Clinical Reasoning Cycle For Nursing Practice: A Case Study

Patient Situation

While provide nursing care to the patients, the nurses have to collect cues of the patient condition, process all the care related information collected from the patient and then arrive at an understanding of the presenting health issue of the patient so that adequate care measures can be taken for the patients (Mudd & Sloand, 2015). Followed by which the nurses are required to implement the planned intervention based on the verdict, evaluate the outcome of the care activities planned and then reflect on the entire process to improve the ability to provide individualized care services. The clinical reasoning cycle is an excellent framework that provides the nursing professionals with a systematic protocol with interlinked steps to follow and adhere to each of the care practice components mentioned above. As mentioned by Hunter and Arthur (2016), the nurses that have effective clinical reasoning skills have been reported to have enhanced positive outcomes associated with patient and hence it is necessary for the nurses to have a clear understanding of the clinical reasoning process. In this essay, I will attempt to explore the clinical reasoning cycle and apply this framework utilizing each of the components of the clinical reasoning cycle taking the assistance of a case study.

Considering the patient situation:

This case study represents the care of Mrs. Connie Brownstone as the patient under consideration. Connie is a 79 year old woman who had been admitted to the eme4regncy department of the health care facility due to the pressing health concern of respiratory distress. She had been brought in by her daughter due to the one day history of the patient suffering from shortness of breath which was not diminished or reduced by medication.

As discussed by Dalton, Gee and Levett-Jones (2015), collecting care cues is one of the most important parts of the care planning procedure as it guides the care planning procedure and helps the nurses provide patient centred individualized care to the patients. There is a varied range information that the nurse has to collect in order to recognize the exact care needs of the patient, such as handover reports, patient history, patient charts, investigations results, medical assessments, and lastly undertaking new patient assessments (Hunter & Arthur, 2016). Her past medical history as mentioned in the case study is asthma, and she had been admitted to the ICU due to status asthmaticus and required endotracheal intubation and ventilation for two days. The past medical data of Connie also indicated that she had allergies to pollen and dust mite as well which can aggravate asthma attacks.

Clinical Reasoning Process

The triage nurse assessment data reveals that the vital signs of the patient includes RR 35, SpO2 90% (room air), HR 125bpm, RR 35, Temp 39.4° Celsius, BP 168/70; which indicates most imbalance in the homeostasis of the body in most cases (Teach et al., 2015). Next, the physical assessment data indicates that Connie had been suffering from Dyspnoea, extreme anxiety, and audible expiratory wheezing, which in this case indicates signs of considerable respiratory blockage; and hence, she had been considered as category 2. During the cubicle nursing assessment, the oxygen saturation rate and blood pressure of the patient reduced further indicating further complications in the patient. During the physical assessment indicated evident use of accessory muscles while breathing along with bilateral expiratory wheeze. The systematic investigation results carried out for her includes presence of hyper-expanded lungs and signs of abnormal ABG results as well.

While processing the information collected, the nurses generally follow a step by step process of interpreting, discriminating, relating, inferring, matching and then predicting care needs from the information with respect to best available evidence (Dalton, Gee & Levett-Jones, 2015). In this case, Connie had been suffering from acute respiratory distress evidenced by the abnormalities in the vital signs and investigation results. First and foremost, the normal respiratory rate of adult is 12 to 20 minutes and in this case, Connie had almost double the respiratory rate and her oxygen saturation has also dropped to 89%, indicating at extreme oxygen insufficiency. Considering the heart rate and blood pressure, Connie had 125 bpm heart rate and 172/75 mmHg blood pressure; whereas the normal heart rate is 100 bpm and blood pressure is 120/80 mmHg. In explanation I would like to mention that during asthma exacerbation that leads to respiratory distress reduces the oxygen availability in the body significantly, as a result, the cardiac load increases in order to be able to meet the oxygen demand of the body which raises the heart rate and drops the blood pressure as well (Johnson, 2017).

However, the most important information is the presence of hyper-expansion in her lungs and her ABG test results. The ABG results indicated high blood pH, low PaCO_2, low PaO₂ and high HCO_3. As per Reddi (2018), the investigation results of the ABG tests indicates alveolar hyperventilation and hypocapnia resulting from an acute episode of respiratory alkalosis. It has to be mentioned that Connie had been an asthma patient and susceptible to allergies caused by pollution. The respiratory alkalosis in patient can be caused due to the bronchial constriction and resultant alveolar hyperventilation. This has also led to hyper-inflation of her Chest and her wheezing is also indicative of bronchial constriction (Brinkman & Sharma, 2018).

Establishing Care Goals

There are various care needs that Connie is exhibiting which requires clinical intervention, however while providing emergency care  relief to a deteriorating patient, it is very important for the nurses to prioritizing the care needs by synthesis of facts and inferences.  The first and foremost care priority for the patient in this case will be the shortness of breath or dyspnoea which was also the presenting problem that the patient was admitted to the facility with. The second care priority for Connie will be the respiratory alkalosis and maintaining the acid base balance in the blood back to normal. The third care priority for Connie will be the high heart rate which can lead to cardiac emergency if adequate interventions are not given to the patient (Mudd & Sloand, 2015).

