Effective clinical reasoning skills in nursing practice ensure positive patient outcomes. Conversely, poor clinical reasoning skills lead to patient’s deterioration (Salminen et al., 2014). The term clinical reasoning in nursing refers to the process of collecting cues, processing patient related information, understanding the health condition of the patient, planning and development of intervention, evaluation of outcome and reflecting on the outcomes and the process. The entire process is a not linear rather each step of the process is a cycle of linked and ongoing clinical encounters (Dalton et al., 2015). Levett Jone developed the clinical reasoning cycle and it is vital in nursing profession. The essay deals with the case study of 49-year-old man Mr. Kasim Al-Mutar who presents to the emergency department with cholecystitis. The essay presents the health assessment of the patient using the Levett Jone’s clinical reasoning framework.
The clinical reasoning cycle is a dynamic Management process and consists of several stages. The first step of the framework is the consideration of the patient’s situation. In the given case study, Mr. Kasim Al-Mutar, a 49 year old man with cholecystitis is presented to the emergency department. He presents following two days of right upper quadrant abdominal pain, vomiting and fever. Cholecystitis is the condition associated with gallbladder inflammation. In this condition, the gallstones obstruct the cystic duct. It result in build up of bile in the gall bladder leading to inflammation. The most common sign of the acute cholecystitis is abdominal pain and tenderness in right upper quadrant or RUQ (Bosch et al., 2016). It is the typical compliant for his age and gender. According to Wichmann et al., (2010) the risk of cholecystitis increases with age. In Australia this is the common condition in 25-30% people aged 50 years and above. Acute cholecystitis is more common in men than women who get gallstones more often. Therefore, it is common for Mr. Kasim to experience these symptoms. However, further assessment is needed to determine the exact cause of the symptom and identify the presence of gallstones.
The next step of the clinical reasoning cycle is collection of cues and information related to the clinical situation presented. For this purpose, it is important to review the handover information. Based on the clinical handover by previous nurse, the patient had heart rate of 126, blood pressure of 100/45 and temperature of 38.5 which indicates fever . The handover informs severe pain in right upper quadrant with last episode of vomiting 2 hours ago. Upon collecting more information on the patient from the previous nurse, it was found that the patient is pale with dry mucous membrane. The patient is thirsty and is requesting water to drink. Additional information gained from the previous reports includes shoulder tip pain. The patient reported a pain score of 7 on a scale of 10. Upon collecting information on patient’s family, it was found that the only member to support and care for Mr. Kasim is his 12-year-old daughter.
The clinical handover does not provide information on presence of abdominal sounds which is the most common diagnostic test ordered to diagnose cholecystitis. The information does not indicate if the pain was initially colicky and if later has turned to be constant. There should have been more information on the level of bilirubin, alkaline phosphatase which, provide an evidence on the obstruction of bile duct. There is a need of complete blood count test for diagnosis and confirmation of a cute cholecystitis by identifying the markers of inflammation (Yabluchansky et al., 2016).
The information collected from the handover needs to be processed to proceed with further health assessment of the patient. The processing of obtained clinical information is the next stage of clinical reasoning cycle. To start with the vital signs the heart rate of patient which is 126 beats per minute is indicative of tachycardia (Yabluchansky et al., 2016). His blood pressure of 100/45 indicates hypotension and fever is indicated by his temperature of 38.8°C. Further, the patient has been vomiting 2 hours ago. According to Yabluchansky et al., (2016) the most common symptoms of acute cholecystitis include fever, vomitting, tachycardia, and abdominal pain. According to McPheeters and Karp, (2015) nausea and vomiting in this condition is associated with biliary colic which is the condition caused when bile duct is temporarily blocked by the gallstones. Therefore, these symptoms match in the case of the patient. The patients of acute cholecystitis report upper abdominal pain, which then radiates to the right shoulder or scapula. Further, the pain frequently begins in the epigastric region and then localises in the RUQ (Bosch et al., 2016). A similar symptom has been absorbed in case of Mr. Kasim whose clinical history shows shoulder tip pain and severe RUQ pain. The pain score of 7 out of 10 indicates a dominant pain. It indicates severe pain that dominates the senses. This severe pain significantly interferes with sleep and limits the ability to perform the normal daily activities (Strong et al., 2014). Further, the pale skin of the patient indicates anaemia, and the patient is dehydrated as evident from the dry mucous membrane and patient’s willingness to drink water. It indicates the need of setting up intravenous fluid immediately (Jeong & Jung, 2016).
It is necessary to judge the present condition of the patient using critical thinking skills to identify the problems and issues. Based on the symptoms of the patient the most suspected diagnosis is acute cholecystitis considering the symptoms and literature (Le & Finlayson, 2016). There is a need of focussed health assessment. The laboratory tests of amylase /lipase, liver function test, cardiac enzymes and b-HCG will better eliminate the irrelevant options from the differential diagnosis. Some of the symptoms are also common in case of common bile duct obstruction, and acalculous cholecystitis (Barie & Eachempati, 2015).These diagnostic tests are essential because acute cholecystitis and common bile duct obstruction is confirmed with increased level of Alanine aminotransferase, aspartate aminotransferase, bilirubin and alakaline. In acute cholecystitis, amylase and lipase are mildly elevated. Therefore, these tests will rule out the possibilities of other problems such as appendicitis (Victory et al., 2017).
