My Assignment Help

Reviewing Patient Background and History: Mrs. Ruby Pascal Simulation Assessment Answer

Mrs. Ruby Pascal Simulation

Setting the scene

Refer to your simulation documents

Epidemiology / pathophysiology of disease processes

The National Health Priority Areas of Obsesity, Diabetes Mellitus and Mental Health was established with the aim of improving health outcomes in all thes areas.

Excess weight, especially obesity, is a major risk factor for cardiovascular disease, type 2 diabetes, some musculoskeletal conditions and some cancers. As the level of excess weight increases, so does the risk of developing these conditions. In addition, being overweight can hamper the ability to control or manage chronic conditions.

The main factors influencing overweight and obesity are poor diet and inadequate physical activity. Increased energy intake from the diet without an increase in energy expenditure through physical activity will result in energy storage as fat and weight gain.

Diabetes is a chronic condition marked by high levels of glucose in the blood. The main types of diabetes are type 1 diabetes, type 2 diabetes and gestational diabetes. The prevalence of diabetes has been escalating over the last 3 decades, with rates tripling over this period—diabetes affected around 1.2 million people in 2014–15. Rates of diabetes are generally higher among males, the elderly, Indigenous Australians and people living in remote and socioeconomically disadvantaged areas. Type 2 diabetes is the most common form, and is largely preventable by maintaining a healthy lifestyle.

Mental illness comprises a wide range of disorders and varies in its severity. The effect of mental illness can be severe on the individuals and families concerned and its influence is far-reaching for society as a whole. Around 7.3 million Australians aged 16–85 (45% of that age group) will experience a common mental disorder such as depression, anxiety or a substance use disorder in their lifetime, according to the 2007 National Survey of Mental Health and Wellbeing. Estimates from the second National Survey of Psychotic Illness conducted in March 2010 suggest that almost 64,000 people have a psychotic illness and are in contact with public specialised mental health services each year.

Your Task:

Use the Clinical Reasoning Cycle (CRC) on the following pages to review the nursing priorities in relation to the care of Ruby.

Consider the CRC on the following pages and following your work on the modules that encompass the NHP and National Health and Quality Safety (NHQHS) Standards, you should be able to answer the workbook questions. This task will assist you to critically think about typical clinical situations that will arise when you are a Registered Nurse and you will be required to assess and make clinical decisions for your patients.

When you have done this, answer the questions at the end of this workbook and submit into Turnitin in the provided template.

Clinical Reasoning Cycle

Now we shall step through the CRC in relation to Ruby’s’ case to prepare you for the

workbook assessment questions. Based on your reading so far:

1. Consider the person and the context

Gain an initial impression of your patient

Consider Ruby’s situation, both socially and physically. What is your initial view of this patient and potential issues for her and her family.

Consider Ruby’s diabetes and obesity and how these may be


Ruby also has a mental health condition, consider the impact of this on her other conditions and her ability to cope at home.

For further background information read the Simulation documentation for Ruby focusing on:

  • Past medical history
  • Psychosocial history
  • Medications

2. Collect cues and information

  1. Review current information
  2. Gather new information
  3. Recall knowledge (A&P, ethics, law, cultural safety)

Consider Ruby’s current admission.

What are the issues with the communication? What may be contributing to this?

Ensure you understand the co-morbidities Ruby has presented with and how they may complicate her admission and discharge.

Consider the nursing role in her deterioration and in her discharge planning

Nursing Documents:

  1. Nursing Notes
  2. Med Chart
  3. Observation charts
  4. Discharge planning checklist

For your convenience a transcript of the handover is provided in the simulation documentation.

3. Process Information: 

Interpret data – what does it all mean?

It is important to consider the potential inter-relationships between mental health, cardio vascular, obesity, musculoskeletal problems and injury prevention.

What are the general nursing problems for patients who experience a pulmonary embolism?

How do you recognise deterioration?

What are some her risk factors for deterioration?

What do you anticipate may be discharge complications for Ruby given her co-morbidities?

4. Identify Problems/ issues

Synthesize all information that has been collected and processed.

You need to consider Ruby’s priority problems and any actual or strong potential problems she may experience while in hospital and on discharge based on your assessment of her and your knowledge of the pathophysiology of her presenting condition and co-morbidities.

5. Establish Goals

As a nurse, what are your desired outcomes for Ivan?

Now you have identified her problems, you need to identify your goals of care for each problem using the SMART acronym.

6. Take Action Intervene

What action/interventions will you do?

The next step is to consider what you will do and ensure your nursing interventions suit the context and are evidence based.

7. Evaluate Outcomes

Assess the effectiveness of actions

Now think about your interventions and how you will evaluate them.

8. Reflect on process and new learning

What have you learned from this experience?

Now consider what you have learnt and what you need to follow up with.


