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Consider the Situation of the Patient

Discuss about the Critical Reasoning Cycle Appertains.

Critical reasoning cycle appertains to the stages that registered nurses are supposed to follow when rendering their services.  Critical reasoning can be termed as a process which is utilized by nurses to collect information, process it,  apprehend it, implement the  substantial interventions, carry out an evaluation of the results  and then gain experience from the par said process. The clinical reason is subject to the nurse's attitude and believed philosophies. Critical reasoning cycle is important due to the fact that it translates to a positive outcome for the patients. Good clinical reasoning skills aid in appropriate diagnosis, proper treatment and effective management of any complications that may arise. The essay will fully utilize the clinical reasoning cycle in looking at the clinical decisions that are made by Registered nurses. The clinical thinking cycle will involve an eight stage process used by a student in his third year during a clinical placement session. In addition, the essay will reflect on the decision that was arrived at,  the experiences  of the student nurses and the relevant recommendations that are imperative to Registered Nurses in their future  practices.

The patient  who has  been taken in the medical  surgery ward is by the name of  Mrs. Sunning Hill who  is 90 years old. Her weight is at 76kgs. She has  an abdominal  wound that  is oozing  and with an underneath odor for a period of 8days. The patient has been in the hospital for a period of 4days. She also has a hearing impairment.

At this stage, the Registered Nurse needs to gather sufficient information that is significant in the situation at hand. The information is pertinent in the providence of high standards and safe nursing care services. The information will entail the medical history of the patient, medications that were administered, the hospital journey of the patient, care plans and the situation of the patient today. The information should also not be limited to the assessments done by nurses when they come onto a shift. A bowel tumor has been discovered after a post surgery diagnosis. The tumor has been linked to the fistula. Faecal draining has been carried out through an ostomy appliance. The use of the appliance has the side effects of irritating the skin surrounding the area (Daily, 2011).  

The care plan is that surgical inputs will not be utilized, palliative care, Physio and SW will be administered through referrals. The observations that are carried out on the patients indicate that the conditions that are prevailing for the patient are normal in reference to the ADS chart. As per the previous knowledge appertaining to nutrition and dietetics, the patient must be encouraged to ensure a full diet and ensure that he sips plenty of liquids frequently (Bruhin et al. 2014). The fistula device being used needs to be monitored to ensure that no leakages are reported.

Collect Information

The student nurse empties the fistula appliance and to document it accurately on the fluid balance chart. The urine and the bowel discharges should also be assessed(Fink et al.2012).The student nurse has knowledge on the apt urine output which can be attained by multiplying the standard output of 0.5m/s  by the weight registered by the patient. The identification of this concept will make the student nurse conversant with the amount of urine output for each given hour (Foxley, 2011). 38m/s per given hour is the appropriate urine output for the patient. The student nurse used the fluid balance chart to review the calculated urine output. It was identified that in a period of 12 hours, the fluid balance chart was completed. The student nurse noticed that the patient had only retained a small amount of urine most. This was confirmed after a scan was carried out and it identified that 750mls of urine was still retained. It was certain to the student nurse that this was uncommon given that in her course, she had learnt that the bladder can only hold up to 600mls (Casey, 2011).  The bladder was  holding a larger amount than normal. It was thus significant for the student nurse to call upon the Registered nurse to help her in carrying out critical baseline observations on the patient.

It was registered that the patient has a pulse rate of 115 beats in every minute. The body temperature was reported at 39 degrees. With the results, the student nurse estimated the deterioration of the patient at a score of four with the aid of the adult deterioration detection system chart(Preece, Horswill, Hill,&Watson,2011). It was also observed that the patient had a score of zero on phlebitis. It has been arrived at that the abdominal fistula is responsible for the excoriation of the skin when it leaks. The patient  is also approved for a  residential care and  so that also should be looked at. There is also the need to monitor the fluid intake and the amount and nature of the output. All the information that was collected was properly documented and handed over to the doctor in charge for a more detailed investigation and for an informed treatment.

At this stage, analyzing the data is considered. A urinalysis test was carried out and the dipstick indicated a PH  of 4.0- 7.9  only and not identifying any other results. The results were not sufficient, but the high body temperatures and the high pulse rate was an indication that the patient may have urinary infections. The surgical site had irritated skin due to the frequent leakages. The high body temperatures may have resulted from the administration of paracetamol that may hinder the verification of the extent of the infection ( Nazarko, 2014). The information that relates to the documentation of the urine output indicates that the information was sufficient and this shows that the patient’s condition may not have been managed sufficiently. In addition, the fact that the patient has a hearing impairment is an indication that proper communication strategies and support gadgets need to be utilized throughout the process.  The other fact is that there is need to administer residential care for the patient appertaining to the prolonged medical care that she is supposed to be exposed to. The abdominal fistula may be due to dehydration, weight loss or sepsis. The urinary infections may have resulted from nosocomial infection (Gesmundo, 2016).  It is absolute that the urinary infection will lead to an infection of the kidney (O’Shea, 2011). At the end, a kidney failure may be experienced.

Process Information

At this stage, the clinical reasoning cycle has the role of helping the nurse identify the facts that appertain to the situation that the patient is in (Levitt-Jones, 2012).The patient has had a urinary tract infection due to the existence of the abdominal fistula. And also she has a wound on the leg due to the irritation that the leakages from the urinary tract cause (Steggall, 2011).  The situation of the patient is due to the delayed treatment of the abdominal fistula.

