Clinical Reasoning For Anaesthesia And Intensive Care

Write about the Clinical Reasoning for Anaesthesia & Intensive Care.

Clinical reasoning cycle is a methodical procedure which is followed by nurses in their practices as it helps them to collect information about the patients and thereby come to an understanding about the problem or the situation of the patient. This cycle then helps the nurses to plan and implement interventions necessary for the patients and then helps in proper evaluation of the outcomes of the interventions on the patients. The entire situation would then be reflected by the nurses so that they can learn from any mistakes that they have made or they can promote their practices for betterment. In the following case study, a patient’s named MR Amari had been admitted and the nurse would follow a proper clinical reasoning skill to develop ideas about the interventions that she would take.

The first step of the clinical reasoning cycle is considering the patient situations. The patient who has been shifted from the emergency department to the medical department is called Mrs. Amari. She is an indigenous New Zealand citizen belong to the Maori tribe. She is living with her son and daughter in law and with two grandchildren. However, she is a patient of hypertension as well as hypercholestemia and these had been the major contributors of the present condition she is suffering from which is transient ischemic attack. Actually, her tribal customs had made her take tobacco for almost years which might have had a very bad impact on her health. Although he had quitted smoking, but the after effects had stayed with her as many researchers suggest that smoking leads to strokes and heart disorders (Miller et al. 2016). Moreover, she has a positive family history of heart diseases and therefore she is also within the vulnerable zone of being affected by heart disorders. Therefore following her family history, it becomes evident that her heredity might have also played an important part in her present condition. After the death of her husband, she had to move in with her son to Australia as he was not being able to cope up with the financial crisis and had been staying in Australia and lives heavily as a carer for her grandchildren.

The second step of the clinical reasoning cycle mainly incorporates the activity of the nurses for collection of cues as well as information about the patient’s condition, giving a detailed explanation of the various details which the nurse should incorporate in her time of critical reasoning so that she can perform the next step properly.

Collection of Cues

When the patient was admitted to the hospital it was seen that the patient had a facial droop and her mouth was diverted to the right side. She had numbness in the right side of her face and also in the right arm. However she did not show any acute signs of stroke like weakness and were easily able to swallow and had a steady gait. She was also able to move her extremities and was able to follow commands. Moreover she did not have a headache and also denied nausea, vomiting, chest pain, diaphoresis as well as visual complaints. She was alert and oriented. Therefore, it helped nursing professionals to come to a conclusion that she was not a stroke patient but rather suffered from TIA (Beltowski 2014). When the nurse of the next shift came, she was handed a document which stated that all the symptoms of the patient had resolved. However, she witnessed an entirely different case. She saw that her condition was again deteriorating as her speech had become slurred again and the right side of the mouth is drooping.

When the nurse of the next morning shift took her vital signs, they did not good results and the nurses understood that the patient is not absolutely in the best health. When the vital signs were taken, it showed that Blood pressure: was 175/98 which was considered to be very high as the normal blood pressure of the individuals should be 120/80 mmHg. Her Pulse was however 9 which was within the range of 60 to 100 betas and considered normal. Her Respiratory rate: 13 which is also between the normal range of 12 to 18 breaths per minute, Oxygen saturation which was also normal was 92%. The glucose level was found to be high as the blood glucose level was 6.6 mol much higher than the mean value of 5.5 mmol/L, Glasgow Coma Scale was 11/15.

In most cases it is seen that TIA of the patients often exposes the patients to a stroke within 48 hours and therefore the nurse should take this point in her consideration. Usually, in the case of TIA, blood flow to the brain usually get blocked or reduced usually by blood clots or due to the formation of plaques in the arterial vessels. This often gives rise to stroke like symptoms (Mellon et al. 2016). Usually within a short time, when the blood flows again, the symptoms go away. They do not cause any brain cell damage or permanent disability. As a result of these, the tests which were conducted did not provide any information of such occurrences in the brain like formation of clots and others. However, this disorder often provides an early sign or warning of the occurrences of stroke as researchers suggest that every 1 in 3 TIA patients have stroke. Therefore the nurse should first take into consideration about the patient’s chance of having a stroke when the symptoms of facial dropping and slurring of speech occurs again (Catangui et al. 2015). For this the nurse should at first provide her with medication to remove any plaques or fatty deposits from the vessel or to prevent blood clots in the arteries that supply blood to the brain and immediately perform diagnostic tests to confirm whether she is having another attack of TIA or is having a stroke. The neurological assessment that would mainly be conducted by the nurse is the FAST assessment which mainly checks the face, arm, speech and time test. The score of the test would help her o understand the seriousness of the issue. She can also conduct the Rosier scale test to check the occurrence of stroke possibility (Howard 2016). She should perform magnetic resonance imaging called MIR scan, computerized topography scan to test for TIA. For the diagnosis of stroke, she should perform tests like carotid ultrasound, cerebral angiogram, echocardiogram. The results of the tests have to be verified in order to check whether she is having another TIA or stroke.

Review

The next step of the clinical reasoning cycle is processing of the information that the nurse usually collects by handling the case effectively. 

