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Key Elements of the Clinical Reasoning Cycle

Question:

What Do Considering the Patient’s Situation in the Chosen Case Scenario?

Levett Jone’s clinical reasoning cycle is an effective used by nurses to excel in practice. Nurse engage in problem solving and decision making process by means of collecting patient’s information, processing the information, interpreting patient issues, planning intervention, evaluating outcome and reflecting on the process. These are the key elements of the clinical reasoning cycle. Nurse with effective clinical judgment skills can facilitate positive outcome in patients., whereas those with poor clinical reasoning skill can contribute to medical errors. This reflects that competent professional practice is dependent not just on clinical knowledge but also on thinking abilities of patients (Levett-Jones & Hoffman, 2013). The essay focuses on analyzing the case of Katie McConnell, a 23 years old patient with mild traumatic brain injury and completing the assessment of patient by means of the key elements of the clinical reasoning cycle.


While considering the patient’s situation in the chosen case scenario, it has been found that Katie McConnell is a 23 year old woman who was admitted to the hospital after being hit by a slow moving care. Due to the accident, she had sustained a subdural haematoma. Subdural hematoma is a condition associated with traumatic brain injury where blood collects below the layer of the dura and the arachnoid mater. It may occur not only in patients with severe head injury, but also in patients with less severe head injuries. Patients with such head injury require emergency neurosurgical assessment and treatment (Lukasiewicz et al., 2016). Katie also has some post concussive symptoms of difficulty in recalling information. Considering this patient situation, it can be said that Katie has higher odds of poor outcome after mild traumatic brain injury (mTBI). This is because Bazarian et al., (2010) has shown that female has high probability of poor outcome after mTBI due to the disruption of estrogen and progesterone production. This indicates that mTBI affects the production of theses hormone leading to poorer outcome in females. Secondly, severity of injury is more in middle and elder age groups than in minor patients (Munivenkatappa et al., 2016).

After observing the presenting condition of Katie, it is also necessary to collect other cues and information about patient by reviewing handover information of patients and identifying other information that may be relevant to the clinical presentation of Katie. The handover report related to vital signs of Katie were as follows HR 89, BP 142/78, SpO2 96%, RR 13. The Glasgow coma score of Katie was 14. The Glasgow Coma scale (GCS) determines the severity of the traumatic brain injury. It is based on the level of consciousness in person following a traumatic injury. It measures the cognitive function of an individual following injury such as eye opening, verbal response and motor response. The GSC score of 13-15 depicts mild traumatic brain injury, the GSC score of 9-12 reflects moderate brain injury and the score of 3-8 reveals severe brain injury (What Is the Glasgow Coma Scale, 2017). From the GSC score of Katie, it is understood that she has mild traumatic brain injury. This means that Katie may develop temporary or permanent neurological symptoms, which needs to be managed.

Relevant Medical Information related to Patient's Situation

Considering the vital sign report of patient, HR of 89 depicts that Kate has normal heart rate. This means she is stable currently. On the other hand, blood pressure of 142/78 suggests that Katie has high blood pressure. This might have occurred due to traumatic brain injury. The intracranial pressure and the blood pressure have relation and studies suggest that people with head injury mostly have high values of blood pressure (Mitchell et al., 2007). The SpO2 value of Katie and breathing rate of patients is normal. Some other vital information is missing in this case. For instance, mTBI leads to building up of the spinal fluid in the spaces of brain leading to increased pressure and swelling in the brain (Dang et al., 2015). However, no such detail is given for Katie’s case. Therefore, monitoring intracranial pressure is essential in Katie’s case. Secondly, TBI also has the possibility of causing brain infection due to entry of bacteria into the meninges and this has not been covered in Katie’s case. Injuries or damage to the cranial nerves also has the possibility affect facial sensation, vision, eye movement and facial muscle paralysis (Dethier et al., 2013). As this information is missing, Katie’s assessment should be done on monitoring these effect cranial nerve damage too.


