The term clinical reasoning is used to determine a cognitive process that guides the practice of nurses and other clinicians. Clinical reasoning determines the way patient information is collected in a clinical case, processed, integrated with the clinician’s knowledge and experience, and ultimately comes to an understanding of the issue which is used to diagnose and manage the patient’s problem (Kriewaldt & Turnidge, 2013). The nurses then plan and implement interventions, evaluate patient outcomes, and finally reflect and learn from the whole procedure. Thus, in preparation for clinical reasoning, nursing students must be provided with opportunities to reflect on and question their assumptions and prejudices; as failure to do so may negatively impact their clinical reasoning ability and consequently patient outcomes (Mariani et al, 2013). The following essay will describe the way of utilizing a clinical reasoning model to handle a clinical issue. Clinical reasoning model of Levett-Jones, 2018, is used as a framework to plan and evaluate a case of person-centred care.
Fig. 1: Diagram of Clinical Reasoning Cycle
While clinical reasoning can be broken down into multiple steps, in reality the phases merge (Kable et al, 2013). Since clinical reasoning is a dynamic procedure, nurses and clinicians often combine two or more phases or even move back and forth until they get engaged in a moral reasoning. Clinical reasoning must arise from this engaged, concerned stance, always in relation to a particular patient and situation.
The patient, Ms Melody King, is a 36 year old woman who has been admitted to the Emergency department, because she had 2-3 days of severe right lower quadrant (RLQ) abdominal pain due to peritonitis, followed by ruptured appendix. She had to go through an immediate laproscopic surgery to remove the ruptured appendix.
Ms Melody has a past medical history of asthma and depression. She takes a few prescribed medications which include Ventolin, Seretide and Sertraline. Her BP was recorded to be 95/45 mmHg, heart rate is 120 and body temperature is 38.3°C. Her respiratory rate is 22/min and she is shallow breathing. Her SpO2 is 95%, recorded on room air. Currently she is suffering from increasing nausea and centralised abdominal pain which she rated 7-8 on a scale of 0-10. Her physical assessment showed a distended abdomen and generalised abdominal guarding. To further investigate her condition, few pathological tests were conducted which revealed a raised WBC count and CRP.
Processing of gathered information
After recording her BP it is evident that she is suffering from hypotension. Her ruptured appendix may have caused the low BP due to the injury and internal bleeding. Also post-operative dehydration, the septic shock resulting from peritonitis, or lack of essential vitamins and minerals in diet can cause low RBC levels in blood and may result in hypotension (LeMone et al, 2015). The medications she takes for asthma and chronic obstructive pulmonary disease, are Ventolin and Seretide, which do not pose any severe adverse effects on the patient. But the antidepressant she takes, Seretide may cause low blood pressure. Her body temperature is a little high (38.3°C), since temperature over 38°C is considered as fever. She is feverish probably due to her illness. Since respiratory rate beyond 25 is considered abnormal, her breathing is in the normal range (22/min). Although she is taking shallow breaths. This is maybe due to the reason that taking deep breaths may cause pain in her abdomen since she has been diagnosed with abdominal guarding (Liebert et al, 2016). After her physical assessment it was found that she has a distended abdomen, which is a typical symptom of post-operative dysfunction of her abdomen, such as accumulation of gas or fluid. After surgery her abdomen has become inflamed and by the most common involuntary protective mechanism to prevent pain, the muscles have gotten rigid. This abdominal rigidity or abdominal guarding is a result of peritonitis. Her centralised pain is due to the appendicitis, which started off at right lower quadrant, but moved towards her belly button. This abdominal guarding is maybe the reason behind her increasing nausea as well (Dalton, Gee & Levett-Jones, 2015). Her pathological reports suggest that she has increased levels of WBC and CRP, both of which occur in response to inflammation.
Identification of the issues
After the laproscopic surgery the patient’s condition is not quite well. She has several problems associated with post-surgical trauma. Among those, the three most important issues that need immediate care are:
- her increasing centralised abdominal pain,
- increasing nausea and
- her low blood pressure
Ms. Melody is suffering from severe hypotension, which may result from various reasons. Her increased nausea and centralised abdominal pain is due to post-operative inflammation and guarding of abdomen. Along with these she has slight fever and shallow breathing. Her increased white blood cell count and C-reactive protein levels is due to the post-surgical abdominal inflammation.
Establishment of nursing goals
I would like to take proper measures to improve her condition. First her increasing abdominal pain should be taken into consideration. Medications must be given if needed to boost her condition. Then I will look into her diet and fluid intake, to develop a better digestive status and reduce her nausea. Then simultaneously her fluid intake must be increased over a period of few days, in order to improve her blood pressure.
- To raise blood pressure:I will increase her fluid intake in order to raise her blood pressure. I will look into it that she never stays dehydrated, which may worsen her condition or even lead to shock. I will maintain her food intake as well; make sure she eats a vitamin and cooking salt rich diet. I will give her alternatively warm and cold showers, which will improve her feverish condition and help to balance her BP.
- To improve nausea:Over the next 2 days, I would improve her nausea status. I will make sure she eats her meals on time, increase her water intake, and give her medications if the condition doesn’t improve. IV administration of 10-20mg of metoclopramide may reduce her post-laproscopic nausea status.