Establishing care goals:

Establishing care goals is an integral part of the clinical reasoning cycle as it allows the nurses to set up a benchmark or care outcome in accordance with the exact needs and preferences of the patient and be able to provide accelerated recovery progress for the patient. In this case, the first care goal will be to address the shortness of breath by reducing the respiratory rate back to normal and enhancing the oxygen saturation levels to at least 95-98% within the next 48 hours. The second care goal will be to reduce the blood pH and restore homeostasis in the patient within next 24-48 hours. The third care goal for me will be to address the high heart rate of Connie by reducing the present rate from 125 bpm to 100 bpm within the next 24 hours.

For the first care priority, first and foremost, Connie will require the aid of pharmacological intervention for bronchodilation such as salbutamol or any other bronchodilator (Tierney & Bhagra, 2018). Along with that, I would also administer beta 2-andrenergic medication such as albuterol and corticosteroids such as budesonide to reduce the inflammation and relieve the bronchoconstriction that Connie is suffering from. Next, she would also require the assistance of external oxygen therapy which will immediately enhance the oxygen saturation and help in reducing the respiratory rate. As she already had 6ml oxygen by Hudson mask I will increase the dosage to enhance the efficiency (Hendriks et al., 2015).

For the respiratory alkalosis, firstly I would provide the patient with electrolytes to restore the homeostasis in the body of the patient. Along with that, I would also administer external CO₂ or provide her with a rebreathing mask which will help restore the PaCO₂ and PaO₂ levels in her body and have a significant impact on the tidal volume (Habib et al., 2016).

Care Interventions

For the third care priority, I will administer anti-arrhythmic medication which will help reduce cardiac load and in turn reduce the heart rate of the patient as well. Along with that, I will also provide her with a comfortable and safe environment calming her so that her anxiety levels are also reduced and she feels increasingly calm reducing her heart rate (Song & Cho, 2015). I will also let her daughter visit from time to time to allow her to feel safe and protected while maintaining the necessary precautions.

While evaluating the outcomes of the care interventions that have been provided, I would like to mention that Connie started feeling significantly better within next 24 hours. On a more elaborative note, her heart rate was successfully reduced with the anti-arrhythmic and anti-anxiety medication, however the aid of comforting measures taken for Connie also helped in visibly improving the care outcomes. The bronchodilators and corticosteroids also helped in reducing the bronchoconstriction effectively and with the enhanced oxygen therapy provided for 10 hours, her respiratory rate reduced back to 20-22 bpm and she could breathe on her own. Although, Connie was reluctant to use the rebreathing exercise, she ultimately agreed after effectively explaining her the need for it which also helped in improving her vitals (Charriot et al., 2017).

Reflection:

Reflecting on the experience, I would like to mention that this had been an exceptional experience for me to plan care for a patient going through a respiratory emergency. This had been the first encounter for me to apply the theoretical framework of the clinical reasoning cycle and it undoubtedly helped me immensely in understanding the exact care needs of the patient and then arrive at a verdict regarding the care priorities which demanded immediate attention for Connie (Dalton, Gee & Levett-Jones, 2015). The implementation of the care interventions although had certain complications and challenges in the beginning with effective communication, patient education and patient centred care, the process of caring for her progressed smoothly.

Conclusion:

On a concluding note, designing and implementing a thorough patient centred and individualized care plan for a patient with complex care needs can be a very challenging and difficult aspect for the nursing professionals. The clinical reasoning cycle is a framework that provides the nurses with the opportunity to adhere to all of the practice standards and apply critical thinking and clinical reasoning skills effectively. This essay helped me explore the components of clinical reasoning cycle in details and plan a curated and individualized care plan for a patient with complex care needs and I believe that this experience will guide my future practice excellently.

References:

Brinkman, J. E., & Sharma, S. (2018). Physiology, Alkalosis, Respiratory.

Charriot, J., Volpato, M., Sueh, C., Boissin, C., Gamez, A. S., Vachier, I., … & Bourdin, A. (2017). Asthma: treatment and prevention of pulmonary exacerbations. Acute Exacerbations of Pulmonary Diseases, 77, 129.

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Hendriks, S. A., Smalbrugge, M., Galindo-Garre, F., Hertogh, C. M., & van der Steen, J. T. (2015). From admission to death: prevalence and course of pain, agitation, and shortness of breath, and treatment of these symptoms in nursing home residents with dementia. Journal of the American Medical Directors Association, 16(6), 475-481.

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Schivo, M., Phan, C., Louie, S., & Harper, R. W. (2015). Critical asthma syndrome in the ICU. Clinical reviews in allergy & immunology, 48(1), 31-44.

Song, W. J., & Cho, S. H. (2015). Challenges in the management of asthma in the elderly. Allergy, asthma & immunology research, 7(5), 431-439.

Teach, S. J., Gill, M. A., Togias, A., Sorkness, C. A., Arbes Jr, S. J., Calatroni, A., … & Kercsmar, C. M. (2015). Preseasonal treatment with either omalizumab or an inhaled corticosteroid boost to prevent fall asthma exacerbations. Journal of Allergy and Clinical Immunology, 136(6), 1476-1485.

Tierney, D., & Bhagra, A. (2018). Evaluation of Shortness of Breath. In Atlas of Handheld Ultrasound (pp. 177-178). Springer, Cham. most care priority for the patient in this case will be the shortness of breath or dyspnoea ery important for the.