The next step of the clinical reasoning cycle is processing of the information that the nurse usually collects by handling the case effectively. The first step is the interpretation steps where the nurses need to assess the result of the steps that she had conducted. In this case, the nurses need to conduct the FAST tool assessment as well as the ROSIER assessment. In the FAST assessment, the nurse should check whether the Face has drooped, whether the patient can lift both the arms, has their speech slurred and if all the three things are present there is an emergency and suggests that the Time is critical for the patients (Wang et al. 2013). Moreover form the rosier scale assessment; if the marks are greater than or equal to +1, then the nurse may become sure of the attack of stroke (Jiang et al. 2014).

Source: (Jiang et al. 2014)

Besides, the different diagnostic tests should also be done in order to confirm the results of the neurological assessment made about the patient’s symptoms. Slurring of speech identified in the assessment shows that either of the sides of the brain has been affected which mainly governs the speech of a patient (Fothergill et al. 2013). This gives the idea to the nurse that a part of the brain is affected by the stroke which is affecting his speech. If the assessment catches the patient having drooping down of the mouth, then the nurse may also consider the brain being affected for which messages are not sent properly. Besides, arms of the patients should also be asked to lift which will help in finalizing the attack (Crapo et al. 2014). Besides, diagnostic tests should be immediately done to be sure that whether any blood clots or abnormality is found in the brain of the patient and whether the patient is suffering from stroke or TIA again.

The change of the GCS scale from 15 to 11 showed that the patients should be immediately taken to the emergency wards for treatment as her condition was found to be deteriorating. Nerve damage was the main reason that were resulting in the slurring of voice and face droop. Oxygen saturation decrease was giving clues that her vital organs are having less oxygen which could have caused her in loss of consciousness and adults.

Gather

The next part would be to infer and relate the patients assessment results with the main rationale hat has resulted in the occurrence of the symptoms. The vital signs show that the patient has high blood pressure than normal. The patient is already seen to suffer from hypertension. When the pressure of blood is high, it can lead to stroke by the damaging as well as the weakening of the brains’ blood vessels (Miller et al., 2016). This causes them to be narrow or even leads to rupture and leak. High blood pressure can also lead to form blood clots in the arteries which lead to brain that blocks the blood flow and causes stroke. She is also a patient of hypercholestemia for which cholesterol which is a fatty substance in the blood can increase in number and high cholesterol in the arteries block the normal flow of blood to brain causing stroke (Jatuzis 2015). All these might have occurred in the patient and therefore the patient is suffering from symptoms of stroke or TIA.

Conclusion:

Therefore the nurse who has to handle a patient showing symptoms of stroke or TIA has first have to conduct a vital sign analysis and neurological assessments of the patient. These tests would be finalized by the performing of important diagnostic tests like MIR, CT scan and others. Then the nurse should try to relate the patient history with the biological rational of the occurrence of the attacks. These would help her to develop interventions based on the management of the causing factors.

References:

Be?towski, J. 2014. Priority paper evaluation: Reverse epidemiology in ischemic stroke: High cholesterol as a predictor of improved survival in stroke patients. Clinical Lipidology, 9(2), 135-139.

Catangui, E.J., 2015. Thrombolysis for patients with acute ischaemic stroke. Nursing Standard, 30(8), pp.40-44.

Howard, R.S., 2016. The management of ischaemic stroke. Anaesthesia & Intensive Care Medicine, 17(12), pp.591-595.

Jatuzis, D., 2015. Ongoing Discussions on Reliability of Diagnosis of Transient Ischemic Attack. Neuroepidemiology, 45(2), pp.111-112.

Mellon, L., Doyle, F., Williams, D., Brewer, L., Hall, P., and Hickey, A. 2016. Patient behaviour at the time of stroke onset: a cross-sectional survey of patient response to stroke symptoms. Emerg Med J, emermed-2015.

Miller, A. P., Navar, A. M., Roubin, G. S., & Oparil, S. (2016). Cardiovascular care for older adults: hypertension and stroke in the older adult. Journal of geriatric cardiology: JGC, 13(5), 373.

Wang, Y., Wang, Y., Zhao, X., Liu, L., Wang, D., Wang, C., Wang, C., Li, H., Meng, X., Cui, L. and Jia, J., 2013. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. New England Journal of Medicine, 369(1), pp.11-19.

Jiang, H.L., Chan, C.P.Y., Leung, Y.K., Li, Y.M., Graham, C.A. and Rainer, T.H., 2014. Evaluation of the Recognition of Stroke in the Emergency Room (ROSIER) scale in Chinese patients in Hong Kong. PloS one, 9(10), p.e109762.

Fothergill, R.T., Williams, J., Edwards, M.J., Russell, I.T. and Gompertz, P., 2013. Does use of the recognition of stroke in the emergency room stroke assessment tool enhance stroke recognition by ambulance clinicians?. Stroke, 44(11), pp.3007-3012.

Crapo, S.A., Wooten, J.M. and Brice, J.H., 2014. Stroke and transient ischemic attack. Prehospital Care of Neurologic Emergencies, p.63.