Charles Sturt University School of Nursing, Paramedicine and Health Sciences Session 202630
Assessment Context
Charles Sturt University sets NRS387 Assessment item 3 as the heaviest task in the subject, worth 60 per cent, and it replaces the earlier two-part structure in which a case analysis carried 50 per cent and a shorter cycle task carried the rest. Students write a single 1,800-word case study against the eight-stage Clinical Reasoning Cycle template, submitted through Turnitin and marked against a standards-based rubric. The 2026 session version keeps the template, the eight stages and the word length intact, and adds an explicit requirement that each stage be labelled with the template heading so markers can locate claims quickly.
Three published versions of this task inform the brief below. The 2023 item asked for three goals and three interventions across eight stages at 1,800 words and 50 per cent, with reflection against a named model. The 2024 item cut that to two goals and two interventions and removed the explicit model requirement, while keeping 1,800 words and raising the value to 60 per cent. The 2025 cycle at Charles Sturt shifted the equivalent task in another subject to 1,400 words and four stages, which signals a tightening of word budgets rather than a change in framework. Stage allocations below follow the 2026 pattern.
Subject Learning Outcomes
This assessment task assesses the following subject learning outcomes:
- Identify and apply assessment frameworks and techniques to the care of infants, children, adolescents, adults and older people in a simulated environment.
- Identify and demonstrate selected evidence-based nursing interventions that promote safety, healing and caring in practice for people across the lifespan in a simulated environment.
- Apply the Clinical Reasoning Cycle to interpret assessment findings, plan, justify and evaluate care in the context of complex clinical scenarios.
The task also contributes to the Charles Sturt Graduate Learning Outcome for academic literacy, which covers the use of credible evidence, structure and referencing conventions.
Assessment Task
Access the case study in the Assessment 3 folder and complete the eight stages of the Clinical Reasoning Cycle in the template provided. Use the stage name as the heading for each section. Word allocations below total 1,800 and markers expect each stage to sit within roughly fifty words of its allocation.
| 1 | Consider the patient situation |
|
200 |
| 2 | Collect cues and information |
|
200 |
| 3 | Process information |
|
250 |
| 4 | Synthesise and identify the problem |
|
250 |
| 5 | Establish SMART goals |
|
200 |
| 6 | Select a course of action |
|
300 |
| 7 | Evaluate outcomes |
|
200 |
| 8 | Reflect on the process |
|
200 |
Consider the Patient Situation
Give the person and the context in about 200 words. Cover location, the people involved, the presenting situation and anything in the history that changes how the cues should be read. Write in third person here and throughout stages one to seven. Detail that does not bear on the reasoning belongs in the bin, not the paragraph.
Collect Cues and Information
List the relevant assessment findings and name the additional data required. Separate what is already known from what the nurse still needs, since the criterion rewards students who notice the gap. Identify the observations that fall outside the expected range for this person, then state which two or three matter most and why. Charts, track and trigger scores, pathology results and the patient’s own words all count as cues.
Process Information
Compare abnormal findings with expected findings and explain the clinical meaning of each. Reference is required at this stage. A number recounted without interpretation earns nothing, while a number tied to a mechanism earns the criterion. Rank the findings so the marker can see the reasoning, rather than presenting a flat inventory of every observation recorded.
Synthesise and Identify the Problem
Name one main clinical issue and explain the pathophysiology behind it. One issue analysed well beats four listed in a sentence each. The Clinical Reasoning Cycle treats synthesis as the point where separate cues become a single defensible statement about what is happening to this person (Levett-Jones, 2023). Link the pathophysiology to the cues already presented, so the synthesis answers the stage rather than sitting beside it.
Establish SMART Goals
Write two person-centred goals in SMART format, with each element labelled. Person-centred means the goal belongs to the patient and reflects what the patient values, not only what the nurse wants to chart. A goal such as maintaining a systolic blood pressure above 100 mmHg within two hours is specific and measurable; a goal such as improving haemodynamic status is neither. No in-text referencing is required at this stage.
Select a Course of Action
Write two nursing interventions, one for each goal, with an evidence-based rationale for each. Order them by clinical urgency and say why that order was chosen. Actions within the nursing role come first, and escalation belongs in the sequence where it actually occurred. Reference each rationale, and prefer a guideline, a systematic review or a textbook chapter over a hospital fact sheet.
Evaluate Outcomes
Explain how the outcomes would be evaluated, including the observations, timeframes and sources of data used. State what a partially met goal would look like and what the nurse would do next in that case. Discuss why evaluation depends on re-examining both objective data and the patient’s own account, since a normal blood pressure can sit beside a patient who feels worse than an hour ago.