The next phase in the physical assessment of Katie is to process the information gained from hand over report and presenting symptoms of patients. The main presenting problem in patients according to handover report and initial assessment includes subdural hematoma, hypertension and cognitive problems such as difficulty in recalling information. It is expected that this problem have occurred mainly in patients due to head injury caused to her by motor vehicle collision. All these reflect the problems associated with people with traumatic brain injury. The problem in cognition is mainly seen in Katie because traumatic brain injury affects the connectivity of the brains and disrupts the function of areas associated with cognition (Fagerholm et al., 2015). The cognition is associated with attention and concentration, processing information, memory, communication, reasoning and problem solving. However after the traumatic brain injury, people have problem in attention, concentration, speech, memory and problems (Rabinowitz & Levin, 2014). Hence, similar problem in concentration and memory was also seen in Katie. Accurate rehabilitation is needed to address this problem.

The sudden blow to the head led to subdural hematoma in patients. This condition lead to symptoms of headache, confusion, changes in behavior and seizure in patients. Subdural hematoma was also the reason for her clinical presentation of difficulty in remembering recent information. It is necessary to check that this condition does not continue in patient for a longer period of time. Although Katie has mild traumatic brain injury which might not cause severe problem to patient, however this symptoms should be addressed so that serious complications does not develops in Katie post mild traumatic brain injury (Sivak et al., 2015). It is also necessary to analyze use of anticoagulants in patients before brain injury because this also has the chance of increasing intracranial complications (Foks et al., 2016). In such situation, knowing about the past medical history of Katie is important to prevent further complication. Inquiry about past medical history of Katie revealed that she suffered from painful ankle because of playing football, however she did not took any painkiller for it. Hence, risk to patient due to use of anticoagulant is low and similar consideration should also be done during planning treatment for Katie.

Implications on the Patient's Situation


The critical reflection and judgment of patient’s present condition suggest that the main problem or issue in Katie is the presence of cognitive impairment in patient. In such condition, patient needs to be further assess regarding progress in subdural hematoma and mild traumatic brain injury. This might include continous assessment of neurological deficits by means of Glasgow Coma Scale. It an effective tool to assess the functional capacity of patient with traumatic brain injury and it would help to predict recovery in cognitive symptoms of patient. This form of detailed assessment will facilitate the development of systematic assistance and implementation of neurological rehabilitation for Katie (Vieira et al., 2015).

The above mentioned problem of cognitive impairment as witnessed in mild traumatic injury patient is not observed in normal individual. This is mainly because normal individual do not sustain such injury and Katie has sustained such injury because of collision from a car. Such collision causes neurodegenerative  damage to the brain. Neurochemical changes and changes in cerebral glucose metabolism is seem. This leads to permanent or temporary impairment, physical and psychosocial disorder accompanied with altered state of consciousness. Traumatic events cause the brain to move rapidly within the skull causing damage. The mild symptoms of traumatic brain injury such as headache, dizziness and nausea may proceed to long-term cognitive deficits in some individuals (Prins et al., 2013). Hence, the goal of treatment should be to reduce the risk of progressive neurodegenerative disease in patients like Katie.


Considering the main problem observed in patients, the main physical assessment needed for Katie is to check her neurological impairment. Firstly, Montreal Cognitive Assessment technique can be used to assess the mild cognitive impairment in patients. The instrument has been found to give reliable results in detecting cognitive impairment in patients with persisting post-concussive symptoms after injury (Hunt & Ouchterlony, 2014). Secondly, neuropsychological assessment will have important implications for patients, as it will determine the treatment and rehabilitation planning for Katie. This form of neuropsychological testing can be done by clinical interview with patients and then conducting several test in patient to assess cognitive and function domains. Clinical interview with patient consist of inquiry of patients education level, learning difficulty, psychological history, previous injuries and current cognitive issues of patuents. Neurosyschological testing uses scores of different tools to assess the cognitive functioning of patent (Kosaka, 2006). As Katie can have adverse neurological, psychological and psychosocial consequence due to subdural hematoma, this form of assessment will effectively quantify the deficit and facilitate early treatment for her.

