Nursing Essay: Clinical Reasoning Cycle - Health Care Priorities.

Clinical Reasoning Cycle

Health care has advanced considerably, aligning with the advancements that have changed the structure of the society. The innovations in the treatment pathways havce opened up new dimensions in the health care and are continuing to do so. Furthermore the renaissance in the health care industry is no longer limited to the advancements of the treatment and medication, revolution has come in the diagnostic system, the care standards and even in the documentation procedure (Woods, 2010). The case study represents a male patient named Giovanni who has been suffering from acute symptoms of manifested heart disorder and was at high risk to morbidity. This essay will attempt to formulate a will articulated nursing plan that will identify and address two health care priorities of the patient and formulate intervention and care plan for him taking the assistance of clinical reasoning cycle.

Clinical reasoning cycle was introduced in the health care in the 1990s to facilitate critical thinking in the field of medicine and health care has never been the same ever since. This cycle is nothing but the assortment of a number of strategic step by step actions that will help the health care professional to understand the patient’s medical situation, elicit vital information, process and analyse the collected information and a draw a logical and clinical reasonable judgment about the cause behind the health care concern that the patient has manifested which will aid the health care professionals to arrive at the most scientifically plausible diagnosis (Levett-Jones et al., 2010 p515-520). The patient in this case study has been experiencing increasing dyspnoea, swelling feet and signs of fatigue which are indicative of acute manifested heart failure. The investigative results shoe large cardiothoracic ratio and cardiac output. The two care priorities for him will be elevating his dyspnoea and decreasing the cardiac output to stabilize his conditions and avoid the risk to morbidity.  

In the profession of nursing there are a lot of challenges that are the part of the daily professional life of the nursing professionals. As the nurses are responsible for the entire care climate of the patient for the duration of their stay at the health care facility and beyond, the nurses need to make a number of challenging clinical judgments corresponding to the care of the patients. Clinical reasoning cycle provides them the opportunity to establish the link between theory and practice to make those clinically reasonable decisions (Levett-Jones et al., 2010 p515-520). In this case study, the cafe plan will be made for a 72 year old man with chronic heart failure in the emergency department using the elements of clinical reasoning cycle.

The first step of a clinical reasoning cycle is to consider the present situation of the patient, proper initial assessment of the patient is an incredible step to the entire treatment pathway as it reveals a wealth of information about the patient. In this case scenario, the patient, Mr. Giovanni is a 72 year old man with coronary artery disorders and has experienced chronic heart failure and has been admitted to the emergency department of the heath care facility. Chronic heart failure can be defined as the condition where arteries are so intensely blocked or congested that the heart is no longer able to flow enough blood to meet the requirements of an adult body (Strait & Lakatta, 2012 p143-164). The patient had been experiencing the problem of shortness of breath and has had been a chain smoker for years and continues to be smoking even now. The care needs of this patient should initiate with stabilizing his vitals followed by resolving the primary health abnormalities or problems that he is experiencing.  

Interpretation Of The Clinical Issues

The nest step of a clinical reasoning cycle is concerned with eliciting and collecting all the relevant information about the patient, his present health concern and his past medical history. This particular step is concerned with the nursing professional to assimilate all relevant data about the patient, the possible signs and symptoms he is exhibiting, and how they are interlinked, to compare them to relevant health care data to arrive at a conclusion about the cause behind these signs and symptoms by the means of processing the information assimilated (Singh & Newman, 2011 p319-329). In this case the patient under consideration is suffering from chronic heart failure brought about by unheralded coronary blockages of massive magnitude. As the heart attack approached the patient had felt the onset of severe dyspnoea and suffocation which did not subside even after sitting in low fowler position using three pillows. The patient has also divulged information regarding his dyspnoea that had been continuing for a few days before the episode of cardiac arrest. The patient conveyed that walking caused him to feel breathless and puffed and even something as nominal as showering caused him to catch his breath. Furthermore the patent has also revealed that the patient had not been able to put his shoes on because of his increasingly swelling feet and the fact that he had not incorporated any changes in his lifestyle and dietary habits up until then and has nit quit smoking even after being diagnosed with chronic coronary artery blockage. The patient continued to smoke and had not integrated exercise regime to help him stay fit either (Shih et al., 2011 p9-17).

Processing this information it is clear that the patient has had all the prior markers of deteriorating coronary heart blockage and had been ignoring those signs rather that acting upon those indicators (McMurray et al., 2012 p 803-869). Moreover the patient is aging and with coronary heart congestion, the patent has not improved this diet and has not quit smoking which has spiked the worsening conditions. The vital signs of the patient revealed his heart rate to be elevated 115 beats per minute and his blood pressure spiked to range around 118 / 60. The respiato0ry rate of the patient reads 26 breaths per minute which is considerably shallow with the oxygen saturation being at 91 %. The body temperature of the patient is feverish and clammy at 36.9 º F. Further physical investigations of the patient revealed the presence of wide spread crackles when checked the auscultation and the presence of pitting oedema along the course of both of his lower limbs. The X-ray image for the chest of the patients revealed a n enlarged cardiothoracic ratio, with the presence of white patchy areas with Kerley B lines occurring in the lower lobes of his chest.

Coronary artery blockages are characterized by the symptoms that the patient has been experiencing, such as increasing dyspnoea, swollen, shallow breathing with crackles noticed upon auscultation and pitting oedema in the lower limbs. Based on the symptoms and the investigative health assessment findings it can be concluded that the patient is suffering from acute manifestation of heart failure and needs immediate interventions to avoid further manifestation of the comp0liaction (Lloyd-Jones et al., 2010 p e46-e215).