Reflect on the Process
Reflect on what the process taught and how it will change practice. First person is acceptable in this stage only. Name the moment the reasoning shifted, since generic statements about learning to think critically read as filler. Referencing is optional here, and a named reflection model is not required in the current version of this item.
Submission Requirements
- Submit one document through Turnitin using the template. Keep the stage headings, add a title page and a reference list, and exclude both from the word count.
- Word count sits on the title page. In-text citations count; the reference list does not.
- Seven-day automatic extension is available through the subject site. Extensions beyond that require an application with supporting evidence.
- Academic integrity applies to all sources, including simulation notes, subject materials and workplace documents.
- Late submission without an approved extension attracts a penalty under the Charles Sturt Assessment Policy.
Marking Criteria
Charles Sturt marks against standards rather than against a curve, so the grade depends on how closely the work matches the descriptors. A script that meets every Credit descriptor and two Distinction descriptors sits at Credit. The failure band signals a threshold that was not met, not an effort judgement.
| Criterion | High distinction 85 to 100 | Distinction 75 to 84 | Credit 65 to 74 | Pass 50 to 64 | Fail below 50 |
|---|---|---|---|---|---|
| Cue collection and interpretation20 per cent | Selects cues that carry diagnostic weight, names the missing data, and explains why the discarded findings were discarded. | Selects relevant cues and identifies missing data with sound justification. | Selects mostly relevant cues and identifies some missing data. | Lists observations with limited selection or justification. | Copies observations without identifying relevance or gaps. |
| Synthesis and pathophysiology20 per cent | Names one issue, explains the mechanism accurately, and shows how the cues converge on that conclusion. | Names one issue with accurate pathophysiology linked to the cues. | Names a plausible issue with largely accurate pathophysiology. | Pathophysiology present but general or partly inaccurate. | No clear issue identified, or mechanism errors that would mislead care. |
| Goals and course of action25 per cent | Goals are person-centred and measurable, interventions follow clinical urgency, and each rationale rests on strong evidence applied to this person. | Goals are measurable and person-centred, with evidence-based rationales and a defensible priority order. | Goals mostly SMART, rationales supported, priority order stated. | Goals partly SMART, rationales thin or generic. | Goals not measurable, or interventions unrelated to the identified issue. |
| Evaluation of outcomes15 per cent | Sets out indicators, timeframes and data sources, and reasons through what a partially met goal would require. | Explains evaluation with indicators, timeframes and attention to both objective and subjective data. | Explains evaluation with some indicators and timeframes. | Describes evaluation in general terms. | No evaluation process described. |
| Reflection10 per cent | Locates a specific moment where reasoning changed and draws a consequence for future practice. | Reflects specifically on the reasoning process and its implications for practice. | Reflects on the process with some specific detail. | Reflection is descriptive or generic. | No reflection, or reflection unrelated to the task. |
| Academic writing and APA10 per cent | Precise prose, template used exactly, APA 7 accurate in text and in the reference list. | Clear prose with minor errors in APA 7. | Understandable prose with several referencing errors. | Mechanical errors that interfere with meaning, or inconsistent referencing. | Structure absent, referencing incorrect, or sources absent. |
Sample Answer Writing Help
Both extracts use a sepsis scenario and follow the template exactly. Substitute the cues in your own case study and keep the reasoning chain visible, since the rubric rewards the links between stages rather than the clinical facts alone.
Follow-Up Reading
Recognise, Relay, React
Escalation failures rarely begin with a missed observation. Burke et al. (2022) analysed 52 articles and grouped the causes of failure to rescue under three phases, recognising deterioration, relaying concern and reacting to it, a structure that maps neatly onto stages two, six and seven of the cycle. Their review found that most improvement strategies target recognition through track and trigger systems while the relay phase receives less attention, even though communication breakdown between bedside nurses and medical teams accounts for a share of the failures. Ede et al. (2024) went further and compared what escalation protocols prescribe with what clinicians do in practice, finding that nurses routinely gather informal information and time the call around medical workload. Three implications follow for a case study:
- Place escalation inside stage six with a named tool, such as ISBAR, rather than an instruction to inform the doctor.
- Explain what happens when the first escalation fails, since a documented expectation of review within thirty minutes is part of the plan.
- Keep the patient and family escalation route in the plan, because consumer-initiated escalation is required under the national standards.
Practice that treats a normal blood pressure as reassurance misses the point of the pattern, and a brief that names the pattern beats one that reports a tidy set of vital signs.
