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Importance of Clinical Reasoning in Nursing Practice

Discuss about the Clinical Judgment and Reasoning for Sequencing of Proposed.

Clinical reasoning is an important skill in nursing practice to engage in safe and effective care. It is the process of critical thinking and decision making that supports the nurse to engage in comprehensive health assessment of patient, identify potential problem in patient and develop nursing care plan accordingly (Carvalho, Oliveira-Kumakura  and Morais, 2017). This report discusses the process of focused health assessment of a patient by the analysis of the case scenario of Lucy, a 32 year old woman with symptom of asthma. The report also provides detailed plan of care for patients based on analysis of clinical assessment findings.  

Lucy is a patient who is suffering from asthma since childhood. Although her asthma is well-controlled by the daily intake of beclomethasone, however current issues for patient is that she has become dyspnoeic and suffering from respiratory issues. To engage in more focused health assessment, the proposed sequence is to first consider the patient situation and her context and then collect all vital cues that can help in assessment of client. To gain an understanding about patient situation, the background of Lucy and people surrounding her will be assessed. Knowing about patient’s background and the people surrounding them is important to gain idea about risk factors of disease. It may also inform about medical history of patient, the role of culture or social life in the diagnosis of disease and changes in factors overtime resulting in present clinical condition (Forbes and Watt 2015). 

In addition, to collect cues related to patient condition, the plan is to first collect data related to medical history, social history, family history and medication history of patient and then engage in clinical assessment of patient as per the signs and assessment of patient. This would help to process the patient information and prioritize care for patient (Brown et al. 2017).  For example, as Lucy is a patient with asthma from childhood, reviewing family history is important to understand the reason behind the cause of disease. Secondly, her social life needs to evaluate to detect environment cause of asthma and presenting issues in patient. As Lucy was suffering from symptom of dyspnea, wheezing cough and chest tightness, the sequence for clinical assessment is to first conduct vital sign assessment of patient and then engage in respiratory assessment. Vital sign assessment like monitoring of BP, pulse, heart beat and oxygen saturation level is necessary to detect signs and severity of breathing difficulty. Vital sign assessment is also important as all the vital signs are associated with the pathophysiology of asthma.  In addition, respiratory assessment of Lucy will be done by means of auscultation of chest and assessment of breathing rate in patient. Hence, respiratory assessment is necessary for Joel to monitor severity of asthma symptoms (Aaron et al. 2017). Lastly, review of patient chart is necessary to identify medications taken by patient and the impact of medication on presenting sign and symptoms. On the whole, the above sequence of assessment can help to process the information and understand the severity of patient’s health condition.

Process of Focused Health Assessment

The data related to health history is an important element of patient focused health assessment as it gives idea about past illness, surgery or any surgical complication in patient. The data related to patient history supports nurse or other staff to gain better understanding about patient’s problem and the complexity surrounding diseases. It helps in proper identification of care priorities and enables the delivery of high quality care (Fawcett and Rhynas 2012). To collect information related to patient history, having patient-centered communication skill is necessary. It helps in establishing rapport with patient and get detailed patient history. After establishing rapport with patient, the question that can be asked related to patient history includes ‘Do you suffer from other illness or have you been diagnosed with any other disease in the past?’. As Joel is a patient with asthma, information related to management of asthma in the past can be obtained by asking question like ‘What medications you have taken in the past to treat symptoms of asthma?’. In addition, family and social history can be obtained by question related to nature of professional life of patient and diagnosis of asthma in other family members. The above process related to history taking for Joel can inform the proposed assessment process as it would help to establish link between past medical history and current symptom in patient. This would help to develop effective care plan for patient in order of priority.

