Discuss about the Clinical Reasoning Cycle for Clinical Decision Making in Nursing.
Clinical reasoning can be described as a process through which the clinical professionals collect cues or information, does the information processing and tries to understand the condition of the patient, plans the effective intervention and implements them accurately, and learns and reflects from the knowledge gained from the clinical reasoning process (Lee et al., 2016). It is the main part of clinical practice due to the reason that the healthcare professionals need to take the decisions based on judgement and the knowledge of the situation (Corbally, 2012). Additionally, it is also important to note that the clinical reasoning demands the most frequently used skills by the nurses. Thus, the nurses that are involved in the everyday episodes of clinical reasoning are found to be responsible for the judgements and the decision which are found in healthcare (Lee et al., 2016). The patient receives a positive outcome due to the application of the clinical reasoning process (Levett-Jones et al., 2010).
Fall can be defined as an event that results in a person who is coming to rest on the ground floor or to any lower level (World Health Organization, 2017). Fall is considered to be a major health issue that affects the people globally. Researchers have shown that death from falls is at the second position that comes only after the deaths from the road traffic (Simpson, Miller & Eng, 2011). Also, it has been found that the high rate of the global death rates has caused due to the falls in adults that belong to the age group of 60 years (World Health Organization, 2017).
The main aim of the paper is the discussion of a situation that has occurred during a clinical practice and it has involved a clinical reasoning cycle.
There are many risk factors that result in the fall in elderly people. 12 high valued researchers conducted have shown that fall in the elderly people has a strong relationship with the environmental and the accidental factors (Rubenstein, 2010). The risk among the elder people is more in comparison to the younger ones is due to the fact of less and dangerous coordinated gait. The next major risk that has been found through the research is the dizziness within the elderly people (Rubenstein, 2010). It is also important to note that dizziness also reflects that an affected person also has depression or anxiety form the side effects of the drugs and the person also has cardiovascular diseases (Rubenstein, 2010).
An accrediting organization called Joint Commission International works for the improvement of the quality of the healthcare in the international community and the also improve the condition of the patient safety (Joint Commission International, 2017). There is another organization called the Health Authority of Abu Dhabi (HAAD) which is a regulatory body in the Emirate of Abu Dhabi and in the healthcare sector (HAAD, 2017). The main goal is to ensure the quality in monitoring the status of the population health and creation of the programs that increase the awareness and also helps the people to adapt to a healthy lifestyle (HAAD, 2017). Both the organization work to ensure that the healthcare providers are working appropriately to deliver high quality and safe healthcare to the patients. Both the organizations ensure the and suggest the quality key performance indicator (KPI) and it includes the domain of the patient safety. Within this domain, it has been mentioned that the rate of fall is an excellent indicator, and this indicator can be used effectively to both decrease and prevent the number of fall within the elderly people (HAAD, 2017).
Clinical reasoning cycle involves the generation of the alternatives and interventions, which include the weighing the interventions and the alternatives on the basis of the available pieces of evidence and selecting the proper evidence-based intervention (Kershaw, 2011). The procedures are provided in detail in next paragraphs.
Within this step, the nurse gets the preview of the of the demographic and the background of the patient. The patient was admitted on the March 6th in the medical ward and the name of the patient is Rashid and his age was 72 years. The rationale behind admitting the patient is dehydration and the because he was feeling ill for the past few days and was not able to drink and eat well. Rashid was living with his wife in the Dibba, Al Fujerah city.
During this stage, the nurse collects all the vital information regarding the patient history and goes through the handover and the medical records for the purpose of defining the additional information with respect to the condition of patient. This stage includes the three vital steps: review, gather and recall.
Review. In this first step, the nurse gains knowledge of the current information with respect to the patient’s current condition. The patient is found to be having hypertension, cholesterol and diabetes for almost 16 years. Rashid is under the mediation and is having the furosemide 20 mg, captopril 25 mg and Lipitor 40 mg and regular dosage of insulin and 5 units of the insulin. Also, the lab report of Rashid showed that he is having a low level of sodium (130 mmol/L), and elevated levels of creatinine level (109 micromol/L), and low level of blood glucose (4.6 mmol/L). Also, his last blood pressure was measured and it was around 99/73 mm Hg.