Reflection Without a Named Model
Students search this often, and the honest answer is that the requirement changed between sessions. The 2023 version of this item asked for reflection against an established model and asked students to reference it; the 2024 version dropped that instruction while keeping the stage at roughly 200 words. Either choice works under the current rubrics, and what does not work is a reflection that describes the task rather than the reasoning. Naming a model adds structure, so a student who uses Gibbs or Driscoll should reference it in APA format and apply the stages rather than listing them. Specificity is the criterion, and a single sentence about the moment you almost accepted a blood pressure without rechecking perfusion says more than a paragraph about learning the value of critical thinking. Hedging belongs here too, because a claim about what you will always do in future invites a marker to test it. Keep the reflection honest about the limits of a simulated scenario.
Where Cue Collection Goes Wrong
Most lost marks at stage two come from selection, not omission. Students copy the entire observation chart and the full medical history, which pushes the stage past 300 words and buries the three findings that matter. A better routine is to list every cue, then delete everything the cue does not change. Simulation studies show that structured scenarios improve clinical reasoning skills among undergraduate nurses, with three of three studies reporting gains in reasoning and four of eight in critical thinking, which supports rehearsal over memorisation (Alshehri et al., 2023). Those gains depend on debriefing that surfaces the reasoning rather than confirming the answer. A second error concerns the missing data requirement, since students state that more observations are needed without naming which ones and why. Naming a repeat lactate at two hours and a chest X-ray to exclude a pulmonary source reads as reasoning, while requesting further investigation reads as filler.
What Separates the Bands
Grades split on the reasoning chain rather than on clinical content. A Credit script names the right issue, sets two measurable goals and cites a guideline for each intervention. A High Distinction script shows the chain, so the cue that mattered most reappears in the synthesis, the intervention answers the goal that was set, and the evaluation names the indicator that would reveal a goal only partly met. Timing is the practical risk here, since stage one is the cheapest place to overspend and the most common. Write stage four first, then work backwards to select the cues the synthesis needs, which keeps stage two lean and makes stage three do actual work. Referencing errors cluster in chapters and in workplace documents, so record full details at first read. Sit the draft at 1,750 words, leave the extra fifty for the sentences that connect one stage to the next, and let the template do its job.
References
Alshehri, F. D., Jones, S., & Harrison, D. (2023). The effectiveness of high-fidelity simulation on undergraduate nursing students’ clinical reasoning-related skills: A systematic review. Nurse Education Today, 121, Article 105679. https://doi.org/10.1016/j.nedt.2022.105679
Australian Commission on Safety and Quality in Health Care. (2021). National Safety and Quality Health Service Standards (2nd ed.). https://www.safetyandquality.gov.au/standards/nsqhs-standards
Burke, J. R., Downey, C., & Almoudaris, A. M. (2022). Failure to rescue deteriorating patients: A systematic review of root causes and improvement strategies. Journal of Patient Safety, 18(1), e140–e155. https://doi.org/10.1097/PTS.0000000000000720
Ede, J., Hutton, R., Watkinson, P., Kent, B., & Endacott, R. (2024). Improving escalation of deteriorating patients through cognitive task analysis: Understanding differences between work-as-prescribed and work-as-done. International Journal of Nursing Studies, 151, Article 104671. https://doi.org/10.1016/j.ijnurstu.2023.104671
Levett-Jones, T. (Ed.). (2023). Clinical reasoning: Learning to think like a nurse (3rd ed.). Pearson Australia.
Clinical Reasoning Cycle: A Complex Deteriorating Patient Scenario
Note: The case study for NRS387 Assessment Item 3 is held in the subject’s Assessment 3 folder. Because the actual patient details were not provided, the following model uses a clearly labelled post-operative sepsis scenario. Replace the patient-specific cues, observations, pathology and goals with those in your case study before submission.
Consider the Patient Situation
Mr Haralambos is a 78-year-old man admitted to a surgical ward following a right hemicolectomy for a bowel obstruction. He is on day three after surgery and has a history of hypertension, type 2 diabetes and chronic kidney disease stage 3. His daughter has been present since the morning and reports that he has become unusually drowsy, has stopped asking for his glasses and no longer wants to drink. Mr Haralambos normally lives at home with his daughter and values independence, although he accepts help with medications and transport.
The clinical context matters because older adults recovering from major abdominal surgery face several competing risks. Post-operative pain, opioid analgesia, reduced oral intake and the metabolic effects of surgery may each explain some changes in his condition. However, his age, diabetes and reduced kidney function also reduce his physiological reserve and may mask or amplify signs of infection and poor perfusion. The nursing priority is therefore to interpret his observations as a changing pattern rather than as isolated values.
Collect Cues and Information
The available cues include a respiratory rate of 26 breaths per minute, oxygen saturation of 92 per cent on 2 L/min via nasal prongs, blood pressure of 98/54 mmHg, heart rate of 112 beats per minute and temperature of 38.4°C. His urine output has fallen to 15 mL per hour over the last two recordings. He appears drowsy, responds slowly to questions and has warm, flushed skin. His surgical wound is mildly erythematous, and he reports increasing abdominal pain despite regular analgesia.