- To reduce abdominal pain:For her increasing abdominal pain I will give her IV pain medications such as opoids, acetaminophen or NSAIDs (ibuprofen, naproxen). This
will help diminish her abdominal rigidity. When her pain will subside, her nausea will eventually drop as well.
I will consult with her doctor and ask for permission from the doctor to change her IV medication rates as needed. I will thoroughly follow any other orders the doctor gives to improve the patient’s current status (Hunter & Arthur, 2016).
Evaluation of effectiveness
Raising her fluid intake will help with her entire health. Since dehydration causes many physical abnormalities, if her fluid or water intake is improved most of her problems will subside. When she will gain a proper water balance in her body, her feverish body temperature will come down to normal, her nausea will be diminished, and most importantly her hypotension condition will improve and she will start developing a normal blood pressure in a few days (Forsberg et al, 2014). A properly balanced diet is a prerequisite to maintaining a healthy state of the body. As long as she continues to have a well-balanced, vitamin rich diet she will develop a much healthier condition (Mather, McKay & Allen, 2015). Her RBC count will raise, leading to a raise in blood pressure as well. Timely consumption of proportioned meals will help her get rid of the vomiting tendency and reduce her nauseated feeling. If these simple measures do not tend to be as effective as needed, then the medications will surely help with her condition. For betterment of her distended abdomen and the abdominal guarding condition she must depend solely on medication (Agha et al, 2016). Even though this is time consuming, inflammation will eventually be reduced by thorough follow up medications (Posel, Mcgee & Fleiszer, 2015). The more reduction of the inflammation will take place the more reduced her pain will be, since her abdominal pain is directly related to the inflammation. After that, her white blood cell count and CRP level will improve as well.
Reflection on process and new learning
When I reflect on the entire procedure, I think that I should have been able to determine the appropriate pain medication dosages properly and sooner than I have done this time. Since Ms King suffered from depression, continuation of her anti-depressants medication led to an increased nausea. I could have convinced her to not take the anti-depressants for a few days after the surgery. If I had the chance to consult a dietician, she could recover much faster with an appropriate diet-plan. If I avail the chance to tend to a patient with a similar condition, next time I will have more expertise in handling an issue like that (Victor-Chmil, 2013).
Clinical reasoning has significant importance regarding the ever increasing numbers of adverse patient outcomes and escalating healthcare complaints. When nurses are skilled professionals capable of effective clinical reasoning, they leave a positive impact on patient outcomes. Critical thinking, application of proper nursing techniques, knowledge about the ongoing research and developments in practice, and acquiring substantial clinical experience: all are essential parts of sound clinical judgement. Informed opinions and decisions based on empirical knowledge and experience are what clinical judgement comprises of. This essay have been done thoroughly following the Levett-Jones clinical reasoning model, which helps to diagnose each and every problems associated with the patient. All the effective measures taken into consideration for improvement of patient’s health status are evaluated for better outcome. Therefore it can be stated that clinical reasoning capability can be developed with experience and decision making ability of the nurses in practice and their reflective potentials.
Agha, R. A., Fowler, A. J., Saeta, A., Barai, I., Rajmohan, S., Orgill, D. P., ... & Aronson, J. (2016). The SCARE statement: consensus-based surgical case report guidelines. International Journal of Surgery, 34, 180-186.
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.
Forsberg, E., Ziegert, K., Hult, H., & Fors, U. (2014). Clinical reasoning in nursing, a think-aloud study using virtual patients–A base for an innovative assessment. Nurse Education Today, 34(4), 538-542.
Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement: Clinical educators' perceptions. Nurse education in practice, 18, 73-79.
Kable, A. K., Arthur, C., Levett?Jones, T., & Reid?Searl, K. (2013). Student evaluation of simulation in undergraduate nursing programs in Australia using quality indicators. Nursing & health sciences, 15(2), 235-243.
Kriewaldt, J., & Turnidge, D. (2013). Conceptualising an approach to clinical reasoning in the education profession. Australian Journal of Teacher Education, 38(6), 7.
LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., & Reid-Searl, K. (2015). Medical-surgical nursing. Pearson Higher Education AU.
Liebert, C. A., Lin, D. T., Mazer, L. M., Bereknyei, S., & Lau, J. N. (2016). Effectiveness of the surgery core clerkship flipped classroom: a prospective cohort trial. The American Journal of Surgery, 211(2), 451-457.
Mariani, B., Cantrell, M. A., Meakim, C., Prieto, P., & Dreifuerst, K. T. (2013). Structured debriefing and students' clinical judgment abilities in simulation. Clinical Simulation in nursing, 9(5), e147-e155.
Mather, C. A., McKay, A., & Allen, P. (2015). Clinical supervisors' perspectives on delivering work integrated learning: A survey study. Nurse education today, 35(4), 625-631.
Posel, N., Mcgee, J. B., & Fleiszer, D. M. (2015). Twelve tips to support the development of clinical reasoning skills using virtual patient cases. Medical teacher, 37(9), 813-818.
Victor-Chmil, J. (2013). Critical thinking versus clinical reasoning versus clinical judgment: Differential diagnosis. Nurse Educator, 38(1), 34-36.