Gather. In this step, the nurse gathers information relating to the patient current situation through the patient assessment. After the completion of the assessment, the patient was found to be having a dry mouth and also had a dark coloured urine. The patient was found to complain about the less frequent urination and excessive thirst. Rashid was feeling fatigue and dizzy for the most part of the time a this was preventing her to lead a normal life. There were other vital signs like the temperature was 36.8, respiratory breath rate was 18 breaths/min, heart rate was 85 beats/min, blood pressure of 99/73 mm Hg. Rashid was assessed through the Morse fall Scale for the purpose of measuring the patient’s risk of fall and the score was 60. The score was found to be 60 due to the intravenous therapy (20), secondary diagnosis (15) and previous history of fall (25). Thus, the patient is exhibiting high risk of fall.
Recall. This step includes the recall of the knowledge relating to the pharmacology and pathophysiology. Patient with the diabetes mellitus must balance their food along with the insulin so that the patient can achieve the optimal level of blood glucose control that will prevent the hypoglycaemia and this will lead to more falls and other related complications (Hulkower, Pollack and Zonszein, 2014). It is also important to note that when the diabetic patients do not eat food rich in carbohydrates then there will be reduced chances of sugar breakdown and it will also increase the risk of fall (Birkeland, 2015). Also, studies have found that drugs that reduce the blood pressure in elderly patients also contribute to falls (Okada et al., 2016). Thus, stopping the cardiovascular drugs can reduce fall by 50 percent (Van Der Velde et al., 2015). Lasix is a cardiovascular is a cardiovascular medication that has helps in flushing out the excess water from the body (Fallahzadeh et al., 2017). Also, it is important to note that the excessive intake of the diuretics can lead to adverse effects like dehydration and hypovolemia and this, in turn, increases the risk of fall (PELTOLA, 2009).
This is a clinical reasoning procedure and it includes the 6 sub stages: predict, match, infer, relate, discriminate and interpret (Griffith, 2013). Each of the sub-stages will be discussed in the following paragraphs.
Interpret. This is all about the analysis of the data and gaining knowledge of the symptoms and the signs and make a comparison between the abnormal and the normal findings. Especially, in this case, the patient exhibits a low blood pressure and this has led to the patient to become hypertensive. The other vital signs are found to be within the normal range. Also, it has been found that the patient is dehydrated and the symptoms noticed are dizziness, dry mouth, excessive thirst. The lab results also depict that there are abnormal conditions of high creatinine level and low sodium level. The most important finding is the abnormal finding that the Morse risk score is high.
Discriminate. It is the ability of a nurse to differentiate between the irrelevant and the relevant information. The most important concern is that the Morse fall risk score is high and along with the dizziness, dehydration hypotension. All these concerns are relevant for the assessing the patient’s condition and they are vital because they indicate patient risk of fall.
Relate. This describes the finding of the relationships between the cluster and cues in order to identify the relationship. The patient condition with respect to the low sodium level, dizziness, dry mouth, oliguria, excessive thirst, hypotension are the vital signs of dehydration. Also, the low levels of the glucose indicate that the patient has a poor oral intake.
Infer: In this stage, logical opinions, as well as deductions, are made. Mr Rashid’s situation states that insufficient fluid intake in the past few days is responsible for his current situation. Besides that, he intakes frusemide, his body has lost the capability to retain fluid. As a result of this, he has developed dehydration as well as hypotension that enhance his risk of falling.
Match. In this stage, the current patients to the past patients or the current situation to the past situation are compared. Studies show that the adverse effect of frusemide involves hypotension. Moreover, if it is prescribed with heart medicines it enhances the effect of hypotension. (Scholefield, Sebti and Harris, 2015).
Predict: Being the final stage of information process, this stage involves predicting the outcome. If IV fluids are not provided to the patient immediately, the patient can go into hypovolemic shock. The mention shock can be defined as a life-threatening condition that results in loss of more than 20 percent of the blood or bloody fluid (Strickler, 2010). Besides that, if the preventive measure is not provided, patients may develop the tendency to feel dizzy and fall due to hypotension. New South Wales in the USA states that majority of the falls has happened in a hospital setting (MSW, 2010).
In this stage, the problem of the healthcare service user is detected and the desired outcomes are described. In order to prevent falls in future, two nursing diagnosis has been formulated. Identification of the issue includes trauma fall due to dizziness resulting from hypotension. Secondly, evidence of fluid volume deficit resulting from inadequate fluid intake has been obtained. The symptoms include dark coloured urine, dry mouth and excessive thirst. The achieved goals are that the patient will not suffer from further trauma fall and will show adequate fluid balance.
