In nursing, clinical decision making is a collaborative and integrative process that involves the collaboration of different departments in order to come up with a perfect plan of care for the client (Standing, 2017). The nurse cannot rely on their assessment data only but they need the help of laboratory technicians, doctors and other specialist in the medical field to adequately diagnose a client in order for them, to come up with a plan of care for the patient that is appropriate and effective to the condition being dealt with (Morton, 2017).
Clinical decision making involves clinical reasoning which is involve acquiring cues from the patient and using ones knowledge and critical reasoning to come up with an appropriate diagnosis and plan of care. In clinical reasoning the nurse will ask the patients questions pertaining to their demographic data, past medical history, presenting medical history and chief complaint at the time of the health assessment (Manning, 2017). All of these factors determine the plan of care accorded to a patient, because they help isolate what has been done and what has not been done, also this process helps isolate if the chief complaint is a new condition or an existing condition. These data also helps identify if the condition has a genetic link or not.
A nurse should have effective clinical reasoning skills for them to be able to offer quality care to their clients and pinpoint conditions that require emergency attention just from the history of the patient and the presenting signs and symptoms (Levett-Jones, 2015). Proper clinical reasoning is needed for proper clinical decision making. Poor clinical reasoning results into poor clinical decision making (LoBiondo-woods, 2014).
In morning handover report, we have A.H, female, she’s 90 years old. Conscious, oriented to person, place, time and situation. She was admitted to the emergency room with complains of unusual body pain and weakness since 1 week. She was transferred to medical ward to complete her treatment. When I did the initial assessment; I asked her about her complaint, and the patient said “I feel very weak and I have pain in all part of my body”. Her vital signs were stable. There is no surgical history. Her medical histories are hypertension (HTN), chronic kidney disease (CKD) and epilepsy. She is on anti-epileptic drugs and atenolol for hypertension. She’s semi-bedridden, she need assistance to walk. Socially, she lives with her housemaid in home. The patient interacts with others easily. Her husband passed away a long ago. Her sons take care of her and visit her regularly.
In the morning report, they said that the patient have a low appetite and her veins is difficult to find, according to dietician, administer 60 gram protein with low salt and low potassium. When I communicated with the patient she said “I don’t like this food” so the dietician change her diet to be modified diet. Her vital signs
The patient appetite and oral intake is moderate. Her mouth dries and patient reports extreme thirst. Pain scale – 0/10 using numeric rating scale, restless and can’t sleep well.
In the night shift report, they said that the patient complaint of pain and swelling in her both elbow, and then the orthopedic doctor came to see her and referred her to radiology for ultrasound. In the x-ray report finding, an abnormal modeling of the radial head is seen associated with osteoarthritis changes of the elbow joint show narrowed humero-ulnar joint space with sub-chondral cystic changes and sclerotic texture. Then the orthopedic doctor decided to perform a fine needle aspiration and injection. After a procedure the patient’s pain scale is 0/10.
Interpret: The chronic kidney disease is as a result of hypertension, also the epileptic episodes are presenting as a result of the chronic kidney disease. Her vitals are normal this means that the medical conditions are well controlled and her adherence to medication is good.
Discriminate: The pain and the weakness can be presenting due to accumulation of waste products in response to chronic kidney disease, also they can be caused by atenolol side effects, which can also be attributed to her lack of appetite.
Relate: Hypertension, its disease process and its treatment is the cause of the complications she is experiencing know.
Infer: In my opinion the client is suffering from complications of the disease process of hypertension and its treatment process, again her old age plays a major factor in causing the discomfort she is experiencing due to her slowed physiologic activities.
Predict: Her prognosis is good, because her vital signs are normal and she reports minimal pain after procedures, which means that her medical conditions are well controlled, and her pain is adequately controlled.
Identify problems issues: The client could be suffering from osteoarthritis as a result of old age, which results from her weakened immunity and disease process of hypertension.
Establish goals: Control the disease process of osteoarthritis. Manage the pain. Provide exercises as tolerated. Prevent further complications. Manage the complications that result from hypertension.
Take action: Institute bed rest for the client. Give methotrexate which is used to manage osteoarthritis. Constantly monitor her vital signs
Evaluate outcomes: The patient will tolerate exercise better. The client will report of reduced body pain. The disease process of osteoarthritis will be slowed and her vital signs will continue to normalize.
Reflect on process and new learning: I have learnt that the disease process of hypertension can result into so many complications augmented by old age.
Recommendation: I recommend aggressive campaigns on primary prevention of conditions like hypertension, because of their disease burden in old age.
Summary: Hypertension can result in a cascade of complications taht are life threatening if not well controlled; therefore prevention is better than cure.
