What Is The Clinical Reasoning Is Stepwise Process?
Clinical reasoning is synonymous with the clinical judgment, problem solving, decision making and critical thinking in nursing practice. Clinical reasoning is stepwise process with incorporation of steps to collect cues and information, to process collected information, to understand problems, to identify patient’s correct complication, to plan and implement nursing interventions and to evaluate outcomes. Based on the condition of the patient, these steps should be modified. Outcome of the nursing intervention depends on the clinical reasoning. Clinical reasoning is the result oriented approach. Incorrect assessment and diagnosis of the patient can result in the administration of wrong treatment. For providing effective nursing intervention to Katie, clinical reasoning is implemented for her assessment and management. Nurse should follow all the steps like collection of information, understanding exact problem, planning and implementing nursing intervention (Cooper and Frain, 2016). All the steps required for clinical reasoning of Katie are discussed in this essay. Pharmacological, social and psychological aspects of Katie are discussed in this essay. Nurse should have strong knowledge and skills of these aspects to execute clinical reasoning in Katie.
Katie is admitted to hospital because she has sustained haematoma due to hit by slow moving car 18 hours ago. In her assessment, it was evident that she had traumatic brain injury. Patients with traumatic brain injury are associated with symptoms like intracranial hemorrhage and haematoma. Haematoma in patients with traumatic brain injury can be detected in first four hours and approximately 50 % with traumatic brain injury are susceptible to haematoma. It is less likely that persons of Katie’s age are less prone to brain injury in comparison with people with older age. In older people, brain injury can occur because of fall. Moreover, recovery from brain injury is faster in persons of Katie’s age in comparison to the older people. People of Katie’s age can recover from brain injury within 5 hours (Qureshi et al., 2015; Plata et al., 2008).
Katie’s handover indicated that her vital signs were as follows : heart rate - 89 beats per minute, respiratory rate – 13 breaths per minute and oxygen saturation (Sp02) - 96 %. All these values reflects normal pulse rate, breathing rate and oxygen saturation level in Katie. Her Glasgow Coma Score was recorded as 14. Her recorded blood pressure was abnormal with raised systolic blood pressure and reduced diastolic blood pressure. She also had complication of memory loss because she was not remembering current things and regaining memory with prompting. Brain injury can affect pupillary size and vision because brain injury can affect retina. In the provided handover information about the pupillary size and vision were missing. Patients with traumatic brain injury are prone to pyrexia and increase in the intracranial pressure. However, there was no mention of temperature and intracranial pressure in her handover. Due to injury, there may be possibility of blood loss, hence blood parameters like haematology full blood count and coagulation screening should have been carried put in her. However, these parameters were missing from her handover. There was no information about blood sugar level and urinary output by use of catheter. Information of the medicines administered to Katie is not available in her handover. This information about medicines would have been useful in planning further course of nursing action (Moppett, 2007). She was having long history of painful ankle, however she was keeping herself away from taking medicine for pain relief.
From the provided information it can be interpreted that her heart rate, respiratory rate and oxygen saturation were normal. Heart rate, respiratory rate and oxygen saturation should be in the range of 70- 100 beats per minute, 12 – 20 breaths per minute and above 94 % respectively in the Katie’s age person. Subdural haematoma patient’s are prone to develop hypertension and bradycardia. Katie’s heart rate was normal. From the provided data, it is evident that Katie also developed systolic hypertension. Katie developed mild coma because her Glasgow Coma score fall in the range of 13 – 14. This coma score reflected mild coma. Traumatic brain injury also affects respiratory system like hypoxia. Katie’s oxygen saturation level was normal (Adams, 2010).
It is evident that, Katie is not remembering recent things. Hence, she is having memory loss. Extent of memory loss can be obtained by performing computed tomography (CT) scan and magnetic resonance imaging (MRI) in Katie. Diagnosis of bleeding disorders should be performed in Katie by using thrombocytopenia test. If surgery needs to be performed in Katie, she should be administered with blood. For this, matching blood group should be identified for her. Artificial intubation should be used in Katie because traumatic brain injury can lead to hypoxia development. Central venous catheter should be used her to measure intracranial blood pressure because traumatic brain injury patients can develop raised intracranial blood pressure.
(Blissitt, 2006). Katie’s age persons are not usually associated with hypertension, memory loss, hyperpyrexia, hypercarbia, renal complications, proprioceptive dysfunction, sensory sensing disorder, facial palsy and paralysis. However, Katie already developed hypertension and memory loss. Due to traumatic brain injury, she is prone developing hyperpyrexia, hypercarbia, renal complications, proprioceptive dysfunction, sensory sensing disorder, facial palsy and paralysis. There is no requirement of artificial intubation and blood loading in persons of Katie’s age. However, due to brain injury, Katie may need supplemental oxygen and blood transfusion (Moppett, 2007, Ponsford et al., 2008).