Based on information obtained from health history and clinical assessment of patient, this sections provides detailed analysis of findings in related to the underlying pathophysiology of asthma. The assessment of patient history revealed that Lucy has had asthma since she was a child and her father was one member of the family, who died because of complications due to asthma. This information indicates that Joel might have developed asthma related complications like wheezing sound and chest tightness because of presence of the condition in blood relatives. Beasley, Semprini and Mitchell (2015) explained that genetic, environmental and host factors are some of the risk factors of asthma. Although family history of asthma is common in patient, however environmental triggers play a major role in development of asthma in patient. By the process of history taking for Joel, environmental risk factors for asthma were also identified. While questioning patient on her profession and nature of work she does, it was found that Joel works as a cleaner in private aged care facility. Hence, it is very likely that Joel might be exposed to allergens and pollutant that lead to exacerbation of her symptom. The exposure of allergen or irritants predispose patient to immune response and the allergen acts as the stimuli that lead to development of airway inflammation. In response to exposure to stimuli like allergens, the bronchial muscles contracts and narrows the respiratory airways resulting in acute exacerbation of asthma (Chung 2015).

On the basis of clinical assessment of patient as per her currently symptoms, the first sequence was to conduct vital health assessment in patient. During vital sign assessment, her body temperature was 38 C, pulse rate was 115, respiration rate was 32, BP was 160/90 and SaO2 was 91%. The vital sign assessment revealed severe respiratory complication in patient as her respiratory rate is higher than the normal value of 12-20 breaths per minutes and her pulse rate is also above the normal range. Her BP reading also shows she is hypertensive, however her SpO2 level is within the normal range. She would have required supplementary oxygen therapy if her SpO2 level had fallen below 90%. However, presence respiratory problems like high breathing rate and increases pulse rate also indicate signs of exacerbation of asthma in patient. This assessment finding is linked to the underlying pathophysiology of asthma. The main pathophysiological features of the disease are bronchial inflammation, shortness of breath, wheeziness and airflow limitations (Sullivan et al. 2016). Similar symptoms were observed in Joel too and this mainly occurred because of airway inflammation process. Respiratory rate increases in patients with asthma because of the action of immune cells like T-lymphocytes, macrophages, neutrophils and mast cells. They contribute to airway inflammation resulting in narrowing of respiratory airways, airflow limitation and consequently respiratory problem in patient. Chronic inflammation also results in permanent changes in airway structure of patient (Fahy 2015).

Collection of Relevant Patient Data

As Joel was dysnpoeic, oxygen saturation assessment was also conducted in patient. Her oxygen saturation rate dropped to 88% which is below the normal range of 95-100%. Hence, from this perspective, it is clear that Joel is in need of supplemental oxygen to prevent symptom of dyspnea. The respiratory assessment of patient also revealed that she had loud expiratory wheeze. She was using her accessory muscles. Symptoms of wheezing are also linked to the pathophysiology of asthma. This can be said because wheezing is produced due to inflammation of the airways and during acute exacerbation, the exposure of allergens or irritants initiate the process for airway inflammation in patient. Due to inflammation of the airway, airflow obstruction and airway limitation is observed in patient. Such pathophysiological changes cause recurrent episodes of wheezing and breathlessness in patient (Lambrecht and Hammad 2015). Airway narrowing is the main physiological event that results in airflow obstruction and the process of airway inflammation establishes the cause of wheezing sound during chest auscultation for Joel.

The review of medication history of Joel revealed that earlier she used to beclomethasone medication to control her asthma. However, after admission to hospital during acute exacerbation, she was given Salbutamol, but her condition deteriorated after giving medication. Hence, in response to this, it is necessary to find out the cause of such deterioration and suggest new medication accordingly for symptom improvement.

The first and foremost assessment that has been done for the patient includes the history of the patient that reveals Lucy had asthma as a child and her father died due to asthma complications.  It has to be mentioned that genetic predisposition associated with asthma is a very common risk factor that enhances the vulnerability of a patient towards exacerbations of asthma. Along with that assessment of the past medical history of a patient reveals crucial clinical cues based on which the patient situational analysis and synthesis of the processed information of the clinical reasoning cycle takes place which provides the foundation based on which the primary and secondary diagnosis will take place (Boulet et al. 2012). Hence it can be concluded that patient history assessment is a very important aspect associated with care planning and it has fundamental significance in the entire procedure. It has to be mentioned that along with genetic predisposition the impact of environmental triggers is also a cute in case of asthma exacerbations. During subjective and objective patient data documentation it was revealed that she had been a cleaner in a private aged care facility. Hence the chances of the patient been exposed to various environmental trigger such as a legends and pollutants is very high that could have been the pathophysiological reason leading to the exercise patience offer symptoms. Hence it has acute importance in the care planning procedure as well (Black et al. 2013).

