1. Reviewing the patient's background and history 

a. Discussing the signs and symptoms of diabetes mellitus type 2

Increased thirst and frequent urination are two of the most prominent symptoms of diabetes mellitus type 2(Lazear, 2015). Along with this, obesity is another critical sign which was prominent in Mrs Pascal (refer to appendix 4). Hence, it can be stated that these signs and symptoms are effective to support the diagnosis of diabetes mellitus type 2 (Vujosevicet al., 2019, p. 437). 

b. Compare and contrast between type 1, type 2 and gestational diabetes

The following table has involved discussion based on comparison and contrasting between diabetes type 1, type 2 and diabetes mellitus. 

Table 1: Pathophysiology of type 1, type 2 and gestational diabetes

(Source: WebMD, 2020)

2. Ways to diagnose obesity

As per the views of Camacho & Ruppel (2017, p. 128), calculation of BMI level and measurement of waist circumference is helpful to diagnose the level of obesity of an individual. In the case scenario, it has been observed that Mrs Pascal had obesity as her BMI rate was >35. Thus, there can be a chance of developing diabetes in her. 

Physiological effects of obesity

Obesity may cause a strain on the whole circulatory system (Arnold & Boggs, 2019). As a result of this metabolic disorder, risk of heart attack as well as risks of hypertension and diabetes may be developed in an obese individual. In the case of Mrs Pascal, the reason for her acute anxiety can be her level of obesity. 

3. Ms Pascal's acute deterioration in the first simulation

a. One risk factor for developing pulmonary embolism

It has been observed that Mrs Pascal encountered critical deterioration due to pulmonary embolism (PE). Her medical history denotes that she used oral contraceptive pill along with paracetamol and antacids. In this respect, taking birth control pills is the reason for developing PE.

b. Ways to educate Mrs Pascal

In order to educate Mrs Pascal in a proper manner, it is necessary to provide her relevant formation regarding the method of diagnosis and treatment of PE. As described by Sharma & Lucas (2017, p. 195), cheat x-ray or ultrasound scan are the primary ways to detect PE. Along with this, computerized tomography pulmonary angiography (CTPA) is one of the most effective ways to detect PE. Providing warfarin is a helpful treatment process of PE which helps to prevent blood clots. 

Appropriate information needs to be given of Mrs Pascal such as the importance of taking anticoagulant medicines that can be effective to reduce the harmful effects of PE. This can be managed through maintenance of frequent oral communication (Arnold & Boggs, 2019, p. 50)

4. Understanding of clinical reasoning cycle

a. The nursing problem of pulmonary embolism

One critical priority nursing problem that was faced by Mrs Pascal is that her treatment process was based on managing her anxiety attack and subjecting her to anticoagulant therapy, but the nurses and physicians were not focused to invest the reasons and treating her problem of PE.

b. Short term goal for Mrs Pascal’s management

The short term goal can be framed as- Appropriate identification of all clinical health problems of the patient to maintain effectiveness in treatment.

Table 2: SMART goal

(Source: Developed by author)

c. Justification of two nursing interventions

In order to achieve the above mentioned short term goal, the following two interventions can be applied.

• Clinical documentation for prescribing proper medications (nursing intervention)

Proper clinical documentation can be effective to assist Mrs Pascal to have effective patient-centred care both in hospital and in-home after discharge.

• Application of effective therapeutic process to prevent patient deterioration (Collaborative intervention)

This intervention can be beneficial to resolve acute health issues of Pascal by providing different types of the therapeutic treatment process in collaboration with different caregiving individuals in a hospital. As stated by Senapati et al., (2018, p.25), implementation of collaborative interventions in nursing care process helps to promote quality outcomes and development of patients’ experiences. 

d. Two ways to evaluate interventions’ outcomes

The following table sheds the light of two different ways which can be beneficial to evaluate the outcomes of nursing interventions. 

Table 3: Ways to evaluate outcomes

(Source: Developed by author)

5. Identification and discussion on strategies of NSQHS standards

Acute care setting in nursing is based on the detection of patient deterioration early as well as implements of healthy management strategies. The 8^th Standard to NSQHS is the proper use of recognition and response system by medical teams is helpful to prevent acute deterioration of physiological conditions of patients (NSQHS, 2020). In this respect, the following two strategies are effective to ensure prevention of patient deterioration as well as managing the nursing care process in an appropriate manner.

• 24*7 monitoring of patients 

Collaborative actions by medical teams are helpful to set an acute caregiving process for patients (Lazear, 2015, p. 100). In addition to this, 24*7 clinical care process can be maintained easily that may be beneficial to prevent acute deterioration of patients’ conditions. 

• Analysis of early medical history in depth to prescribe effective medications and therapeutic care

It is another suitable strategy of the collaborative workforce which is helpful for prescribing effective medications for patients. Providing better therapeutics and clinical care process helps the patient to be recovered and help the clinical care team to prepare discharge checklist which will be helpful to manage caregiving process in the home of the patient (Zarit, 2017, p. 720). 