Health Care Priorities

According to the guidelines of the clinical reasoning cycle, the identification of the problems or issues of the patient under consideration needs to be done by the means of processing the information assimilated and comparing them to the existing evidence based literature on chronic heart congestion and resultant heart failure (Kane et al., 2011p856-863). The primary focus in this case should be on elevating and removing the congestion of the blocked arteries so that the blood flow can be restored to normal standards as per the adult body requirements.

From all the symptoms that the patient has been exhibiting, it is clear that the patient is exhibiting all signs of manifested heart failure with prior symptoms that have been neglected so far. The initial investigations of the patient revealed that the patient has higher cardiothoracic ratio which is indicative of an enlarged heart (Hanson et al., 2013 p1-16). The symptoms that the patient had been experiencing such as increasing dyspnoea or shortness of breath, swelling feet due to pulmonary oedema in the lower limbs and extreme fatigue leads to the acute decompensated heart failure.  Acutely decompensated heart is caused by extreme congestion and leads to be the cause behind the acute respiratory distresses and multiple organ failure (Goldstein et al., 2011p1011-1021).

Now in order to device a well organized care plan for a chronic heart failure patient a lot of factors need to be taken into consideration, it is imperative that the care plan is comprehensive with emphasis on the individual needs and requirements of the patient taking into considerations the scientific and ethical care approaches (Goldstein et al., 2011 p1011-1021). It has to be understood that the nursing interventions need to be logical and clinically reasonable based on genuine and accurate evidence based practice to address the primary needs and health priorities. It has to be considered that heart is the most vital organ in the body and metabolic and physiological functions and the health priorities for patients suffering with heart congestions is relieving the respiratory distress and decreasing the cardiac output and restore the vitals to normal before surgical removal of blockage can take place (Donneyong et al., 2014 p114).

In order to achieve the first goal selected according to the needs and requirements of the patient, as the patient had been suffering with extreme respiratory distress, it is imperative for the nursing professional to construct and administer interventions that can relieve the patient from his distress. There are a lot of interventions techniques that can be selected for relieving the respiratory distress of the patient under consideration, however the age and health co-morbidities of the patient also needs to be taken into account (Greenwood et al., 2012 p453-460). The patient has been experiencing bouts of breathlessness and puffiness in the days leading to the episode of heart failure and the condition has only manifested with the lack of any care interventions. Midzolam and morphine are considered to be one of the best pharmacological interventions that are administered all over the globe in order to relieve the patients of respiratory distress. Administration of diuretics likes furosemide and bronchodilators like aminophyllin used in combination however are more effective and with lesser side effects and can effectively relieve the patient of the respiratory distress (Chen & Frangogiannis, 2010 p 415-422). The rationale behind selection of this intervention is the fact that these two medications used in combination can target the impaired gaseous exchange tremendously. Furosemide is known for its properties of reducing alveolar congestion and bronchodilators dilate the congested airways to ensure the gas exchange revert backs to normal. As morphine have significant side effects, considering the age and health complexities of the patient, morphine should not be administered to the patient and second intervention option would be the most effective for the patient (Bui, Horwich & Fonarow, 2011 p 30-41).

The next most vital health priority for the patients going through acute decompensated heart failure is reducing the cardiac output. Tachycardia is often associated with the coronary artery congestion and is often considered to be a contributing factor for the further complications that arise due to congestive heart failure. As the patient is exhibiting all the common symptoms of ventricular abnormalities, such as decreased cardiac output, crackles upon tachycardia, hypotension and skin pallor, it can be concluded that the patient is in need for surgical removal of the blockage (Butcher et al., 2013). However prior to the surgery there are a few independent  interventions that the nursing professional caring for the patient under consideration needs to undertake. Administration of diuretics and vasodilators are mandatory in order to decrease the cardiac output. Administration of beta androgenic antagonist drugs and blood thinners can also aid in decreasing the cardiac load and elevating the blood flow within the body (Kavousi et al., 2012 p438-444). Considering the present condition of the patient these medications will help in reducing the cardiac load in the patient and in turn will decrease the myocardial infarction significantly so that the vitals of the patient can be restored enough for him to perform surgical coronary artery bypass graft (Bui, Horwich & Fonarow, 2011 p30-41).  

Conclusion:

On a concluding note, it is evident that the patient is at high risk with the cardiac failure he has experienced at this age can seriously lead to fatal consequences if adequate care is not taken. It has to be considered that Mr. Giovanni is 72 years old and sustaining a manifested acute cardiac failure is going to be critical for him with the age related complications that arise. However, with the correct nursing intervention and medication the worst can be avoided. Apart from the immediate interventions mentioned above, the nursing professional attending to him will have to consider keeping him comfortable and warm at all times. The patient needs to maintain a liquid diet and should be kept well hydrated. The nursing professional should pay attention to keeping the room clutter free for him and the call light within his reach, the bed rails for him should be raised as well to ensure that the patient dose not entertain a fall which is common at this age group and can reach nursing help easily at the time of need. Last but not least, the vitals of the patient should be monitored diligently and a registered nurse should pay close attention to the changes in his condition. With all these interventions, devised taking the assistance of clinical reasoning cycle, the risk of morbidity can be avoided.

References:

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