If the fever is due to infection it will be evident from the rise in WBC (positive blood cultures). The correct information of the diagnosis can be achieved from the acute abdominal series and ultrasound of the right upper quadrant. In case the acute abdominal series is negative then the information from the ultrasound test will be the last resort for correct diagnosis. It is because the right upper quadrant ultrasound informs about the presence of the gallstones, perichocholecystic fluid, thickening of the gall bladder wall thickening, sonographic Murphy’s sign and other abnormalities in pancreas, liver, kidney and other things such as air in the wall of the gallbaaldder. Further, secondary imaging tests such as computed tomography can help identify the extrabilary disorder (Adhikari et al., 2014).
Most of the symptoms direct towards that of acute cholecystitis, which in most cases occur due to gallstones. However, in many patients having gallstones do not lead to these symptoms. Some patients may not have cholecystitis, however, may present with similar symptoms such as inflamed gallbladder (Yabluchansky et al., 2016). In cases other than acute cholecystitis such as catarrhal inflammation, patients have been found to be infected with pyogenic bacteria that lead to fever. It may result in inflammation and perforation of the mucous membrane. These conditions are different from the cholecystitis. In case of the patient Mr. Kasim, the possibility of Jaundice is not present. In most cases unless common bile duct obstruction, Jaundice is absent (Guo et al., 2014). Many people with typical gall bladder attack have similar symptoms but do not have severe pain similar to acute cholecystitis (Jeong & Jung, 2014).
The last step of the clinical reasoning cycle is the detailed health assessment of the patient. Prior to the assessment ad developing care plan there is a need of detailed assessment which include the following-
Ultrasonography- it is the initial imaging test preferred for the patient of cholecystitis. It is followed by CT scan which is secondary imaging test to identify extra-biliary disorders. It also identifies acute complications of cholecystitis. Cholecystography as per Le and Finlayson, (2016) can reveal the stones in the biliary system. The nurse must assess the skin and mucous membrane followed by assessment of peripheral pulses and capillary refill. Followed this the nurse must assess for abdominal distension, and any reluctance to move. Nurse must report if there is any frequent belching and guarding in patient. Later the nurse must assess the pattern of the pain and any risk of malnutrition.
Based on the assessment the major goals for the patient include relieving pain and promoting rest. The immediate attention to the patient include maintaing fluid and electrolyte balance and prevention of complications (Adhikari et al., 2014).
In conclusion, the competent professional practice requires sophisticated thinking skills. Critical reasoning in nursing is vital as nurses are significant part of the judgements and the decision-making in heath care. Patients are sometimes presented with the complex symptoms which may overlap with other diseases. Ineffective judgment may lead to development of inappropriate interventions. Consequently, it may give rise to patient’s deterioration and mortality. Thus, clinical reasoning cycle is one of the most important learning approaches for preparedness of professional nurse practice.
Adhikari, S., Morrison, D., Lyon, M., Zeger, W., & Krueger, A. (2014). Utility of point-of-care biliary ultrasound in the evaluation of emergency patients with isolated acute non-traumatic epigastric pain. Internal and emergency medicine, 9(5), 583-587.
Askew, J. (2005). A survey of the current surgical treatment of gallstones in Queensland. ANZ journal of surgery, 75(12), 1086-1089.
Barie, P. S., & Eachempati, S. R. (2015). Acute acalculous cholecystitis. In Acute Cholecystitis (pp. 187-196). Springer International Publishing.
Barie, P. S., & Franck, P. (2015). History of Medical and Surgical Management of Acute Cholecystitis. In Acute Cholecystitis (pp. 1-16). Springer International Publishing.
Bosch, D., Schmidt, J. N., & Kendall, J. (2016). Acute Cholecystitis Detected by Serial Emergency Department Focused Right Upper Quadrant Ultrasound. Journal of Medical Ultrasound, 24(2), 66-69.
Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based education to'flip'the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, The, 33(2), 29.
Guo, S., Lei, J., Zhai, Y., Chen, P., Zhang, H., Zhang, J., ... & Guo, Y. (2014). Quantitative Analysis of Focal Liver Injury Using the Apparent Diffusion Coefficient in Patients with Biliary Obstruction from Common Bile Duct Stones: A Pilot Study. Current Molecular Imaging, 3(3), 240-245.
Jeong, C. Y., & Jung, S. H. (2016). Acute Cholecystitis after Screening Colonoscopy. Korean Journal of Pancreas and Biliary Tract, 21(4), 228-231.
Le, S. T., & Finlayson, E. (2016). Surgical vs Non-Surgical Management of Acute Cholecystitis in Nursing Home Patients. Journal of the American College of Surgeons, 223(4), S118.
McPheeters, R. A., & Karp, J. (2015). ABDOMINAL PAIN, NAUSEA, AND VOMITING. Emergency Medicine Secrets.
Salminen, H., Zary, N., Björklund, K., Toth-Pal, E., & Leanderson, C. (2014). Virtual patients in primary care: developing a reusable model that fosters reflective practice and clinical reasoning. Journal of medical Internet research, 16(1), e3.
Strong, J., van Griensven, H., & Vincenzino, B. (2014). Pain assessment and measurement.
Victory, J., Meytes, V., Parizh, D., Ferzli, G., & Nemr, R. (2017). Co-existent appendicitis and cholecystitis. Annals of Laparoscopic and Endoscopic Surgery, 2(1).
Wichmann, M. W., Lang, R., Beukes, E., Esufali, S. T., Jauch, K. W., Hüttl, T. K., & Hüttl, T. P. (2010). Laparoscopic cholecystectomy—comparison of early postoperative results in an Australian rural centre and a German university hospital. Langenbeck's archives of surgery, 395(3), 255-260.
Yabluchansky, M., Bogun, L., Martymianova, L., Bychkova, O., Lysenko, N., & Makienko, N. (2016). Cholelithiasis, chronic cholecystitis and functional biliary disorders.
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