Elaborating on the vital sign assessment, results indicate that the patient had high respiratory rate, high blood pressure, and high temperature. All of these symptoms are associated with acute asthma exacerbations and have significant value in the diagnosis and post Diagnostic care planning procedure. However, it has to be mentioned that the oxygen saturation of the patient is within the normal rates hence, it does not indicate at significant results relevant to the care scenario of the patient. However, later the oxygen saturation count of the patient declined to 88% which indicated at acute inflammation of the airways and bronchial spasms. Hence this result also holds significance in understanding the etiology of the present condition of Joel and planning of further care plans (Zipkin et al. 2013). It has to be mentioned in this context that the condition of the patient deteriorated further with implementation of Salbutamol, it is a significant result that will direct the path the care planning and implementation will take.

Nursing diagnosis

Nursing goal

Intervention

Rationale

Ineffective breathing pattern

The patient will be relieved from the shortness of breath and will be able to breathe normally. The patient will be able to revert to normal breathing rates and the oxygen saturation will enhance.

Assessment of the patient’s vital signs, assessment of the  respiratory rate, depth, and rhythm. Auscultation of the breathing sounds for checking the presence of adventitious sounds such as wheezes and stridor (Croisant 2014). 

Assessment of the presence of paradoxical pulse of 12 mm Hg or greater and monitoring the oxygen saturation of the patient.

Administration of external oxygen therapy.

Administration of albuterol, levalbuterol and terbutaline.

Administration of Inhaled Corticosteroids such as Pulmicort, Flovent, Vancenase, Asmanex Twisthaler.

It will be beneficial for understanding the exact extent of broncho-spasms and inflammation of the bronchial airways

It will provide key information regarding the severity of the shortness of breath or dyspnoea and will direct the exact plan of care.

It will provide the necessary boost of oxygen to enhance the oxygen saturation to normal levels and evade the risk of mortality (Chunchu et al. 2012).

Administration of Short-acting beta2-agonists are bronchodilators will help in relaxing the muscles lining the airways that carry air to the lungs;

Corticosteroids  will help in reducing inflammation in the airways that carry air to the lungs and reducing the mucus production.  

Ineffective airway clearance

The blockage of the bronchial airways of the patent will reduce and the respiration rate of the patient will come back to normal levels. The frequency and severity of the wheezes will also reduce. 

Assessment of color changes in the buccal mucosa, lips, and nail beds (Woods et al. 2012).

Assessment of effectiveness of cough and the amount, color, odor and viscosity of the secretions.

Monitoring oxygen saturation by the means of pulse oximetry and monitoring the chest X ray results (Ivanova et al. 2012).

Monitoring arterial blood gases.

Performing airway clearance depending on the need of the patient.

The presence of cyanosis in the patient will indicate low oxygenation and that ineffective breathing to maintain adequate tissue oxygenation in the body.

Will indicate whether or not the patent has acquired any secondary infection.

Will aid in discovering key information regarding presence of infiltrates, lung inflation, or the presence of barotraumas

It will indicate at the severity of the infection that the patient has attained (Ivanova et al. 2012).

Will aid in clearing the airway drastically and help in better breathing.

Hypertension

The blood pressure of the patient will reduce and the pulse rate will come to normal levels.

Assessment of the blood pressure levels of the patient and the pulse rate.

Administration of anti hypertensives such as Diuril, Esidrix/HydroDIURIL, Naturetin, Lozol, Diulo, Hydromox (Black et al. 2013).

Will aid in discovery of the key knowledge regarding the levels of hypertension.

Will help in vasodilation and reduce BP in turn avoiding the chances of strokes

Hyperthermia

The body temperature of the patent will revert back to normal levels.

Provide warm and comfortable environment for the patient.

Providing cooling blankets (Zipkin et al. 2013).

Administration of antipyretics and serum electrolytes

The patient will feel comfortabl and wil be relived from any extra stressors.

Will help in reducing the body temperature non-pharmacologically

The antipyretics will help in reducing the temperature and sodium based serum electrolytes will help in reducing the impact of profuse sweating (Black et al. 2013). 