Several findings require clarification. The nurse needs a repeat lactate, blood cultures, full blood count, urea, electrolytes and creatinine, C-reactive protein, arterial or venous blood gas, chest X-ray and review of recent fluid balance. A wound swab may be required if the wound appears infected, while a medication review is needed to determine whether opioids, antihypertensives or diuretics are contributing to hypotension or reduced renal perfusion.
The most important cues are the rising respiratory rate with hypoxaemia, hypotension with tachycardia and oliguria, and the new change in mental state. These findings suggest that Mr Haralambos is not simply uncomfortable after surgery; they indicate possible inadequate tissue perfusion. His lactate result, once available, will help determine the severity of hypoperfusion and guide the urgency of resuscitation.
Process Information
A respiratory rate of 26 breaths per minute is markedly elevated for a resting adult and, together with an oxygen saturation of 92 per cent on supplemental oxygen, suggests increased respiratory work and impaired gas exchange. Post-operative atelectasis, pulmonary oedema, aspiration or a pulmonary source of infection may contribute. The finding is clinically important because respiratory compensation often precedes a clearer diagnosis and may reflect the body’s response to metabolic acidosis.
Hypotension, tachycardia and oliguria form a coherent pattern of reduced effective circulating volume and impaired organ perfusion. In sepsis, inflammatory mediators cause vasodilation, increased capillary permeability and fluid movement into tissues. The resulting reduction in venous return lowers cardiac output, while reduced renal perfusion decreases urine production. Tachycardia may initially maintain blood pressure, but it also increases myocardial oxygen demand in an older patient with limited reserve.
A temperature of 38.4°C, abdominal pain and wound erythema raise concern for a post-operative infectious source. Drowsiness is particularly significant because it may indicate poor cerebral perfusion, sepsis-associated encephalopathy, medication effects or a combination of these factors. A lactate of 3.4 mmol/L, if confirmed, would support anaerobic metabolism secondary to inadequate oxygen delivery. The three findings that should drive immediate action are the red-zone observation pattern, falling urine output and altered mental state, because they signal physiological deterioration rather than expected post-operative recovery.
Synthesise and Identify the Problem
The main clinical problem is probable sepsis with sepsis-induced hypoperfusion following abdominal surgery. The available cues converge on this interpretation: fever and wound changes suggest infection; tachycardia, hypotension and oliguria indicate circulatory compromise; and drowsiness, tachypnoea and hypoxaemia show that perfusion and oxygenation are deteriorating.
Sepsis begins when an infection triggers a dysregulated host response. Inflammatory mediators cause widespread endothelial dysfunction, vasodilation and capillary leak. Plasma shifts from the intravascular space into tissues, reducing effective circulating volume despite possible fluid retention. Reduced preload and vasodilation lower tissue perfusion, while microvascular dysfunction limits oxygen delivery even when macrovascular blood pressure appears maintained.
Reduced renal perfusion explains oliguria, while anaerobic metabolism in poorly perfused tissues produces lactate. Hypoxaemia may arise from ventilation-perfusion mismatch, pulmonary complications or increased metabolic demand. The clinical significance is that Mr Haralambos is at risk of progressive organ dysfunction. Without prompt recognition, source control, antimicrobial therapy and perfusion-focused resuscitation, sepsis may progress to septic shock, acute kidney injury, respiratory failure and death.
Establish SMART Goals
Goal 1: Mr Haralambos will maintain a systolic blood pressure above 100 mmHg within two hours of recognition of deterioration.
-
Specific: Maintain systolic blood pressure above 100 mmHg.
-
Measurable: Blood pressure will be measured continuously or at least every 30 minutes.
-
Achievable: The goal is achievable through fluid resuscitation, monitoring and escalation to the medical team.
-
Relevant: The goal addresses hypoperfusion and reduces the risk of organ injury.
-
Time-bound: The target will be reviewed within two hours.
Goal 2: Mr Haralambos will have a lactate level below 2.0 mmol/L and a urine output greater than 0.5 mL/kg/hour within four hours of commencing resuscitation.
-
Specific: Improve tissue perfusion as shown by lactate clearance and urine output.
-
Measurable: Serial lactate results and hourly urine output will be recorded.
-
Achievable: The goal is achievable through prompt antimicrobial therapy, fluid resuscitation and medical review.
-
Relevant: The goal directly addresses sepsis-induced hypoperfusion.
-
Time-bound: The outcome will be evaluated four hours after treatment begins.
