ThanksRS211 Assessment item 3- Clinical Presentation Report Case Study of ‘Margaret Law’ Use...

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ThanksRS211 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 current 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

Rimsha · Accepted Answer

Running Head: CLINICAL PRESENTATION REPORT	1
CLINICAL PRESENTATION REPORT		13
CLINICAL PRESENTATION REPORT
 CASE STUDY OF ‘MARGARET LAW’
Table of Contents
Introduction	3
Primary survey	3
Pathophysiology	6
Nursing Management	8
Conclusion	10
References	11
Introduction
This paper is based on the case study of a 63 years old patient named Margaret who is admitted to the hospital by her husband as she was suffering from immense pain in small rural multipurpose service. As mentioned by Afsar (2019), multipurpose service facility can be defined as the facility where combined care is provided to the people living in rural and remote communities where separated healthcare facilities such as care homes, clinics and hospitals are not available. 
These multipurpose services provide the flexible mix of services to the patients so that community health can be improved. As per the case study, the nearest hospital, which can treat coronary disease, is around 2 hours away from the multipurpose service. Apart from this, only one general practitioner was available at the site. The troponin result and ECG indicate that Margaret suffered from the heart attack. As mentioned by Morton, Turiano, Mroczek, and Ferraro (2018), it has been seen that heart attack is an emergency medical condition, which occur when clotting in the blood resulted in hindering the flow of blood to the heart. 
These results in the lack of oxygen in her heart, as an outcome, tissue of the body dies. It must be noted that patient is overweight, and history of hypertension, type II diabetes mellitus, right total knee replacement, and hiatus hernia. Following assignment conducts the clinical assessment of the patient and develops the clinical report. This report consists of primary survey assessment, pathophysiology of the condition of the patient, and nursing intervention related to the condition of the patient. 
Primary survey
	A to E
	Framework 
	Assessment 
	A
	Airway
	· The airway of the patient is patent. This is because patient can talk in normal voice
· There is no obstruction in the airways. This is because patient talks in complete sentences, but these sentences are short
	B
	Breathing 
	· Patient report the shortness of breath. Although, the oxygen saturation level is normal 94%. 
	C
	Circulation 
	· Patient is showing chest pain at the scale of 7/10. This indicates that patient is suffering from the high chest pain.
· The blood pressure of the patient is 101/65 mmHg. This shows that patient has high blood pressure. The normal blood pressure range is 120/80-140/100mmHG
· There is a regular but weak radial pulse in the patient. The heart rate of the patient is 95bpm. The normal heart rate range is between 60 and 100.
	D
	Disability 
	· The GCS 15 which is normal. 
· In triage, the level of patient is 2. The category 2 means patient’s condition is very critical and immediate treatment needs to be given. 
	E
	Exposure
	· The body temperature of the patient is 36.2 degree Celsius which is 1 degree lower than the normal body temperature (37 degree Celsius). Thus, body seems cool to touch.
· Margaret seems pale and diaphoretic. Margaret looks grey and sweaty all over. 
	The airway is patent. As mentioned by White, Bartley, Shakeel, Nates, and Hankin (2016), when a patient on assessment can speak in complete sentences when suffering from the medical condition, then it means airway of the patient is patent. There is no obstruction in the passage, which can affect the speaking of the individual. In context of breathing, patients complain for the shortness of breath. As mentioned by Tierney, and Bhagra (2018), shortness of breath can be defined as the condition in which patient feel uncomfortable because they have difficulty in getting air fully into the lungs. It has been seen that when patient suffered from heart or lungs issue, there can be obstruction of the breathing. The shortness of breath can be for short duration of time depending upon medical condition. 
	In context of circulation, patient reported 7/10 chest pain. This is very high level of pain. As suggested by Sakhnini, and Bisharat (2019), it has been seen that high level of chest pain is an indicator of the potential heart attack. When a person has high chest pain, shortness of breath and sweating, this is a clear indicator of heart attack. When high chest pain occurs and leading to heart attack, this means there is blockage in the blood flow. As an outcome, tissue dies due to lack of oxygen. The blood pressure of the patient is 101/65 mmHg. 
This is higher than the normal blood range. As stated by Iwakiri, and Groszmann (2020), it has been seen that blood pressure above the normal range which is 120/80-140/100 mmHg, results into hypertension. Apart from this, it has been seen that patient has a long history of hypertension, which can weaken her heart. The radial pulse of the patient is weak. As mentioned by Xu, Yuan, Ding, Gao, and Huang (2018), it has been seen that weak radial pulse means that heart is going to stop. Apart from this, radial pulse in used to measure the blood gas. The weak radial pulse means there is slow flow of blood in the body. 
	The GCS level of the patient is 15. As mentioned by Kehoe et al. (2016), it has been seen that GCS score is a neurological scale, which is used to measure the level of consciousness of the individual. It has been seen that patient is completely conscious. This is because the GCS level is 15/15. There is no indication of the brain injury. The triage category of patient is 2. As noted by Liu, Wang, Liu, Yue, and Bell (2017), triage categorization at the emergency help in understanding the action that needs to be take. 
Category 1 and 2 are the severe category of the triage, which needs immediate action. It has been seen that patient has triage 2 category.

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...

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