Reference:

Aaron, S.D., Vandemheen, K.L., FitzGerald, J.M., Ainslie, M., Gupta, S., Lemière, C., Field, S.K., McIvor, R.A., Hernandez, P., Mayers, I. and Mulpuru, S., 2017. Reevaluation of diagnosis in adults with physician-diagnosed asthma. Jama, 317(3), pp.269-279.

Beasley, R., Semprini, A. and Mitchell, E.A., 2015. Risk factors for asthma: is prevention possible?. The Lancet, 386(9998), pp.1075-1085.

Black, M.H., Zhou, H., Takayanagi, M., Jacobsen, S.J. and Koebnick, C., 2013. Increased asthma risk and asthma-related health care complications associated with childhood obesity. American journal of epidemiology, 178(7), pp.1120-1128.

Boulet, L.P., FitzGerald, J.M., Levy, M.L., Cruz, A.A., Pedersen, S., Haahtela, T. and Bateman, E.D., 2012. A guide to the translation of the Global Initiative for Asthma (GINA) strategy into improved care. European Respiratory Journal, 39(5), pp.1220-1229.

Brown, D., Edwards, H., Seaton, L. and Buckley, T., 2017. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

Cabana, M.D., Slish, K.K., Evans, D., Mellins, R.B., Brown, R.W., Lin, X., Kaciroti, N. and Clark, N.M., 2014. Impact of physician asthma care education on patient outcomes. Health Education & Behavior, 41(5), pp.509-517.

Carvalho, E.C.D., Oliveira-Kumakura, A.R.D.S. and Morais, S.C.R.V., 2017. Clinical reasoning in nursing: teaching strategies and assessment tools. Revista brasileira de enfermagem, 70(3), pp.662-668.

Chunchu, K., Mauksch, L., Charles, C., Ross, V. and Pauwels, J., 2012. A patient centered care plan in the EHR: Improving collaboration and engagement. Families, Systems, & Health, 30(3), p.199.

Chung, K.F., 2015. Targeting the interleukin pathway in the treatment of asthma. The Lancet, 386(9998), pp.1086-1096.

Croisant, S., 2014. Epidemiology of asthma: prevalence and burden of disease. In Heterogeneity in Asthma (pp. 17-29). Humana Press, Boston, MA.

Fahy, J.V., 2015. Type 2 inflammation in asthma—present in most, absent in many. Nature Reviews Immunology, 15(1), p.57.

Fawcett, T. and Rhynas, S., 2012. Taking a patient history: the role of the nurse. Nursing Standard (through 2013), 26(24), p.41.

Forbes, H. and Watt, E., 2015. Jarvis's Physical Examination and Health Assessment. Elsevier Health Sciences.

Ivanova, J.I., Bergman, R., Birnbaum, H.G., Colice, G.L., Silverman, R.A. and McLaurin, K., 2012. Effect of asthma exacerbations on health care costs among asthmatic patients with moderate and severe persistent asthma. Journal of Allergy and Clinical Immunology, 129(5), pp.1229-1235.

Lambrecht, B.N. and Hammad, H., 2015. The immunology of asthma. Nature immunology, 16(1), p.45.

Sullivan, A., Hunt, E., MacSharry, J. and Murphy, D.M., 2016. The microbiome and the pathophysiology of asthma. Respiratory research, 17(1), p.163.

Todd, S., Walsted, E.S., Grillo, L., Livingston, R., Menzies?Gow, A. and Hull, J.H., 2018. Novel assessment tool to detect breathing pattern disorder in patients with refractory asthma. Respirology, 23(3), pp.284-290.

Woods, E.R., Bhaumik, U., Sommer, S.J., Ziniel, S.I., Kessler, A.J., Chan, E., Wilkinson, R.B., Sesma, M.N., Burack, A.B., Klements, E.M. and Queenin, L.M., 2012. Community asthma initiative: evaluation of a quality improvement program for comprehensive asthma care. Pediatrics, 129(3), pp.465-472.

Zipkin, R., Schrager, S.M., Keefer, M., Marshall, L. and Wu, S., 2013. Improving home management plan of care compliance rates through an electronic asthma action plan. Journal of Asthma, 50(6), pp.664-671.

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