Select a Course of Action
The first intervention addresses the most urgent problem: restoration of perfusion and prevention of further deterioration. The nurse should immediately escalate using an ISBAR handover, obtain blood cultures before antimicrobial administration where safe and feasible, administer prescribed intravenous crystalloid as ordered, and ensure antimicrobials are given without delay. The Surviving Sepsis Campaign recommends measuring lactate in suspected sepsis, administering at least 30 mL/kg of intravenous crystalloid within the first three hours for sepsis-induced hypoperfusion or septic shock, and giving antimicrobials immediately, ideally within one hour, where septic shock or a high likelihood of sepsis exists (Evans et al., 2021).
Fluid resuscitation requires active nursing assessment rather than a fixed volume delivered without review. The nurse should assess blood pressure, heart rate, respiratory rate, oxygen saturation, lung sounds, peripheral perfusion and urine output after measured fluid increments. Balanced crystalloid is preferred where available because large volumes of unbalanced fluid may contribute to hyperchloraemic acidosis (Evans et al., 2021). Escalation must name the red-zone observations, lactate, urine output, mental-state change and suspected source of infection. The Australian Commission on Safety and Quality in Health Care requires health services to have escalation criteria that include physiological deterioration, altered mental state and clinician, patient or family concern (Australian Commission on Safety and Quality in Health Care, 2026).
The second intervention addresses the first goal and focuses on continuous surveillance and early recognition of a poor response. The nurse should place Mr Haralambos on continuous cardiac and oxygen saturation monitoring, record full vital signs at least every 30 minutes, maintain oxygen therapy according to prescribed targets, and monitor hourly urine output through an indwelling catheter where clinically appropriate. A structured ISBAR escalation should be repeated if the systolic blood pressure remains below 100 mmHg, lactate does not fall, urine output remains low or mental state worsens.
The order of care reflects clinical urgency. Recognition, escalation, cultures, antimicrobials and initial fluid resuscitation occur in parallel within the first minutes. Catheter insertion, wound assessment, pressure-injury prevention, family communication and documentation follow once immediate resuscitation is underway. This sequence matters because delayed antimicrobials and delayed escalation are associated with worse outcomes in sepsis, whereas careful monitoring prevents both under-resuscitation and fluid overload in an older patient with chronic kidney disease.
Evaluate Outcomes
Evaluation of Goal 1 will focus on systolic blood pressure, heart rate, level of consciousness, peripheral perfusion and response to fluid therapy. The nurse will review blood pressure every 15 to 30 minutes during active resuscitation, then according to the local deterioration protocol once the patient stabilises. A met goal would show a systolic pressure above 100 mmHg, improving alertness, warm peripheries and a heart rate moving toward the patient’s baseline.
A partially met goal would show only limited improvement, for example a systolic pressure of 95 mmHg with persistent tachycardia, oliguria or drowsiness. In that situation, the nurse would repeat escalation, request urgent medical review, review fluid responsiveness and consider whether vasopressor support, intensive-care referral or another source of deterioration is required. The response should not assume that a single normal blood-pressure reading confirms recovery.
Evaluation of Goal 2 will use serial lactate measurements, hourly urine output, oxygen saturation, respiratory rate and the patient’s own report of breathlessness, pain and thirst. Lactate should be repeated approximately two to four hours after resuscitation begins, because the Surviving Sepsis Campaign recommends serial lactate measurement to guide resuscitation in patients with elevated lactate or septic shock (Evans et al., 2021). A lactate that remains elevated despite fluid therapy, or urine output that remains below 0.5 mL/kg/hour, indicates that the goal is only partly met and requires reassessment of the working diagnosis, fluid strategy and escalation plan.
Objective data alone cannot establish recovery. A blood pressure that returns to the normal range may coexist with persistent confusion, breathlessness or reduced urine output. The nurse must therefore compare observations with the patient’s account, family observations and the overall trajectory. Evaluation is a repeated clinical judgement, not a final confirmation that sepsis has resolved.
Reflect on the Process
Working through this scenario showed how easily a nurse can focus on one abnormal vital sign and miss the meaning of the whole pattern. The moment that changed my reasoning occurred when I stopped treating the blood pressure of 98/54 mmHg as the central problem and recognised that the respiratory rate, lactate, urine output and drowsiness together described inadequate perfusion. A single number can appear manageable; a pattern of deterioration demands a different response.
I also recognised that escalation is not simply “informing the doctor.” A clear ISBAR handover, including the trend in observations, lactate, urine output and mental state, gives the receiving clinician enough information to act quickly. In future practice, I will document the time of escalation, the specific concerns communicated and the expected response. I will also invite the patient and family to raise concerns, because worry from a family member can be an early warning that objective observations do not yet show.
