NURS1201 Clinical Reasoning Cycle

a) Briefly describe what is involved in the processing information phase. As a nurse, what is the purpose of processing information?

b) Identifying normal versus abnormal: Using your list of cues in question 3b, list what cues you consider are not in the normal range for Mrs Randall (using supportive literature)

c) Discriminate: From the cues identified above, identify the one cue that would be your priority for Mrs Randall (what are you most concerned about), and why? 

 

Answer:

The Importance of Clinical Reasoning

Clinical reasoning, as the due procedure followed by nurses and other clinicians in finding out all the possible problems faced by a patient, helps in perceiving imminent patient decline (Levett-Jones, et al., 2010). Nurses enriched with problem solving skills stand a better chance of positively influencing a patient’s outcome as they see the bigger picture of the situation (Purling & King, 2012). Nurses with poor critical thinking skills on the other hand are the core reason why some clinics experience antagonistic events from a patient. Collecting and processing information, detecting the problem & anticipating an outcome and taking action are some of the major skills that have a bearing on the patient’s final situation (Levett-Jones T. H.-S., 2010). A wrong diagnosis of the whole situation will obviously lead to the worsening of the patient’s condition since ineffective treatment options will be applied.

 In the analysis of the cues collected, nurses and clinicians can study previous cases with similar signs (Higgs, 2018). This will definitely boost their reasoning as they seek to find out the patient’s real condition and a correct treatment method will be assigned. Every nurse will definitely not want to be on the receiving end of the patient’s critics due to inappropriate treatment methods. Therefore, nurses and clinicians should sharpen their clinical reasoning skills as early as the university and college level. Relying on previous worked examples to find solutions has proven to be inadequate, thus other learning materials should be accessed all the time (Montpetit-Tourangeau, et al., 2017). Graduates, just like qualified nurses and clinicians, will be expected to counter to patients’ deterioration. Partial experience and elementary knowledge makes the care of deteriorating patients challenging (Purling & King, 2012). Nurses should be in a position to spot all the elusive symptoms in order to make precise treatment decisions.

Considering the patient’s situation.

Nurses have an obligation to know about the patient’s physical and psychological information. Nurses should study the patient’s medical reports and books to understand the patient’s current condition and medical status in order to draw out facts of the patient’s clinical circumstance (European Heart, 2018). Therapeutic communication should be used to find out the patient’s psychological information. Nurses should also run a few tests in order to be aware of the patient’s weight, height, body temperature and blood pressure. This helps nurses and other clinicians to plan the patient’s assessment and treatment. An accurate assessment of the patient’s situation helps avoid patient’s deterioration.

Collecting cues and information

The importance of collecting cues

Relevant and precise diagnosis protects the patient from the possibility of pointless testing and payment for the unnecessary tests (Muhrer & C., 2014). A keen examination of the patient’s history of medical conditions provides important information to the diagnosis. Correct diagnosis helps in finding out the patient’s possible conditions. More appropriate and accurate analytical tests are carried out when the patient’s symptoms are scrutinized profoundly.

Current information about Mrs. Randall

Mr. Randall, a 76-year-old woman, has been admitted at the Orthopaedic ward from the Emergency Department after she had a fall at home.  Mrs. Randall’s important signs upon admission are:

• Blood pressure 145/90 mm Hg
• Temperature 36.8^o Celsius
• Pulse rate 110 beats per minute
• Respiration rate 18 breaths per minute
• Oxygen saturation 95%

Mrs. Randall has a history of high blood pressure (hypertension) and is on antihypertensive medication, Avapro 150mg/day. According to the physical exam, Mrs. Randall also has pain and redness on her left foot.

Additional assessment on Mrs. Randall

Mrs. Randall’s new blood pressure, pulse rate and oxygen saturation should be checked to check for changes. This is because Mrs. Randall’s blood pressure and pulse rate are high while the oxygen saturation is close to getting low. The minimum oxygen saturation should be at 95%.

A keen examination of Mrs. Randall’s left foot has to be done to check for a metatarsal bone fracture due to the pain and redness on her left foot.

A psychological examination should also be done to establish whether Mrs. Randall has stress problems arising from her late husband’s death. Mrs. Randall has not been at the local bowling and local church since her husband died yet she was an active member.

Processing information

Purpose of processing information

Nurses interpret the information collected to get an understanding of the patient’s symptoms. A comparison between the normal body conditions and the patient’s condition is made to determine what is normal or unusual about the patient. Nurses then categorize the information on the basis of relevance. A relationship pattern is formed between the clues before an inference is made. Nurses then compare the current situation to past incidents before predicting an outcome. This helps the nurse to make a more accurate decision when prescribing the treatment plan.

Identifying abnormal cues

• Blood pressure of 145/90 mm Hg against the normal 139/89 mm Hg which is the maximum normal blood pressure (Disha, 2018).
• Pulse rate of 110 beats per minute as opposed to the normal 72 beats per minute (Disha, 2018). 

Discrimination of cues

Mrs. Randall’s blood pressure is quite high while her temperature is slightly low, however, her pulse rate is very high and should be keenly checked and a test for tachycardia has to be done.

Identifying problems or issues

Difference between actual and potential nurse diagnosis

An actual nursing diagnosis is a scientific conclusion about the patient’s health condition at the time of the nursing assessment. This is substantiated by patient’s symptoms.

A potential nursing diagnosis is medical decree about a health problem which the patient or the patient’s family is risk of developing in the future.  

