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The Clinical Reasoning Cycle

Discuss about the Process Of Engaging In Critical Reflection.

While engaging in care of patients with chronic conditions, a nurse has to analyze and interpret multiple factors that can have an impact on their health outcome. The ability to interpret and analyze different factors to prioritize care for patient is dependent on clinical expertise as well as critical reflection skills. The process of engaging in critical reflection is the pathway through which nurse can deduce the main patient problem and plan the best care priority for the recovery of patient. Clinical reasoning cycle is one of the process that can be used by nurse to analyzed and process complex patient information in a systematic manner and understand the care needs of patient. The essay utilizes the steps of the clinical reasoning cycle to the case of Peter Mitchell, a 52 year old patient with morbid obesity and type 2 diabetes and analyzes the information from the case to identify two care priorities for patient. The rational for choosing specific care priorities is also provided by applying clinical reasoning cycle as a means of justification.

The clinical reasoning cycle is an eight step process of cyclical intervention and by passing through those steps, nurse can make inference regarding care plan and treatment goals for patient (Dalton, Gee & Levett-Jones, 2015). The clinical reasoning cycle stars with the first stage of considering the patient situation. The analysis of Peter Mitchell’s scenario reveals that the patient is suffering from poorly controlled diabetes, obesity ventilation syndrome and apnoea and he was admitted to the hospital with these complaints. This information gives an overview about the context of Peter’s case.

The next step to get more information about patient is to collect cues/information about patient. This is obtained from nursing assessment records, patient chart and observations on discharge of patient. The factor contributing to his presenting symptom is understood from his past medical history. Peter Mitchell had history of hypertension, obesity, hypertension, depression, sleep apnea and gastro oesophageal reflux disease. Another vital cue to the case is that the patient was a heavy smoker taking 20 cigarettes per day. His problem of ventilation syndrome and sleep apnea is also understood from the fact that he failed to continue with low energy, high protein diet (LEHP) and light exercise to facilitate his weight reduction. Sleep apnea and ventilation is syndrome is a problem most commonly linked to obesity and obesity worsens apnea because of fat deposition at different sites (Romero-Corral et al., 2010). The review of Peter’s past medical history also revealed that Peter faced difficulty in finding job and maintaining social relationship due to weight gain.

Identifying Patient Information

As the main purpose of the essay is to identify two main care priorities for Peter, it is necessary to identify two problems that will threaten or increase health risk for patient. Hence, the problem inherent in patient can be identified by processing the information that has been collected from patient charts and observation. Peter was overweight from the beginning as his weight three years ago was 105kg, however his health issues has increased currently because he constantly gaining significant amount of weight. His current weight is 145 kg with a BMI of 50.2 kg/m2. From this information, it can be interpreted he is a patient with morbid obesity. A person who has a BMI of 25-30 kg/m2 is defined as overweight and BMI above 40 kg/m2 is defined as morbid obesity. His obesity comes under class III obesity and such individuals are at high risk of illness and death (Kitahara et al., 2014). From this evaluation, it can be said that obesity is one of the problem in patient that contributed to symptom of apnea and ventilation syndrome and obesity. Evidence suggest that the prevalence of these problem is increasing in parallel with obesity epidemic in United States Manthous & Mokhlesi, 2016).


Apart from his part and current medical history, the patient’s current observation also needs to be processed to prioritize care for Peter. His last observation detail was BP 180/92 mm HG, RR 23 Bpm, HR 102 Bpm and SPO2 95% on RA.  Although his heart rate and SPO2 value are within normal range, however his blood pressure value indicates that Peter is hypertensive. His respiratory is also above the normal range (12-20 Bpm). This abnormality in vitals sign might have emerged due to his poorly controlled diabetes and high BGL level. Patients who are diabetic are highly likely to suffer from hypertension and this common link has been found due to the overlap between the etiology and disease mechanism for both the condition (Cheung & Li, 2012). Hence, hypertension in patient with diabetes should be taken seriously in patient as he may also have the risk of developing cardiovascular condition (White, Wang & Jelinek, 2010).. The symptom of diaphoresis in patient was also seen due to poor glucose control in patient.