The process reinforced that clinical reasoning requires curiosity as well as knowledge. I would ask earlier whether the patient’s baseline cognition, usual blood pressure and medication effects explain the findings. I would also avoid treating a stable-looking observation as reassurance when the broader clinical picture is worsening. The most useful lesson is to keep returning to the question: what is happening to this person, and what evidence would change my next action?
References
Australian Commission on Safety and Quality in Health Care. (2026). Recognising and responding to acute deterioration standard. https://www.safetyandquality.gov.au/national-standards/nsqhs-standards/recognising-and-responding-acute-deterioration-standard
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., McIntyre, L. A., Ostermann, M., Prescott, H. C., Rotondo, A., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsani, F., Moreno, R., Menon, K., & Cecconi, M. (2021). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine, 47(11), 1181–1347. https://doi.org/10.1007/s00134-021-06506-y
Levett-Jones, T. (Ed.). (2023). Clinical reasoning: Learning to think like a nurse (3rd ed.). Pearson Australia.
New South Wales Health. (2025). Recognition and management of patients who are deteriorating (PD2025_014). https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2025_014.pdf
Seymour, C. W., Gesten, F., Prescott, H. C., Friedrich, M. E., Iwashyna, T. J., Osborn, T. M., & Levy, M. M. (2017). Time to treatment and mortality during mandated emergency care for sepsis. New England Journal of Medicine, 376(23), 2235–2244. https://doi.org/10.1056/NEJMoa1703028
Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J.-D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Greenfield, J. L., Deutschman, C. S., & Vincent, J.-L. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801–810. https://doi.org/10.1001/jama.2016.0287
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Clinical Reasoning Cycle: A Complex Deteriorating Patient Scenario
Note: The case study for NRS387 Assessment Item 3 is held in the subject’s Assessment 3 folder. Because the actual patient details were not provided, the following model uses a clearly labelled post-operative sepsis scenario. Replace the patient-specific cues, observations, pathology and goals with those in your case study before submission.
Consider the Patient Situation
Mr Haralambos is a 78-year-old man admitted to a surgical ward following a right hemicolectomy for a bowel obstruction. He is on day three after surgery and has a history of hypertension, type 2 diabetes and chronic kidney disease stage 3. His daughter has been present since the morning and reports that he has become unusually drowsy, has stopped asking for his glasses and no longer wants to drink. Mr Haralambos normally lives at home with his daughter and values independence, although he accepts help with medications and transport.
The clinical context matters because older adults recovering from major abdominal surgery face several competing risks. Post-operative pain, opioid analgesia, reduced oral intake and the metabolic effects of surgery may each explain some changes in his condition. However, his age, diabetes and reduced kidney function also reduce his physiological reserve and may mask or amplify signs of infection and poor perfusion. The nursing priority is therefore to interpret his observations as a changing pattern rather than as isolated values.
Collect Cues and Information
The available cues include a respiratory rate of 26 breaths per minute, oxygen saturation of 92 per cent on 2 L/min via nasal prongs, blood pressure of 98/54 mmHg, heart rate of 112 beats per minute and temperature of 38.4°C. His urine output has fallen to 15 mL per hour over the last two recordings. He appears drowsy, responds slowly to questions and has warm, flushed skin. His surgical wound is mildly erythematous, and he reports increasing abdominal pain despite regular analgesia.
Several findings require clarification. The nurse needs a repeat lactate, blood cultures, full blood count, urea, electrolytes and creatinine, C-reactive protein, arterial or venous blood gas, chest X-ray and review of recent fluid balance. A wound swab may be required if the wound appears infected, while a medication review is needed to determine whether opioids, antihypertensives or diuretics are contributing to hypotension or reduced renal perfusion.
The most important cues are the rising respiratory rate with hypoxaemia, hypotension with tachycardia and oliguria, and the new change in mental state. These findings suggest that Mr Haralambos is not simply uncomfortable after surgery; they indicate possible inadequate tissue perfusion. His lactate result, once available, will help determine the severity of hypoperfusion and guide the urgency of resuscitation.
Process Information
A respiratory rate of 26 breaths per minute is markedly elevated for a resting adult and, together with an oxygen saturation of 92 per cent on supplemental oxygen, suggests increased respiratory work and impaired gas exchange. Post-operative atelectasis, pulmonary oedema, aspiration or a pulmonary source of infection may contribute. The finding is clinically important because respiratory compensation often precedes a clearer diagnosis and may reflect the body’s response to metabolic acidosis.
Hypotension, tachycardia and oliguria form a coherent pattern of reduced effective circulating volume and impaired organ perfusion. In sepsis, inflammatory mediators cause vasodilation, increased capillary permeability and fluid movement into tissues. The resulting reduction in venous return lowers cardiac output, while reduced renal perfusion decreases urine production. Tachycardia may initially maintain blood pressure, but it also increases myocardial oxygen demand in an older patient with limited reserve.