  1. Review patients background and history. Ms Ruby Pascal has multiple comorbidities including diabetes mellitus type 2.
    1. Identify and discuss (2) signs and symptoms that support a diagnosis of diabetes melitus type 2. (2 marks)
    2. Using evidence, compare and contrast the pathophysiology of type 1, type 2 and gestational diabeties melitus. (3 marks)
  2. Obesity is a significant risk factor for diabetes melitus type 2. Discuss how obesity is diagnosed and describe (2) physiological effects it can have on the body. (3 marks)
  3. Ms Pascal’s acute deterioration in the first simulation scenario is due to a pulmonary embolism.
    1. Identify and discuss (1) risk factor Ms Pascal has for developing a pulmonary embolism. (2 marks)
    2. Discuss how you would educate Ms Pascal about the diagnosis and treatment of a pulmonary embolism, including information you would give and how you would deliver this information (4 marks)
  4. Using your understanding of the clinical reasoning cycle:
    1. Identify one priority clinical nursing problem that Ms Pascal is experiencing related to her pulmonary embolism (1 mark)
    2. From the identified clinical priority nursing problem, state one (1) short term goal for Ms Pascal’s management using the SMART framework. (2 marks)
    3. Based on the short-term goal, state and justify (2) interventions (nursing, collaborative or pharmacological) which would assist to achieve Ms Pascal’s short-term goal. (4 marks)
    4. Provide and justify two (2) ways you would evaluate the outcomes of your interventions (one for each intervention) (4 marks)
  5. Review Standard 8 of the NSQHS. Identify and discuss two (2) strategies to ensure that patient deterioration is identified early and managed appropriately by nurses in the acute care setting. Justify each with evidence(4 marks)
  6. During the second simulation scenario, Ms Pascal requires anticoagulation therapy. In relation to Ms Pascal’s clinical scenario:
    1. Discuss the pharmacokenetics of heparin and warfarin and compare and contrast their use in the management of a pulmonary embolism. (4 marks)
    2. Identify two (2) medications that may interact with warfarin. (1 mark)
    3. Review Standard 4 of the NSQHS. Using the standard and other relevant literature, identify and justify two (2) nursing considerations when administering anticoagulant therapy. (2 marks)
  7. Ruby also has General Anxiety Disorder, therefore good communication is an integral in making sure she receives person centred care.
    1. Discuss the difference between Anxiety and General Anxiety Disorder (GAD)
    2. Identify and explain the assessment tool used to screen for GAD (2 marks)
    3. The first step in undertaking any nursing assessment of a person with an anxiety disorder is to develop raport and a working therapeutic alliance. Discuss what is meant by this and justify why it is important. 
    4. Anxiety levels range from mild, moderate, severe and panic. Identify and justify two (2) physiological characteristics of a severe anxiety levels. (2 marks)
    5. Ruby is experiencing a severe anxiety episode. Identify two (2) nursing interventions (excluding pharmaceutical) and provide a rational(4 marks)
  8. Ms Pascal has multiple comorbidies requiring complex interdisciplinary care both in hospital and on discharge.
    1. Define interdisciplinary care and discuss why it is important in achieving patient centred care. (2 marks)
    2. Identfy two healthcare professionals in the community that Ruby should be referred to on discharge to assist and justify why they are essential in Ruby’s ongoing care. (2 marks)
    3. Identify and justify two (2) nursing responsibilities to help prepare Ruby for discharge. (2 marks)


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. 

Pathophysiological features 
Type 1 
Type 2 
Gestational diabetes 
Nature of diabetes 
Non-insulin dependent 
Form of insulin resistance 
Major symptoms 
Frequent urination 
Acute weight gain or weight loss 
Unusual thirst and nausea 
Risk symptoms 
Heart attack 
Heart diseases and stroke 
Severe damage to the heart, kidney, eyes 
Main treatment process 
  • Effective measurement of blood sugar level (Lazear, 2015)
  • Proper meal planning 

Healthy eating and regular exercise 
Maintaining weight within control and healthy meal planning 

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 antacidsIn 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.

Appropriate identification of all clinical health problems of the patient to maintain effectiveness in treatment.
It can be measured by checking the rate of deterioration or improvement of Pascal’s health problem 
It can be attained by analyzing medical conditions and application of proper diagnostic methods 
It will be helpful to prescribe medicines which will not affect Pascal’s health conditions in an adverse manner 
1 month 

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. 

Types of interventions 
Ways to evaluate outcomes 
Clinical documentation for prescribing proper medications
Analysis and monitoring of patients’ conditions using Obs Chart
Critical level of conditions deterioration, as well as improvements, can be assessed well
Application of effective therapeutic process to prevent patient deterioration
Formation of medication chart and progress notes 
It way can be beneficial for assessing medical conditions of Pascal and bringing changes in her progress notes for the better treatment process.

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 8th 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 ScaleHamilton 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

Customer Testimonials