Clinical Reasoning Cycle: A Critical Reflection On A Nursing Clinical Decision Essay.

Write a 2000 word essay which discusses one clinical decision that you have been involved with during a Bachelor of Nursing clinical placement, using all eight stages of the clinical reasoning cycle (Levett-Jones et al., 2010). In this essay your critical reflection on the clinical decision (stage eight) is a significant component of this task (please see weighting in marking criteria). You need to identify a different patient scenario to the one you discussed in your first essay.

Analyse how each stage of the clinical reasoning cycle (Levett-Jones et al., 2010) was applied to your decision.

In stage eight (8) critically reflect on what you have learnt from applying the clinical reasoning cycle to your chosen decision (you may choose to draw on other models of reflection).

In your essay discuss three relevant Registered Nurse Standards for Practice (2016).

Analyzing the Clinical Reasoning Cycle in a Nursing Clinical Decision

In terms of literature, clinical reasoning, decision making and critical thinking are in most cases used interchangeably. Clinical reasoning is a process by which nurses collect cues, do processing of information, comprehend the problem of a patient, implement interventions, do evaluation of outcomes, reflect on and learn from the processes. The process of clinical reasoning is affected by the attitude of a person and their preconceptions. Clinical reasoning is a spiral linked and ongoing clinical encounters. The following discussion show the phases of clinical reasoning (Barrows , Norman , Neufeld , & Stephanie, 2015).

A decision-making process that I was basically involved in is evidence-based practice which was meant to review the effects of integrate care pathways (ICPs) on the provision of an integrated service for the patients. This review focused on the healthcare for the grown-ups who suffered a stroke and included acute care, rehabilitation and the prolonged aid in the hospital and also the societal setting. The ICPs were a perfect intervention of interests while integration of service was the results (Elstein , Shulman , & Sprafka , 2015). We critically appraised papers and finally came up with a conclusion that ICPs can be effective when they are used to ensure that patients get the most relevant assessments in clinics and hence improvement in the documentation of the goals of the rehabilitation process. The second case, the process that I came through in the decision making cycle was to consider the situation of a client I was attending. He was a 60 years old patient in ICU and was suffering from abdominal aortic aneurysm surgery (Mattingly & Fleming, 2014). Nurses hence are supposed to use the evidence obtained from these research with an aim of making decisions like for the expert opinion with respect to the quality criteria, the control experience and also the randomized control trials (Charlin , Boshuizen , Custers, & Feltovich, 2015).

A good example of a method for the EBP is a pain assessment mechanism for which guidance was developed by the pain society of Britain and has worked to review the ongoing evidence guidance that helps all practitioners and nurses to be aware of the pains that exist in parents, asks more about the pains by making use of descriptive words like is it sore, is it hurting, aching and so forth and this helps the nurses in decision making (Norman, 2016). It also helps the nurses to locate the pain by the nurses asking the patients to show where they feel the pain so that the nurses may at long run know the intensity of the pain and hence reevaluate their results. In my case, in the second phase, I was supposed to collect enough information concerning the patient. I could get to assess the patient and also reviewed the current information at hand. Precisely, I went through the patient history, the charts and the medical assessments taken previously and found out that the client had a history of hypertension and he used to take hyper blockers (Bowen, 2016). His Bp read 140/80 an hour before the assessment. As I assessed the patient, his Bp changed to 110/60 and his temperature read 38 degrees. The Bp was related to the fluid status and the Epidurals could drop the Bp since they cause vasodilation in most cases (Boshuizen & Schmidt, 2014).

Critical Reflection on the Nursing Clinical Decision

Tools for the assessment of pain assist us as nurses in the determination of the cause and provision of best management of pain and treatment for the patient. For a comprehensive assessment of pain by the nurses, we needed to address the type of pain and also know the detailed history of the intensity of the pain (Pesut , Herman , & Herman, 2014). The latter helped us in the identification of the intensity of pain assessment tools which were based on the ages of the patients, the physical, emotional and cognitive status and also their preferences. We used the verbal rating scale (VRS) as a pain assessment tool in the patients. Our main aim here was to know the intensity of the pain by asking the patient to match the pain to a given number. The reason for using VRS is because a nurse cannot be able to measure the intensity of pain in a patient unless the patient says (Barrows , Norman , Neufeld , & Stephanie, 2015). The patients then used to tell us the intensity of the pain: moderate pain, mild pain, severe or even worst pain. Once the intensity of the pain was determined by use of VRS, we as nurses were supposed to make a decision concerning the type of analgesic management and intervention to make use of in order gain optimal comfort and function with least negative effects from the analgesic therapy.

When processing of the information at hand, I found out that the Bp of the patient was very low since he was normally hypersensitive (Barrows , Feltovich, & Meshack, 2013). The temperature of the patient was up but I was not too much worried about it but I was more concerned about the Bp and the pulse. I rather checked urine output and the saturation of oxygen. The hypertension tachycardia and oliguria were exemplary signs of an impending shock. After increasing the epidural; the level of Bp of the patient went down. During the time of making inferences, I discovered new relationships and made deductions and also came up with opinions by interpreting both the subjective and objective cues (Ajjawi & Higgs, 2015). I noticed that his Bp could be low as a result of the loss of blood during the surgery or even due to an epidural. I then matched the situation that was at hand and compared it to the past situation and found out that AAAs in most cases had hypotension post op. I guessed then that if I failed to administer more fluids, then he could go into a shock (Barrows , Norman , Neufeld , & Stephanie, 2015).