A temperature of 38.4°C, abdominal pain and wound erythema raise concern for a post-operative infectious source. Drowsiness is particularly significant because it may indicate poor cerebral perfusion, sepsis-associated encephalopathy, medication effects or a combination of these factors. A lactate of 3.4 mmol/L, if confirmed, would support anaerobic metabolism secondary to inadequate oxygen delivery. The three findings that should drive immediate action are the red-zone observation pattern, falling urine output and altered mental state, because they signal physiological deterioration rather than expected post-operative recovery.
Synthesise and Identify the Problem
The main clinical problem is probable sepsis with sepsis-induced hypoperfusion following abdominal surgery. The available cues converge on this interpretation: fever and wound changes suggest infection; tachycardia, hypotension and oliguria indicate circulatory compromise; and drowsiness, tachypnoea and hypoxaemia show that perfusion and oxygenation are deteriorating.
Sepsis begins when an infection triggers a dysregulated host response. Inflammatory mediators cause widespread endothelial dysfunction, vasodilation and capillary leak. Plasma shifts from the intravascular space into tissues, reducing effective circulating volume despite possible fluid retention. Reduced preload and vasodilation lower tissue perfusion, while microvascular dysfunction limits oxygen delivery even when macrovascular blood pressure appears maintained.
Reduced renal perfusion explains oliguria, while anaerobic metabolism in poorly perfused tissues produces lactate. Hypoxaemia may arise from ventilation-perfusion mismatch, pulmonary complications or increased metabolic demand. The clinical significance is that Mr Haralambos is at risk of progressive organ dysfunction. Without prompt recognition, source control, antimicrobial therapy and perfusion-focused resuscitation, sepsis may progress to septic shock, acute kidney injury, respiratory failure and death.
Establish SMART Goals
Goal 1: Mr Haralambos will maintain a systolic blood pressure above 100 mmHg within two hours of recognition of deterioration.
-
Specific: Maintain systolic blood pressure above 100 mmHg.
-
Measurable: Blood pressure will be measured continuously or at least every 30 minutes.
-
Achievable: The goal is achievable through fluid resuscitation, monitoring and escalation to the medical team.
-
Relevant: The goal addresses hypoperfusion and reduces the risk of organ injury.
-
Time-bound: The target will be reviewed within two hours.
Goal 2: Mr Haralambos will have a lactate level below 2.0 mmol/L and a urine output greater than 0.5 mL/kg/hour within four hours of commencing resuscitation.
-
Specific: Improve tissue perfusion as shown by lactate clearance and urine output.
-
Measurable: Serial lactate results and hourly urine output will be recorded.
-
Achievable: The goal is achievable through prompt antimicrobial therapy, fluid resuscitation and medical review.
-
Relevant: The goal directly addresses sepsis-induced hypoperfusion.
-
Time-bound: The outcome will be evaluated four hours after treatment begins.
Select a Course of Action
The first intervention addresses the most urgent problem: restoration of perfusion and prevention of further deterioration. The nurse should immediately escalate using an ISBAR handover, obtain blood cultures before antimicrobial administration where safe and feasible, administer prescribed intravenous crystalloid as ordered, and ensure antimicrobials are given without delay. The Surviving Sepsis Campaign recommends measuring lactate in suspected sepsis, administering at least 30 mL/kg of intravenous crystalloid within the first three hours for sepsis-induced hypoperfusion or septic shock, and giving antimicrobials immediately, ideally within one hour, where septic shock or a high likelihood of sepsis exists (Evans et al., 2021).
Fluid resuscitation requires active nursing assessment rather than a fixed volume delivered without review. The nurse should assess blood pressure, heart rate, respiratory rate, oxygen saturation, lung sounds, peripheral perfusion and urine output after measured fluid increments. Balanced crystalloid is preferred where available because large volumes of unbalanced fluid may contribute to hyperchloraemic acidosis (Evans et al., 2021). Escalation must name the red-zone observations, lactate, urine output, mental-state change and suspected source of infection. The Australian Commission on Safety and Quality in Health Care requires health services to have escalation criteria that include physiological deterioration, altered mental state and clinician, patient or family concern (Australian Commission on Safety and Quality in Health Care, 2026).
The second intervention addresses the first goal and focuses on continuous surveillance and early recognition of a poor response. The nurse should place Mr Haralambos on continuous cardiac and oxygen saturation monitoring, record full vital signs at least every 30 minutes, maintain oxygen therapy according to prescribed targets, and monitor hourly urine output through an indwelling catheter where clinically appropriate. A structured ISBAR escalation should be repeated if the systolic blood pressure remains below 100 mmHg, lactate does not fall, urine output remains low or mental state worsens.