The next step of the clinical reasoning cycle is process of identifying problem/issue in patients. By the analysis and processing of patient information, two major problems identified in patient are poorly controlled diabetes and morbid obesity in patient. These two conditions have contributed to hospitalization for Peter and presence of presenting symptoms of shakiness, diaphoresis, difficulty in breathing during sleep and increased hunger (Raveendran, Wong & Chung, 2017).). Based on this inference, two specific care priorities for patient have been identified. By focusing on the two care priorities, proper direction for establishing goals for care of Peter is possible. Hence, informed by the two care priorities, the nursing care plan for patient is to implement appropriate clinical intervention to control his BGL level. Another nursing goals for care of patient is to take steps to reduce his weight gain and motivate Peter to continue with diet programs and light exercise recommended to him after consultation with dietician and physiotherapist respectively.

Identifying Patient Problems

Based on the above care plan, this section provides detailed explanation regarding the care priorities and the course of action to be taken to fulfill the goals for care. The number one care priority for the health and well-being of Peter is related to management of obesity, weight gain and other obesity associated symptom in patient. Peter had been suffering from the issue of difficulty in sleeping while breathing which is a clinical manifestation of sleep obstructive apnea. To provide relied to patient from breathing difficulty, the action is to control weigh gain in patient by means of lifestyle intervention. This is important because obesity is one of the major risk factor of sleep apnea and taking steps to control weigh gain may address this symptom in patient too. Evidence suggest that obesity is one of the risk factor for increase in prevalence of obstructive sleep apnea in general population. 10% changes in body weight leads to a parallel change of 30% in the apnea hypopnea index (An index for sleep apnea severity) (Schwartz et al., 2008). Hence, weight loss is one of the effective strategies to treat the problem as changes in adiposity improve upper way function during sleep (Araghi et al., 2013). Before implementing the lifestyle intervention, Peter can be encouraged to lose weight by providing education regarding the risk factors of obesity and the benefit of lifestyle intervention on reducing the severity of presenting symptom in patient.

In case of Peter, health behavior change is vital to fulfill the two identified care priorities. For this reason, patient education has been taken as the first course of nursing action as extensive education can only motivate patient to change their health behavior. Secondly, to help Peter lose weight, the nurse need to collaborate with dietician and physiotherapist so that both dietary intervention and exercise intervention can be provided to patient. Dietary strategies can help patient to lose weight (Look AHEAD Research Group 2010). The combination of both dietary and exercise intervention has been proposed because dietary intervention alone cannot be effective in producing significant changes. Physical activity intervention will help in weight loss maintenance (Araghi et al., 2013). Another plan of action to address obesity related symptom in patient is to implement smoking cessation therapy. This is extremely important for Peter because he is a heavy smoker and smoking will increase risk of respiratory and cardiovascular complication in the future (Dare, Mackay & Pell, 2015). Hence, nurse led smoking cessation intervention can be implemented for Peter too. Proper advice given by nurse can help patient to successfully quit smoking. As Peter is a heavy smoker, addiction will be one major issue in smoking cessation. Nurse can also implement nicotine replacement therapy in the form of chewing gum, transdermal patches or nasal sprays so that patient is less motivated to smoke  and the transition from cigarette smoking to complete abstinence becomes easier for Peter (Chauhan et al., 2016). 

Identifying Care Priorities


For care priority related to management of uncontrolled glucose level in patient, implementation of both pharmacological and non pharmacological intervention is necessary. Based on advice from clinician, nurse can provide medications like Metformin to Peter. Metformin is a first line of drug clinically used for diabetes patient and drug acts to suppress hepatic glucose production (An & He 2016). The non pharmacological intervention for controlling symptoms of diabetes in patient includes implementing lifestyle measures such as weight loss and physical activity. As Peter discontinue exercise previously, he should be encourage to engage in simple activities like walking only so that complications related to diabetes and hypertension can be addressed. Diet changes, physical activity and changes in life style have been found to reduce the development of cardiovascular disease in type 2 diabetes patient (Chen et al., 2015).