In this stage, appropriate action is chosen from several alternatives. In order to prevent further trauma, fall, safety measures implementing safety measures I highly crucial. However, appropriate assessment should be done prior to implementation. From the assessment of Mr Rashid, it has been found that he has low blood pressure which is 99/73 mmHg and he feels fatigue as well as dizzy all time. Apart from that, the Morse fall risk score is about 60. The implementation includes positioning the bed at the lowest position possible as well as raising up the side rails. However, the implementation of raising up the side rails is controversial. According to several studies, raising the side rails up can protect the patient from falling (Healey et al., 2008). While other studies argue that raised side rails are the major reason behind injury of several patients. Other intervention includes keeping a bell at t hide of the patient so that he can signal wherever assistance is needed. Moreover, the patient is advised to change his position slowly to prevent dizziness resulting from postural hypertension. Apart from these measures, the blood pressure of the patient needs to be checked on regular basis to prevent hypertension. Along with that hypertension as well as diabetes medication needs to be reviewed daily to prevent both hypoglycemia and hypotension to prevent trauma fall.
The second nursing diagnosis was fluid volume deficits. The assessment includes excessive thirst, dark-coloured urine and frequent urination. The effective implementation includes encouraging the patient to intake 2-3 litres of fluid per day. Moreover, in the taking of IV fluids should be initiated to return the fluid balance to normal. Along with that, it is crucial to make the patient understand the causes of the disease and provide him with the required teaching plan.
In this stage evolution of the effectiveness of the actions implemented on the patient is performed. Considering the fact that the patient has not experienced fall since the time he has been hospitalized, the desired goal is met. Mr Rashid will be discharged soon. In order to prevent further fall after his discharge, the patient is provided sufficient education to prevent fall at home. This includes wearing well-fitted shoes and keeping the environment uncluttered. Apart from that, the patient was provided 4 litres of fluid within 48 hours of hospitalization. His blood sugar increased by 119/74 and sugar level increased by 140 mmol/L. Along with that, his urination was evidenced to be of sufficient amount. The patient has developed the ability to intake sufficient amount of oral fluid. He is also able to discuss the symptoms of fluid volume deficit and what his supposed to do if he feels any of the symptoms in future.
The process will e reflected by using Rolfe model of reflection. This model includes three questions, that is, what? so, what? and now what? the following factors will answer each of the three mentioned questions.
What. In this question, actions, responses as well as the feeling of the health care service user are answered. The patient got admitted to the hospital due to critical hypotension as well as dehydration with frequent Morse fall risk score of 60. I along with my employees were working to prevent further morose fall of the patient due to dizziness resulting from hypertension. I felt empathy for Mr Rashid, the patient since he has no one to care for him. The reason behind that is he resides alone with his wife.
So what. In this question, the learning experiences and the new knowledge acquired has been discussed. I understood the need of providing more knowledge to the patient about his disease that is hypertension as well as diabetes along with the importance of his medication and its side effects. Teaching the actions which should be taken by the patient immediately. In case he feels any type of symptoms were also necessary. Moreover, it was highly crucial to ensure that the patient does not suffer from any further fall both in the hospital and in his home after getting discharged.
Now, What. In this portion things that needs improvement is discussed. Firstly, it would have been better if I could provide the patient with a home nurse who can ensure complete care to the patient and thus further complications can be prevented. This is crucial since Mr Rashid is an elderly patient, he can forget the instructions and information provided to him.
The recommendations to ensure enhancement in the quality of treatment of patients is as follows. Firstly, the patients who suffer from the high risk of Morse fall needs to be educated about the causes of Morse fall. According to studies, this education will not only enhance the self-efficiency of the patients but will also reduce the fear of fall from their mind (Prevention of falls and fall injuries in the older adult, 2011). Secondly, education about Morse fall should also be provided to the nursing students as well to the nursing staffs. Along with that, the healthcare home should effectively manage polypharmacy by implementing processes. The management of the hospital should review the medication daily. Reviewing medication regularly will help the management to assess the response of the patient to medication and the relation of those responses to fall. It will not only improve the outcomes of the patients but it will also result in a reduction of the financial burden of the patients (Fonad et al., 2010).
From the above discussion, it can be concluded that Morse fall has become a global concern. Several elderly patients are facing the same issue that has been faced by Mr Rashid. Side effects of medication can be considered as a serious issue that imposes a negative impact on the elderly patient majorly. Finally, it can be said that with the help of clinical reasoning and effective critical thinking, issues like hypertension and Morse fall can be highly diminished.
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