The order of care reflects clinical urgency. Recognition, escalation, cultures, antimicrobials and initial fluid resuscitation occur in parallel within the first minutes. Catheter insertion, wound assessment, pressure-injury prevention, family communication and documentation follow once immediate resuscitation is underway. This sequence matters because delayed antimicrobials and delayed escalation are associated with worse outcomes in sepsis, whereas careful monitoring prevents both under-resuscitation and fluid overload in an older patient with chronic kidney disease.
Evaluate Outcomes
Evaluation of Goal 1 will focus on systolic blood pressure, heart rate, level of consciousness, peripheral perfusion and response to fluid therapy. The nurse will review blood pressure every 15 to 30 minutes during active resuscitation, then according to the local deterioration protocol once the patient stabilises. A met goal would show a systolic pressure above 100 mmHg, improving alertness, warm peripheries and a heart rate moving toward the patient’s baseline.
A partially met goal would show only limited improvement, for example a systolic pressure of 95 mmHg with persistent tachycardia, oliguria or drowsiness. In that situation, the nurse would repeat escalation, request urgent medical review, review fluid responsiveness and consider whether vasopressor support, intensive-care referral or another source of deterioration is required. The response should not assume that a single normal blood-pressure reading confirms recovery.
Evaluation of Goal 2 will use serial lactate measurements, hourly urine output, oxygen saturation, respiratory rate and the patient’s own report of breathlessness, pain and thirst. Lactate should be repeated approximately two to four hours after resuscitation begins, because the Surviving Sepsis Campaign recommends serial lactate measurement to guide resuscitation in patients with elevated lactate or septic shock (Evans et al., 2021). A lactate that remains elevated despite fluid therapy, or urine output that remains below 0.5 mL/kg/hour, indicates that the goal is only partly met and requires reassessment of the working diagnosis, fluid strategy and escalation plan.
Objective data alone cannot establish recovery. A blood pressure that returns to the normal range may coexist with persistent confusion, breathlessness or reduced urine output. The nurse must therefore compare observations with the patient’s account, family observations and the overall trajectory. Evaluation is a repeated clinical judgement, not a final confirmation that sepsis has resolved.
Reflect on the Process
Working through this scenario showed how easily a nurse can focus on one abnormal vital sign and miss the meaning of the whole pattern. The moment that changed my reasoning occurred when I stopped treating the blood pressure of 98/54 mmHg as the central problem and recognised that the respiratory rate, lactate, urine output and drowsiness together described inadequate perfusion. A single number can appear manageable; a pattern of deterioration demands a different response.
I also recognised that escalation is not simply “informing the doctor.” A clear ISBAR handover, including the trend in observations, lactate, urine output and mental state, gives the receiving clinician enough information to act quickly. In future practice, I will document the time of escalation, the specific concerns communicated and the expected response. I will also invite the patient and family to raise concerns, because worry from a family member can be an early warning that objective observations do not yet show.
The process reinforced that clinical reasoning requires curiosity as well as knowledge. I would ask earlier whether the patient’s baseline cognition, usual blood pressure and medication effects explain the findings. I would also avoid treating a stable-looking observation as reassurance when the broader clinical picture is worsening. The most useful lesson is to keep returning to the question: what is happening to this person, and what evidence would change my next action?
References
Australian Commission on Safety and Quality in Health Care. (2026). Recognising and responding to acute deterioration standard. https://www.safetyandquality.gov.au/national-standards/nsqhs-standards/recognising-and-responding-acute-deterioration-standard
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., McIntyre, L. A., Ostermann, M., Prescott, H. C., Rotondo, A., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsani, F., Moreno, R., Menon, K., & Cecconi, M. (2021). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine, 47(11), 1181–1347. https://doi.org/10.1007/s00134-021-06506-y
Levett-Jones, T. (Ed.). (2023). Clinical reasoning: Learning to think like a nurse (3rd ed.). Pearson Australia.
New South Wales Health. (2025). Recognition and management of patients who are deteriorating (PD2025_014). https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2025_014.pdf
Seymour, C. W., Gesten, F., Prescott, H. C., Friedrich, M. E., Iwashyna, T. J., Osborn, T. M., & Levy, M. M. (2017). Time to treatment and mortality during mandated emergency care for sepsis. New England Journal of Medicine, 376(23), 2235–2244. https://doi.org/10.1056/NEJMoa1703028
Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J.-D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Greenfield, J. L., Deutschman, C. S., & Vincent, J.-L. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801–810. https://doi.org/10.1001/jama.2016.0287
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