Nurse should set achievable goals for Katie. Nurse should be aimed at maintaining normal blood pressure, oxygen saturation and respiratory rate in Katie. Nurse should assess Katie for physical and vital signs. Blood pressure and hypoxia condition should be assessed by using blood pressure apparatus and arterial blood gas (ABG) test respectively. If these tests indicate abnormal values, nurse should amend management plan accordingly. Nurse should assess blood pressure and hypoxia condition before and after administration of the medications and medical management like artificial intubation. Nurse should work in collaboration with psychologist to manage her speech problem and memory loss. Memory loss should be evaluated in Katie by giving different types of tasks to her. These tasks would be helpful in the assessment of extent and type of memory loss (Schultheis and Whipple, 2014). Paralysis should be evaluated in Katie by assessing reaction time to particular task. Nurse should evaluate 24 hour urine output in her by using catheter because she developed cardiovascular complications due to brain injury. Intracranial pressure should be evaluated in her by using central venous catheter. Based on the results obtained for intracranial pressure, nurse should consult doctor for surgery
Nurse should be well aware of the entire medical, clinical and nursing knowledge and skills for effective practice of clinical reasoning. In case of Katie, nurse collected all the information related to physical and vital signs assessment. Nurse analyzed data and interpreted it to know exact nursing problem of Katie. This identification of the exact problem, helped nurse to plan nursing care for Katie. From the collected data, nurse separated normal and abnormal condition in Katie. Normal conditions comprises of heart rate, respiratory rate and oxygen saturation level. Abnormal conditions comprises of memory loss and mild coma. Katie’s handover would have been made more informative by incorporating information about pupillary size, pyrexia, central venous pressure, blood count and coagulation. It has been suggested that assessment for pupillary size, pyrexia, central venous pressure, blood count and coagulation should have been performed in Katie. Effective implementation of the clinical reasoning can be achieved by using this stepwise approach. Nurse should think in an analytical and logical way to provide nursing care to Katie. Nurse should not focus only on the provided information. Nurse should identify missing information which would be helpful in identification of the exact problem of Katie. This additional information can be useful in modifying nursing intervention to be provided to nurse. Thus lateral thinking would be helpful in implementing complete and holistic care to Katie. Success rate of collection of information from Katie can be increased by implementation of reflective communication with Katie and giving information to Katie about her diseased condition and possible outcomes. In summary, effective implementation of clinical reasoning can be helpful in identifying problems in Katie and providing targeted nursing intervention.
Adams, J.P. (2010). Non-neurological complications of brain injury". In John P. Adams; Dominic Bell; Justin McKinlay. Neurocritical care : a guide to practical management. London: Springer. pp. 77–88.
Blissitt, P.A. (2006). Care of the critically ill patient with penetrating head injury. Critical Care Nursing Clinics of North America, 18(3), 321–32.
Carone, D., and Bush, S.S. (2012). Mild Traumatic Brain Injury: Symptom Validity Assessment and Malingering. Springer Publishing Company.
Cooper, N., and Frain, J. (2016). ABC of Clinical Reasoning. John Wiley & Sons.
Guy, R., Furmanov, A., Itshayek, E., Shoshan, Y., and Singh, V. (2014). Assessment of a noninvasive cerebral oxygenation monitor in patients with severe traumatic brain injury. Journal of Neurosurgery, 120(4), 901–907.
Moppett, I.K. (2007). Traumatic brain injury: Assessment, resuscitation and early management. British Journal of Anaesthesiology, 99(1), 18–31.
Plata, C.M., Hart, T., Hammond, F.M., Frol, A., et al., (2008). Impact of Age on Long-term Recovery From Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation, 89(5), 896–903.
Ponsford, J., Draper, K., and Schonberger, M. (2008). Functional outcome 10 years after traumatic brain injury: its relationship with demographic, injury severity, and cognitive and emotional status. Journal of the International Neuropsychological Society, 14(2), 233–242.
Qureshi, A.I., Malik, A. A., Adil, M.M., Defillo, A., Sherr, G., and Suri, K. (2015). Hematoma Enlargement Among Patients with Traumatic Brain Injury: Analysis of a Prospective Multicenter Clinical Trial. Journal of vascular and interventional neurology, 8(3), 42–49.
Schultheis, M. T., and Whipple, E. (2014). Driving after traumatic brain injury: evaluation and rehabilitation interventions. Current Physical Medicine and Rehabilitation Reports, 2(3), 176–183.
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