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Kimberley Thole
, Substantiation of care
Kimberley Thole
Name: Kimberley Thole
Student number: xxx
Name supervisor: xxx
Name mentor: xxx
Course code: xxx
Name department: Emergency Medicine Department
Date: 07/12/2024
,Table of contents
Ch.1: Introduction 2
Ch. 2: Assessment of the situation 3
Ch. 3: Clinical problems 6
Ch. 4: Additional tests 10
Ch. 5: Clinical policy 12
Ch. 6: Clinical course 19
Ch. 7: Review 21
Ch. 8: Communication 26
Ch. 9: ICT applications 27
Ch. 10: Case study 27
Ch.11: Anti plagiarism statement 29
Bibliography 30
Appendices 33
1
, Ch.1: Introduction
This portfolio showcases the module ‘substantiation of care’, which revolves around clinical
reasoning within the various stages of the nursing process. For this module, a
high-complexity case (see Appendix 1) was used of a trauma patient who endured a
traumatic brain injury after an incident with a scaffold. He was brought into the Emergency
Medical Department (EMD) where his condition was assessed using the ABCDE method.
A nursing plan was composed according to the proactive nursing method. This method
consists of six steps that give structure to the clinical decision-making process. Clinical
reasoning is about continuously assessing the situation critically and making decisions
based on that assessment. It is the translation of knowledge into practice. The proactive
nursing method helps to oversee, analyze, address, and monitor situations, allowing for
quicker action taking, and thus improving patient safety (Bakker & Van Heycop Ten Ham,
2014).
In the first step, the emphasis is on forming a clinical picture of the patient. This is done
based on the patient’s medical history, complaints and symptoms, laboratory results, and
other examination findings. The second step focuses on identifying and explaining the
clinical issues by analyzing and possibly linking the collected data. Another goal is to
determine which problems should be prioritized and which can be dealt with later. In the third
step, it is determined which valuable information is still missing and what additional
examinations are needed. In the fourth step, the clinical policy is developed, and in the fifth
step, the short- and long-term effects of this plan are described. In the sixth and final step,
the established nursing outcomes are evaluated (Enurse, n.d.).
2
Kimberley Thole
, Substantiation of care
Kimberley Thole
Name: Kimberley Thole
Student number: xxx
Name supervisor: xxx
Name mentor: xxx
Course code: xxx
Name department: Emergency Medicine Department
Date: 07/12/2024
,Table of contents
Ch.1: Introduction 2
Ch. 2: Assessment of the situation 3
Ch. 3: Clinical problems 6
Ch. 4: Additional tests 10
Ch. 5: Clinical policy 12
Ch. 6: Clinical course 19
Ch. 7: Review 21
Ch. 8: Communication 26
Ch. 9: ICT applications 27
Ch. 10: Case study 27
Ch.11: Anti plagiarism statement 29
Bibliography 30
Appendices 33
1
, Ch.1: Introduction
This portfolio showcases the module ‘substantiation of care’, which revolves around clinical
reasoning within the various stages of the nursing process. For this module, a
high-complexity case (see Appendix 1) was used of a trauma patient who endured a
traumatic brain injury after an incident with a scaffold. He was brought into the Emergency
Medical Department (EMD) where his condition was assessed using the ABCDE method.
A nursing plan was composed according to the proactive nursing method. This method
consists of six steps that give structure to the clinical decision-making process. Clinical
reasoning is about continuously assessing the situation critically and making decisions
based on that assessment. It is the translation of knowledge into practice. The proactive
nursing method helps to oversee, analyze, address, and monitor situations, allowing for
quicker action taking, and thus improving patient safety (Bakker & Van Heycop Ten Ham,
2014).
In the first step, the emphasis is on forming a clinical picture of the patient. This is done
based on the patient’s medical history, complaints and symptoms, laboratory results, and
other examination findings. The second step focuses on identifying and explaining the
clinical issues by analyzing and possibly linking the collected data. Another goal is to
determine which problems should be prioritized and which can be dealt with later. In the third
step, it is determined which valuable information is still missing and what additional
examinations are needed. In the fourth step, the clinical policy is developed, and in the fifth
step, the short- and long-term effects of this plan are described. In the sixth and final step,
the established nursing outcomes are evaluated (Enurse, n.d.).
2
