only child. Her father died of an anterior myocardial infarct at age 57 and her mother died of breast cancer at the age of 72. Mrs Bott currently lives with her son, due to the recent death of her husband, Barry. They are in the process of trying to sell the family home. She has three other children, all of whom live interstate.
Rhonda Bott’s current medications are: Sertraline 100mg maneØ Rectinol HC topically as requiredØ At the time of arrival Mrs Bott had a provisional diagnosis of stroke. Mrs Bott was ordered a CT scan of the head which was conducted 4 hours after her arrival to ED, the results excluded the presence of a haemorrhagic stroke but indicated ischemic stroke. A 12 lead ECG was also conducted on arrival and Mrs Bott was found to be in atrial fibrillation.
Directions
This assessment task requires you to apply aspects of the Clinical Reasoning Cycle (CRC) to the above case study, using the following questions/instructions to guide and organise your response.
Your answers should be presented in an integrated essay format (rather than short-answer responses) and be informed and supported by your reading of current research and literature.
- What additional data/cues would you gather in regard to this case, and how and why would this be performed?
- Draw upon existing knowledge and relevant scholarly literature to process the above information.
- Given that the diagnosis of ischaemic stroke has already been confirmed, identify and explain two other issues/problems for Mrs Bott that emerge from your analysis of the data (remember, these do not necessarily have to be other specific diagnoses/conditions, but could be particular problems that arise due to the stroke).
- Select one of these issues/problems and establish a clear goal for your care.
- Discuss your key actions/interventions for achieving this goal, drawing upon appropriate practice literature.
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