At this point, the nurse is supposed to pose the goals that need to be achieved at the end of the diagnosis and the treatment of the patient. The primary goal is to treat the primary infection that is the abdominal fistula and also to properly document the urinary output (Slater, 2015). In addition, the student nurse should ensure that the patient is able to be cleared and allowed to receive residential care and also the communication of the patient looked at. Lastly, the bladder should be properly drained of the urine that it is holding.

This stage involves the nurses taking informed actions and coming up with care plans for the patient. After establishing the goals to be achieved, it was the responsibility of the Registered Nurse and the Student nurse to converse with the nurse who is in charge of the department and to place the next course of action to him or her. After talking to the nurse in charge about the patient, the student nurse had to inform the doctor of the current  situation of the patient and also to review the most likely antibiotics that should be administered to the patient. The appliance that was causing a leakage was to be removed and replaced by another ostomy appliance that could reduce the infection of the wound on the leg (Wilde et al.2017).  Another bladder scan was to be undertaken to determine if the patient was having the appropriate urine discharge. In addition, the wound on the leg needed to be checked so as to verify if the further infection was taking place (Bradley et al.2013).

At this point, it will be essential for the student nurse to look into the actions that were passed. The process that is to be involved should be evaluated to look at its efficiency to be able to provide quality services to the patient.  The doctor’s review called for the administration of the intravenous antibiotics and the insertion of the cannula. It was then seen that the patient retained no urine and the wound was well dressed and less infected. In addition,  the residential care was significant in that it could aid in the monitoring of the situation of the patient and deal with any further complications that may arise (Choi et al.2014).The patient was later on to be subjected to Physio and SW to look into the tumor in the abdomen.

Identify the Problem

At this stage, which is the last step of the clinical reasoning cycle, it is imperative to reflect on the decisions that the nurses and the doctor arrived at regarding the patient. It is also important for recommendations to be made. That is recommendations that are vital for the future in the case that such a scenario evolves. The student was conversant with the Gibbs reflective cycle (Gibbs, 1988) to review the situation that the patient has. The student nurse was able to identify concerns that should be worked on in future. For instance, why should be a patient be infected continuously for 4 days with an ostomy appliance that was causing leakages that were irritating the skin and as result causing to a wound on the leg.

The recommendation was that proper documentation should be carried out especially on the urine output and  it should be  indicated on the chart for a more informed decision.  In addition, the care givers should make sure that such patients are able to access palliative care for quick recoveries. The information given should be critically being thought out so that proper treatment is given to the patient. In conclusion, the clinical reasoning cycle should always be involved in the whole process of diagnosis and treatment (Nursing and Midwifery Board of Australia, 2016).  All the stages are imperative in the process and should be followed strategically per a patient’s situation.

References

Bradley, M. J., DuBose, J. J., Scalea, T. M., Holcomb, J. B., Shrestha, B., Okoye, O., ... & Ivatury, R. R. (2013).

Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective AAST Open Abdomen registry. JAMA surgery, 148(10), 947-955.

Bruhin, A., Ferreira, F., Chariker, M., Smith, J., & Runkel, N. (2014). Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen. International Journal of Surgery, 12(10), 1105-1114.

Casey,G.(2011). Incontinence  and retentioan. How  the bladder  misfunction. Nursing  New Zealand(wellington,NZ),17(7),26-31.

Choi, J. H., Jeon, B. G., Choi, S. G., Han, E. C., Ha, H. K., Oh, H. K., ... & Park, K. J. (2014).

Rectourethral fistula: a systemic review of and experiences with various surgical treatment methods. Annals of Coloproctology, 30(1), 35-41.

Dailly, S.(2011). Prevention of the indwelling catheter-associated urinary tract infections. Nursing Older People,23(2), pp.14.

Fink, R., Gilmartin, H., Richard, A., Capezio, E., Boltz, M.,& Wald, H.(2012). Indwelling urinary catheter management and catheter –associated urinary  t6ract  infection prevention

practices in nurses improving care for health system elders hospitals. American Journal of Infection Control,40(8), pp.715-720.

Foxley, S.(2011). Indwelling urinary catheters. Accurate monitoring of urine output. British Journal of Nursing,20(9),pp.564-569.

Gesmundo, M.(2016). Managing indwelling urinary catheters.Kai Tiaki; Nursing  New Zealand,22(6),pp.14.

Gibbs, G.(1988). Learning by doing: A guide to teaching and learning methods. Oxford Polytechnic Further education  Unit: Oxford, England.

Levett-Jones, T.(2012). Clinical Reasoning: Learning to think like a nurse. Sydney, Australia.

Nazarko, L.(2014). Does paracetamol help or hinder healing in bacterial infections? British Journal of  Community Nursing,19(7).

Nursing and  Midwifery  Board of Australia .(2016). National Competency  Standards for the Registered  Nurse.

O'Shea, L.(2011). Diagnosing urinary tract infections. Practice  Nurse,40(9).pp.20.

Slater, N. J., Bokkerink, W. J., Konijn, V., Bleichrodt, R. P., & van Goor, H. (2015). Safety anddurability of one-stage repair of abdominal wall defects with enteric fistulas. Annals of surgery, 261(3), 553-557.

Steggall, M.J.(2011). Urine samples and urinalysis. Nursing Standard ( Royal College  of Nursing) Great Britain),22(14-16),pp.22.

Wilde,M.H.,Dougherty,M.c.,& Rose,B.(2017). Awareness of urine flow in people with long-term urinary catheters. Journal  of Wound, Ostomy and Continence Nursing,

22(2),pp.164-174.

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