“Related to” is used when referring to the patient’s assessed medical condition (diagnosis) while “evidenced by” is used when listing the observations validating the patient’s diagnosis. Both are used during the actual nursing diagnosis. 

Altered pulse rate - related to - diagnosed tachycardia - evidenced by - increase in pulse rate 110 beats per minute and blood pressure 145/90 mm Hg. 

Risk related a fractured left foot metatarsal bone as evidenced by pain and redness on the left foot. 

• To return the pulse rate to a normal range of 60 to 100 beats per minute as soon as possible.
• To return the blood pressure to the normal range of 120/80 – 139/89 mm Hg over time.

Taking action

Assessment

Assessment of Mrs. Randall’s pain on her left foot, psychological problems caused by her husband’s death, withdrawal from kinfolk and her attitude towards the hospital staff considering her statement she makes about not wanting to be in hospital.

Education

Mrs. Randall needs to rest due to the pain on her left foot. She also needs to take her medication in order to lower the high blood pressure and pulse rate.

Medication

Mrs. Randall has to start an antianxiety medication on order to reduce the pulse rate and an antihypertensive medication, Avapro 150 mg per day for the high blood pressure. Mrs. Randall also has to continue taking the dose of 1000mg Panadol PRN to relieve the pain on her left foot.

Intervention/care

Monitoring the lab results for the tests on Mrs. Randall and administering the medication as prescribed to help in reducing the pulse rate & blood pressure and relieve the pain on her left leg (Wayne, 2016). A psychology education programme for Mrs. Randall’s anxiety management has to be implemented (Higdon, 2018).

Evaluation

Purpose of evaluating nursing interventions

Evaluating the nursing care is done to aid in the study of nursing practise.  The patient’s features & application of care and the selected outcomes are comprehensively accounted for in the evaluation (Benner, Kyriakidis, & Stannard, 2011). Evaluation is done after the patient’s nursing care has been implemented in order to improve the quality of nursing care.

Evaluation of Mrs. Randall 

Mrs. Randall’s pulse rate, blood pressure, oxygen saturation and condition of her left foot are checked and evaluated to ascertain that there have been improvements in their conditions. The type of nursing care administered is also evaluated in order to prove that it was appropriate and effective (S & Epstein DR, 2003). The pulse rate and blood pressure should have reduced to the normal 72 beats per minute and 120/80 mm Hg respectively (Rubin, 2011).

Reflection

The second phase of clinical reasoning cycle, collecting cues and information, is easier to understand since it involves collection of information about the patient, medical reports and the general knowledge about health science. Assessment of this information is much easier when references to scientific books are made.

It helps in making flexible decisions and administration of quality care as a nurse. Nurses’ and other clinicians’ ability to offer non-toxic and high quality care to patients improve with improvement in the reasoning, thinking and judgement abilities (Cowan, 2017). It helps in avoiding collection of inadequate cues and implementation of appropriate treatment methods.

References

Benner, P., Kyriakidis, P. H., & Stannard, D. (2011). Clinical Wisdom and Interventions. New York: Springer Publishing Company.

Berman, A., Snyder, S. J., Kozier, B., Erb, G. L., Levett-Jones, T., Dwyer, T., …David S. (2018). Critical Thinking and Nursing Process. In B. Ingham-Broomfield, Kozier and Erb's fundamentals of nursing (pp. 192-203). Melbourne: Pearson.

Cowan, E. (2017). Importance of Clinical Reasoning. Interprofessional Ambulatory Care Unit.

Disha, E. (2018). General Knowledge 2018 Capsule with Current Affairs Update. New Delhi: Disha Publications.

European Heart, A. (2018). The Clinical Reasoning Cycle: The 8 phases and their significance. European Heart Association.

Higdon, T. (2018). What Is Nursing Intervention? - Definition & Examples. Fundamentals of nuersing.

Higgs, J. (2018). Clinical Reasoning in the Health Professions. Sydney: Elsevier - Health Sciences Division.

Levett-Jones, T. (2018). Diagnosing. In A. Berman, S. J. Snyder, B. Kozier, G. L. Erb, T. Levett-Jones, T. Dwyer, …David, S. Kozier & Erb's Fundamentals of Nursing Australian Edition (pp. 221-229). Melbourne: Pearson.

Levett-Jones, T. H.-S. (2010). The “Five Rights” of Clinical Reasoning: an educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients. Nurse Education Today, 515-520.

Levett-Jones, T., Sundin, D., Bagnall, M., Hague, K., Schumann, W., Taylor, C., & Wink, J. (2010). Learning to think like a nurse. HNE, 15-19.

Montpetit-Tourangeau, K., Dyer, J. O., Hudon, A., Windsor, M., Charlin, B., Mamede, S., & Van Gog, T. (2017). Fostering clinical reasoning in physiotherapy: comparing the effects of concept map study and concept map completion after example study in novice and advanced learners. BMC medical education, 17(1), 238.

Muhrer, & C., J. (2014). The importance of the history and physical in diagnosis. The Nurse Practitioner, 30-35.

Purling, A., & King, L. (2012). A literature review: graduate nurses' preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 3451-3465.

Rubin, A. L. (2011). High Blood Pressure for Dummies. Hoboken: John Wiley & Sons.

S, S., & Epstein DR. (2003). Enhancing the evaluation of nursing care effectiveness. PubMed labs, 26-38.

Wayne, G. (2016). Decreased Cardiac Output. Nurses labs.