Her admission was a very good plan of action to isolate what caused the pain despite having baseline vital signs and chronic conditions that were adequately controlled. The admission was in accordance to the HAAD standards, which identify nursing as both a science and art, where by one is required to apply technical knowledge in day to day life situations(Bowden, 2003). These regulations identify the nurse as a profession with competent persons who are entrusted with delicate situations and they are able to tackle them effortlessly (Fook, 2007).
The knowledge level of the nurse highly determines the effectiveness of the decision making process. Nurses who are knowledgeable are able to implement this process effectively with minimal room for error (Yost, 2015).
The level of unity between the different departments associated with patients care determines the effectiveness of the process. Good rapport between department leads to efficient client care and a better prognosis.
If the level of knowledge is not adequate the nurse is likely to make mistakes when planning for patient care, because their critical thinking process is questionable.
Disunity among the department might lead to biased patient care which results into a poor prognosis.
Nurse have to be open minded and open to correction and addition to their knowledge especially when making clinical decisions in regards to patient care. In our case study we see the nurse constantly evaluating the patient’s level of pain and learning from other professional on the diagnosis of the patient. A patient who presented with body pain and weakness has now been admitted and she is undergoing review by the orthopedic doctor (Magee, 2015).
The most important lesson we learn from this case study is to pay attention to details and do a thorough assessment on our patients before letting them go. Ideally the patient could have just been put on analgesics and bed rest at home to relieve the pain, but due to the detailed history that was taken the patient was admitted because the nurse found out that there could be an underlying condition on top of the controlled hypertension, chronic kidney disease and epilepsy. Again this patient is on a number of medications whose side effects can result to the development of other conditions (Higgs, 2008).
It is very important for us as nurses to be open to anything because the human body is very dynamic and anything can develop in span of minutes, what was normal in a minute can be very abnormal in the next minute. It is important to understand the human body and its ability to change sporadically. Understanding this will help us tackle any challenge brought our way. Another important aspect of this is being aware of ourselves and respecting the diversity of human beings. Not everyone beliefs what you believe I, being able to isolate this and be comfortable with it plays a very important role is influencing patient care positively.
Errors and assumption have greatly influenced how I work and how I relate with patients and other medical professionals. Clearly nobody is perfect that is why collaborative approach is very vital in providing patient care, because no diagnosis is too certain, sometimes even a misdiagnosis can take place.
This approach in clinical decision making should be integrated in the nursing education curriculum, nursing students should be taught that when they make mistakes it is not demeaning but it should be a learning opportunity (Hunter, 2016).
Health professionals should be taught to respect each other’s profession and ideas because we have all studied the human body and nobody is perfect and certain, because misdiagnosis can occur. Also when one is corrected during the clinical reasoning cycle we should embrace that as positive criticism as an opportunity for learning more and expanding our knowledge boundaries (Lee, 2018). The clinical reasoning cycle should be included the curriculum for nursing education at all levels.
Conclusion
In clinical practice, the most important thing of all is to listen to a patient carefully, alleviating their anxiety and answering all their questions. Even the most minute symptom or information can make big difference in the plan of care, this shows that we should document all the information provided by the client and we should not dismiss any data provided (Dalton, 2015). Collaboration and consultation when deciding on patient care is the first step to providing quality care.
Bowden.,S. (2003) Enhancing your professional nursing practice through critical reflection. Abu Dhabi Nurses retrieved rom:https://www.abudhabicme.com/main/doc/nurs01c28_31.pdf
Dalton, L. (2015). using clinical reasoning and simulation based education to flip the enrolled nurse curriculum. Australian journal of advanced nursing, 2(33), 29.
Fook, J., Gardner, F. (2007). Practising Critical Reflection: A Resource handbook.Retrieved from:https://www.mcgraw-hill.co.uk/openup/fook&gardner/resources/6.pdf
Hunter, S. (2016). clinical reasoning of nursing students on clinical placement. Nursing education in practice(18), 73-79.
Kable, A. (2013). student evaluation of simulation in undergraduate nursing programs in Austrilia using quality indicators. Nursing and Health sciences, 2(15), 235-243.
Lee, L. (2018). Education to improve dementia care:impact of structured clinical reasoning approach . Family medicine50(3)195-203.
Levett-Jones, T. (2015). Medical surgical nursing. Pearson higher education AU.
LoBiondo-woods, G. (2014). Methods and critical appraisal for evidence based practice. Elsevier health sciences.
Magee, S. (2015). Profesional development plan.
Manning, W. (2017). Clinical decision making in fluency disorder. Plural publishing.
Morton, P. (2017). Critical care nursing a holistic approach. Lippincott Williams and Wilkins.
Standing. (2017). Clinical judgement and decision making in nursing. Learning matters.
Yost, J. (2015). The effectiveness of knowledge translation interventions for promoting evidence informed decision making among nurses in tertiary care. Implementation science, 1(10), 98.
Higgs, J. (2008). Clinical reasoning in the health professions. Elsevier Health Sciences.
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