The essay demonstrated the use and application of the key elements of the clinical reasoning cycling in analyzing the clinical presentation of patients, identifying problem in patient and reflect on the appropriate technique to carry out comprehensive assessment of patient. This was done by means of the case scenario of Katie McConnell, who has sustained subdural hematoma after a car accident. The application of the clinical reasoning cycle helped in effectively reviewing handover information of patients, determining the cause of presenting symptoms and planning further assessment to check the progress and recovery of patient during the treatment process.

Reference

Bazarian, J. J., Blyth, B., Mookerjee, S., He, H., & McDermott, M. P. (2010). Sex differences in outcome after mild traumatic brain injury. Journal of neurotrauma, 27(3), 527-539.

Dang, Q., Simon, J., Catino, J., Puente, I., Habib, F., Zucker, L., & Bukur, M. (2015). More fateful than fruitful? Intracranial pressure monitoring in elderly patients with traumatic brain injury is associated with worse outcomes. journal of surgical research, 198(2), 482-488.

Dethier, M., Blairy, S., Rosenberg, H., & McDonald, S. (2013). Emotional regulation impairments following severe traumatic brain injury: An investigation of the body and facial feedback effects. Journal of the International Neuropsychological Society, 19(04), 367-379.

Fagerholm, E. D., Hellyer, P. J., Scott, G., Leech, R., & Sharp, D. J. (2015). Disconnection of network hubs and cognitive impairment after traumatic brain injury. Brain, 138(6), 1696-1709.

Foks, K. A., Volovici, V., Kwee, L. E., Haitsma, I. K., & Dippel, D. W. (2016). Serious delayed intracranial complications after mild traumatic brain injury in oral anticoagulant use. Nederlands tijdschrift voor geneeskunde, 160, D285.

Hunt, C., & Ouchterlony, D. (2014). Sensitivity of the Montreal Cognitive Assessment for Out-Patients With Mild Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation, 10(95), e53.

Kosaka, B. (2006). Neuropsychological assessment in mild traumatic brain injury: A clinical overview. British Columbia Medical Journal, 48(9), 447.

Levett-Jones, T. & Hoffman, K. (2013). Clinical reasoning: What it is and why it matters. In: T. Levett-Jones (Ed.). Clinical Reasoning: Learning to think like a nurse. French’s Forest: Pearson.

Lukasiewicz, A. M., Grant, R. A., Basques, B. A., Webb, M. L., Samuel, A. M., & Grauer, J. N. (2016). Patient factors associated with 30-day morbidity, mortality, and length of stay after surgery for subdural hematoma: a study of the American College of Surgeons National Surgical Quality Improvement Program. Journal of neurosurgery, 124(3), 760-766.

Mitchell, P., Gregson, B. A., Piper, I., Citerio, G., Mendelow, A. D., & Chambers, I. R. (2007). Blood pressure in head-injured patients. Journal of Neurology, Neurosurgery & Psychiatry, 78(4), 399-402.

Munivenkatappa, A., Agrawal, A., Shukla, D. P., Kumaraswamy, D., & Devi, B. I. (2016). Traumatic brain injury: Does gender influence outcomes?. International journal of critical illness and injury science, 6(2), 70.

Prins, M., Greco, T., Alexander, D., & Giza, C. C. (2013). The pathophysiology of traumatic brain injury at a glance. Disease models & mechanisms, 6(6), 1307-1315.

Rabinowitz, A. R., & Levin, H. S. (2014). Cognitive sequelae of traumatic brain injury. Psychiatric Clinics of North America, 37(1), 1-11.

Sivak, S., Nosal, V., Bittsansky, M., Dluha, J., Dobrota, D., & Kurca, E. (2015). Type and occurrence of serious complications in patients after mild traumatic brain injury. Bratislavske lekarske listy, 117(1), 22-25.

Vieira, R. D. C. A., de Oliveira, D. V., Teixeira, M. J., & da Silva Paiva, W. (2015). Scales for assessment of patients with traumatic brain injury. Patient preference and adherence, 9, 1631.

What Is the Glasgow Coma Scale?. (2017). Brainline.org. Retrieved 2 May 2017, from https://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html

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