The next stage in the clinical reasoning cycle after the take ‘action step’ is evaluating outcome step. The intervention proposed for Peter can be evaluated for effectiveness in patient by assessment of vital signs in patient. This would give idea regarding positive or negative changes in hypertension and breathing rate. Secondly, patient’s compliance to smoking cessation strategy and lifestyle intervention also needs to be checked to understand patient’s ability to continue with healthy lifestyle. After implementing a nursing intervention, reflection is also a critical element to understand what went right for patient or what acted as the roadblock in the path to reflection. Based on this kind of reflection, nurse can improve their skills and engage in continous professional development.

The essay looked at the case scenario and health information of Peter Mitchell to identify and justify two specific priorities of care for patient. The process of identifying problem in patient and prioritizing care was done by the application of the steps of the clinical reasoning cycle. It served as an appropriate critical reflection tool used in daily practice to plan care priorities for patient guided by patient’s assessment information, presenting condition and past medical and social history.

References

An, H., & He, L. (2016). Current understanding of metformin effect on the control of hyperglycemia in diabetes. Journal of Endocrinology, 228(3), R97-R106.

Araghi, M. H., Chen, Y. F., Jagielski, A., Choudhury, S., Banerjee, D., Hussain, S., ... & Taheri, S. (2013). Effectiveness of lifestyle interventions on obstructive sleep apnea (OSA): systematic review and meta-analysis. Sleep, 36(10), 1553-1562.

Chauhan, P., Dev, A., Desai, S., & Andhale, V. (2016). Nicotine replacement therapy for smoking cessation. Pharmaceutical and Biological Evaluations, 3(3), 305-312.

Chen, L., Pei, J. H., Kuang, J., Chen, H. M., Chen, Z., Li, Z. W., & Yang, H. Z. (2015). Effect of lifestyle intervention in patients with type 2 diabetes: a meta-analysis. Metabolism-Clinical and Experimental, 64(2), 338-347.

Cheung, B. M., & Li, C. (2012). Diabetes and hypertension: is there a common metabolic pathway?. Current atherosclerosis reports, 14(2), 160-166.

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.

Dare, S., Mackay, D. F., & Pell, J. P. (2015). Relationship between smoking and obesity: a cross-sectional study of 499,504 middle-aged adults in the UK general population. PloS one, 10(4), e0123579.

Kitahara, C. M., Flint, A. J., de Gonzalez, A. B., Bernstein, L., Brotzman, M., MacInnis, R. J., ... & Weiderpass, E. (2014). Association between class III obesity (BMI of 40–59 kg/m2) and mortality: a pooled analysis of 20 prospective studies. PLoS medicine, 11(7), e1001673.

Look AHEAD Research Group. (2010). Long term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes: four year results of the Look AHEAD trial. Archives of internal medicine, 170(17), 1566.

Manthous, C. A., & Mokhlesi, B. (2016). Avoiding management errors in patients with obesity hypoventilation syndrome. Annals of the American Thoracic Society, 13(1), 109-114.

Raveendran, R., Wong, J., & Chung, F. (2017). Morbid obesity, sleep apnea, obesity hypoventilation syndrome: Are we sleepwalking into disaster?. Perioperative Care and Operating Room Management.

Romero-Corral, A., Caples, S. M., Lopez-Jimenez, F., & Somers, V. K. (2010). Interactions between obesity and obstructive sleep apnea: implications for treatment. Chest, 137(3), 711-719.

Schwartz, A. R., Patil, S. P., Laffan, A. M., Polotsky, V., Schneider, H., & Smith, P. L. (2008). Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches. Proceedings of the American Thoracic Society, 5(2), 185-192.

White, F., Wang, L., & Jelinek, H. F. (2010). Management of hypertension in patients with diabetes mellitus. Experimental & Clinical Cardiology, 15(1), 5–8.

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