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Your clinical experience
Describe your clinical experience for this week.
Did you face any challenges, any success? If so, what were they? Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales. Mention the health promotion intervention for this patient. What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse? Support your plan of care with the current peer-reviewed research guideline.
Full Answer Section
General Appearance: Appears anxious and distressed.
Other Systems: No significant abnormalities noted.
Plan of Care:
Immediate Management:
Administer oxygen.
Monitor vital signs closely.
Obtain an electrocardiogram (ECG) and cardiac markers.
Prepare for potential acute coronary syndrome (ACS).
Differential Diagnoses:
Acute myocardial infarction (AMI)
Pulmonary embolism
Costochondritis
Rationale: The patient's presentation, including chest pain, diaphoresis, and cardiovascular abnormalities, is consistent with AMI. However, other conditions such as pulmonary embolism and costochondritis must be considered in the differential diagnosis.
Health Promotion Intervention:
Educate the patient about risk factors for heart disease, such as smoking, hypertension, and high cholesterol.
Encourage the patient to adopt a healthy lifestyle, including regular exercise, a balanced diet, and stress management.
Refer the patient to a cardiologist for further evaluation and management.
Challenges and Successes
Challenge: Communicating effectively with the patient and his family due to language barriers.
Success: Successfully obtained a comprehensive history and conducted a thorough physical examination despite language challenges.
Learning from Experience
This week's clinical experience has reinforced the importance of effective communication and cultural sensitivity in patient care. It has also highlighted the critical role of timely assessment and diagnosis in managing acute medical conditions. By accurately identifying the patient's condition and initiating appropriate treatment, I was able to contribute to his care and potentially prevent serious complications.
Research Guideline
The American College of Cardiology/American Heart Association guidelines for the management of acute myocardial infarction were used to inform the plan of care for this patient. These guidelines provide evidence-based recommendations for the initial assessment, diagnosis, and treatment of ACS.
Reference:
American College of Cardiology/American Heart Association Task Force on Practice Guidelines. (2021). 2021 Guideline for the Management of Acute Myocardial Infarction. Journal of the American College of Cardiology, 78(24), e142-e239.
Sample Answer
Clinical Setting: Kisumu County Hospital, Medical Ward
Patient Encounter:
I encountered a 65-year-old male patient, Mr. Ochieng, presenting with a chief complaint of chest pain. He described the pain as a sharp, stabbing sensation that radiates to his left arm. The pain is associated with shortness of breath and diaphoresis.
Assessment:
Vital Signs: Blood pressure 140/90 mmHg, heart rate 100 beats/min, respiratory rate 24 breaths/min, temperature 37.5°C, oxygen saturation 92% on room air.
General Appearance: Appears anxious and distressed.