6. Second simulation of Mrs Pascal

a. Discussing pharmacokinetics of heparin and warfarin

Warfarin is the most widely used anticoagulant but it is not critically effective as heparin. Two tests are mainly conducted by clinicians such as Prothrombin time and INR. In the comments of Ayerst et al. (2017), heparin works faster than warfarin. Most of the time heparin is given to patients to prevent the previous clotting of blood. Heparin has the most effective pharmacological importance as it can be provided to pregnant women whereas warfarin cannot be given to them.

In order to treat pulmonary embolism heparin and warfarin can be applied in different ways. It has been observed that heparin is given to patients subcutaneously that is an injection under the skin or intravenously. As mentioned by Spenceret al., (2019, p. 169), warfarin is used as a pill to patients that ultimately lead to creating huge bleeding. Mrs Pascal was given heparin as she had intravenous blood clotting at an acute level. 

b. Two medications that interact with warfarin

Two medications that interact with warfarin are aspirins and antacids or laxatives (Gov, 2020, p. 1). Thus, Mrs Pascal was not given warfarin as she had previous medical history to intake paracetamol and antacids. 

c. Nursing considerations for administering anticoagulant therapy

Standard 4 of NSQHS highlights that development of medication system is helpful for health service organizations to treat the patients in an efficient manner NSQHS, (2020). Based on these guidelines, two nursing considerations for administering anticoagulant therapy can be as mentioned below- 

• Assessing the previous history of thrombosis

This nursing practice is essential to administer anticoagulant therapy in an efficient manner. In this regard, chances of bleeding or haemorrhage assess which ultimately helps to detect whether there is any chance of increased thrombosis (Nagy, Heemskerk &Swieringa, 2017, p. 442)

• Measuring prothrombin time (PT)

This nursing consideration can be helpful to assess whether the rate of clotting is appropriate for patients or not. Besides, it can be further helpful to determine the rate of calcium in the body, thus the process of medications becomes easier (Ayerstet al., 2017, p. 278).

7. Providing person-centred care to Ruby

a. Differences between anxiety and GAD

General anxiety denotes tension regarding a particular event whereas the GAD is based on the chronic and unsubstantiated worry that ultimately leads to long term mental stress (Meek, 2019).Different associated risks may include difficulties in relaxing, sleeping and reducing concentration. As per the report by Meek (2019), GAD may involve the critical level of insomnia and constant difficulties in concentration. Moreover, GAD includes restlessness, muscle pain and fatigue which are not so critical in case of normal anxiety. 

b. Assessment tools to screen GAD

It has been observed that a number of medical caregiving centres use a number of effective assessment techniques to screen GAD. In this respect, some assessment tools are there such as overall Anxiety Severity and Impairment Scale, Hamilton Anxiety Rating Scale and Leibowitz Social Anxiety Scale (ADAA, 2020).

c. Definition and importance of the therapeutic alliance

The therapeutic alliance is an effective mode of communication which helps to maintain a steady relationship within caregivers and patients. In order to treat an anxiety patient, it is necessary to develop a rapport with him/her (Zarit, 2017, p. 720). The therapeutic alliance is the way to build a rapport. 

It is important to maintain effective communication in the caregiving process as well as it is helpful to know the basic reasons for the anxiety of a patient.

d. Two nursing interventions for severe anxiety

It has been observed that the anxiety level of individuals can be differentiated into four stages such as mild, moderate, severe as well as panic. In the thoughts of Saeed et al. (2017, p. 1290), different levels of anxiety have different symptoms. In this respect, two physiological characteristics of severe anxiety are racing heart with chest pain and muscle tension with trembling (Aihw, 2020).

e. Nursing interventions for Ruby

Providing effective comfort measures and educating patients with the healthy communication system is helpful for Mrs Ruby to be recovered from her severe anxiety. Sharing personal thoughts as well as having effective care giving support may help her to lead an anxiety-free life.

8. Needs of interdisciplinary care both in hospital and on discharge

a. Definition and discussion on interdisciplinary care

Interdisciplinary care is the process to meet physical, psychological as well as spiritual needs of the patients. As opined by Wilson & Seymour (2017, p. 130), the interdisciplinary care team involves different types of medical care providers who can be able to provide healthy patient-centered care to all patients equally. 

In order to provide effective patient-centred care process, it is necessary to meet their needs not only for medical purposes but also physical, psychological along with spiritual needs (Nagy, Heemskerk &Swieringa, 2017, p. 445). 

b. Needs of two healthcare professional for Ruby on discharge

After discharge, Ruby can be referred to private nurses and occupational therapists which are the efficient healthcare providers in the community. Private Nurses can be helpful for her to have 24*7 critical patient-centred care and proper administrations of medications (Megaritis et al. 2018, p. 521). Along with this, occupational therapists can be helpful to maintain regularity of anticoagulation therapy of Pascal in her home. 

c. Identifications of nursing responsibilities during discharge

It is considered as critical responsibilities of nurses to prepare a patient mentally and physically before discharge. In this respect, it is required to teach Ruby regarding her health conditions and what kinds of care will help her to be recovered. On the other hand, the formation of a follow-up care plan is another responsibility of nurses to guide Ruby before her discharge.