Relevant Registered Nurse Standards for Practice

As the world health organization suggests, the nursing decision should be based on the analgesic administration ladder.in the cases that simple analgesic like paracetamol needs to be utilized for mild pain and the weak opioids for the average pain severe or worst pain needs to be reviewed and a relatively strong opioid analgesic like morphine should be used in the administration to improve the patient's comfort (Charlin , Boshuizen , Custers, & Feltovich, 2015). I synthesized the facts and inferences with an aim of making a definitive diagnosis of the problem that my patient had. I realized that the patient was hypovolemic and the epidural had worsened the Bp by making it have vasodilation (Barrows , Norman , Neufeld , & Stephanie, 2015).

The management of time is a factor that acts as a barrier in the utilization of pain assessment tool. An interruption like answering a telephone call, the participation in the doctors round effect pain assessment and causes a delay in the pain management and the patients may also find it impossible to request for a pain relief since they fear being termed as a nuisance (Barrows , Norman , Neufeld , & Stephanie, 2015). As a result of these interruptions, the patients then suffer in their emotional, physiological and physical function in their daily lives. The knowledge of pharmacology and analgesic increases the chances of having a decrease in anxiety and also improves the mood and leads to an increase in the level of comfort of the patient. For my cases, if I was to describe what I desired and wanted to happen without time wastage, I would then say that I wanted to improve the hemodynamic status of my patient (Charlin , Boshuizen , Custers, & Feltovich, 2015). I would get the Bp of the patient up and the output of the patient back to normal in the next one hour.

The utilization of pain assessment tools for the adults who fluently are able to speak and communicate English is easy. The patients are able to give their consent concerning the treatment they got. However, the elderly adults who have cognitive impairment will just be confused and hence are not able to produce a reliable measurement of the intensity of pain (Barrows , Norman , Neufeld , & Stephanie, 2015). The latter will at long run result in an untimely intervention. The patients who have impairment in communication like disability in learning and those suffering from mental health show the most severe challenges in the management of pain and hence nurses find it hard to tell when the patient is in pain and also when the patient is experiencing pain relief. In my case as a nurse, I was supposed to depend on a facilitator for the description of the pain whereby I was supposed to query the reliability during the decision. The pain assessment tools that are used for the young people and specifically children are complex (Barrows , Norman , Neufeld , & Stephanie, 2015). A good example is for the case of babies who are not in a position to communicate has a decision and consent relays to the parents. Therefore, during decision making about interventions, nurses are required to make use of the ethical principles of generosity and non-maleficence to get the best pain assessment to give pain comfort to the patients. In a different case for the client who was suffering from hypertension, the best alternative that I went for was to ring a doctor with an aim of getting an order to increase his IV rate of the patient and also administer auramine if it was needed at any given point (Charlin , Boshuizen , Custers, & Feltovich, 2015).

Understanding Clinical Reasoning, Decision Making, and Critical Thinking

In the evaluation of the overall effectiveness of the results acquired, I was supposed to ask myself if the situation had already improved or not. When I checked the Bp of the patient, it had gone up but I needed to keep an eye on him since he had a high probability of having the need for some auramine sometime later. The level of urine output was averaging to 30 milliliters per hour.

In the contemplation of what I had learned, I learned that any failure to gather enough relevant cues in the establishment of a differential diagnosis may make one get insignificant possibilities being missed out. Given that a description of any given illness is more specific, then the likeliness of the event being judged to occur is much more likely to be in existence. If the history of the patient taken is not adequate, then thee may be unspecified possibilities which in any way may be discounted for.in this study, I noted that I should have taken the most relevant and enough history of the patient so as to come up with concrete results. Next time I will be keen to make sure that I thoroughly review the current information of the patient and also be keen on the medical assessments that had been collected previously (Barrows , Norman , Neufeld , & Stephanie, 2015).

Conclusion

For a nurse to make any clinical reasoning effective, he or she must be able to observe the situation of his or her patient, collect enough information concerning the patient and process the information, identify the problem of the client and establish goals and objectives, take action and do a thorough evaluation of the effectiveness of the outcomes to make sure that there is effectiveness and also room for improvement.

References

Ajjawi , R., & Higgs, J. (2015). Using Hermeneutic Phenomenology to Investigate How Experienced Practitioners Lear n to Communicate Clinical Reasoning. The qualitative report, 37(3), 432-456.

Barrows , H. S., Feltovich, P. J., & Meshack, S. J. (2013). The process of clinical reasoning . Medical education, 5, 214-254.

Barrows , H. S., Norman , G. R., Neufeld , V. R., & Stephanie, N. R. (2015). The clinical reasoning of randomly selected physicians in general medical practice. Clinical and investigative medicine, 13(2), 256-289.

Boshuizen , H. P., & Schmidt, H. G. (2014). On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cognitive science, 16(2), 153-165.

Bowen, J. K. (2016). Educational strategies to promote clinical diagnostic reasoning. New England Journal of Medicine, 37(4), 432-446.

Charlin , B., Boshuizen , H. P., Custers, E. J., & Feltovich, P. J. (2015). Scripts and clinical reasoning. Medical education, 12(2), 287-313.

Elstein , A. S., Shulman , L. S., & Sprafka , S. A. (2015). Medical problem solving an analysis of clinical reasoning. New York.

Mattingly , C., & Fleming, M. H. (2014). Clinical reasoning. Forms of inquiry in a therapeutic practice, 12(3), 27-29.

Norman, G. (2016). Research in clinical reasoning: past history and current trends. Medical education, 17(3), 432-456.

Pesut , D. J., Herman , J., & Herman, J. (2014). Clinical reasoning:The art and science of critical and creative thinking. Delmar: Albany^ eNY NY .