Nursing : Practical Guide To Clinical Medicine

Clinical reasoning is a process which one applies to make clinical decisions, which is a process by which health professionals determine who needs what and when. To ensure continuity of care it is essential that health care professionals stay flexible in their approach to decision making. To provide high quality safe health care it is dependent upon the ability to reason, judge and think which otherwise can stay affected by lack of proper experience (Moodle.une.edu.au, 2016). The clinical reasoning cycle are basically tools allowing the health care professionals to be capable of making a choice by applying a systematic process considering man clinical predisposing contributing factors which has been previously applied to evaluate a case study and finally develop and implement the best possible care for patients.

The cycle of clinical reasoning requires the health professionals to be able to examine and be able to discuss the steps to be taken in a clockwise manner to enable the process of decision making, enabling a clear formulation of the care plan as shown  (“School of Nursing, Midwifery and Social Work – The University of Queensland, Australia”, 2016). This process of cycle has been applied in the current case involving patient of 24 year old male. The logical thought processes of the care team who was caring for the patient will be explored by the overall process of the Clinical Reasoning Cycle to demonstrate the decision making process which is used in practice. (Levitt-Jones et al, 2015).

Figure 1 Clinical reasoning cycle

Source: www.utas.edu.au

An otherwise healthy male of 24 year old presents with a 3 day old cough accompanied by fever, chills, green colored sputum, slight shortness of breath, pain  seen at the right side of the chest. The body temperature is 102 F with vital signs being normal. The patient appears well. At the right base on the lung, few crackles are noted. No other abnormalities are seen ((“A Practical Guide to Clinical Medicine”, 2016). This cycle has been used in the current case scenario which involves this patient. The process of thought of the team responsible for care who are responsible for caring for him are analyzed through utilization of the clinical reasoning cycle to demonstrate how the clinical decision  is actually used in practice

Step 1: Considering the patient situation

This clinical situation can be seen to be most consistent with a bacterial pneumonia which is well-compensated. Other possibilities could include asthma flair, viral infection and pulmonary embolism (P.E)

Step 2:  Collect cues and information

Everything cannot explain all of the findings which are present or is not supported by the objective data. A viral function shouldn’t cause a lung exam which is focal in nature; it is seen that asthma is also able to cause cough and shortness of breathing, but wheezing should be present; also a pulmonary embolism can also cause this symptoms but it should not result in fever, sputum production and chills. (Felten, S., & Cydulka , 2015). Further, this P.E.S generally occurs in patients who have risk factors, none of which are present in this case. Unlikely diagnoses may also be present such as eosinophilic pneumonitis, histoplasmosis and malignancy. This would only be taken into consideration if the course of the patient deviates remarkably from the expected and/or could not be explained on the basis of those things.

Most clinician would feel comfortable to proceed without further diagnosis to rule out other purposes. Other health providers may have seen a similar case and have treated the patient with a bacterial infection which later turned out to be P.E. For this reasons, obtaining a CXR (confirming the presence or absence of an infiltrate) CBC (For the identification of leukocytosis c/w and bacterial infection), D-Dimer ( breakdown product of clot elevated in DVTs/PEs) as well as an EKG( to check for stigmata of a P.E.). All these are preferable (Chugh et al., 2015). This approach is not incorrect as it is driven by a clinician’s experience, which for several reasons has an impact on decision making. This becomes helpful as long as it is based on logic. It is not always feasible as it comes with a price.

If not treated, bacterial processes tend to get worse if not treated, eve in case of an otherwise healthy 23 year old. The symptoms which requires medical emergency in case of bacterial infections is high fever, which the patient shows (fever of 102 F), shortness in breathing and appearance of green sputum.

An effective nursing care plan is important for this patient, including measures like providing humidified oxygen therapy, mechanical ventilation in case of respiratory failure, provision of high calorie diet and enough fluid intake. Bed rest and analgesics to relieve chest pain should be the interventions.

In this case therapy should be started on an outpatient basis where an antibiotic is targeted against Strep, H. Flu, pathogens which are most commonly seen to be associated with infections related to respiration inflicting in this age group. Treatment should be lasting for week, an arbitrary duration and the patient is instructed to return for an evaluation on the last day to ensure that the infection was treated completely and antibiotics can be discontinued.

The outcomes expected out of the care given are normal sputum color, no chills, fevers or shortness of breath. No pain in the chest. No crackles in the left side after a physical examination.

As per the clinical reasoning cycle applied on the case study, the patient recovered as the desired outcomes were achieved.  In this case study, the clinical reasoning used is in the form of practice based requiring a background of scientific and technology based knowledge about various cases which are general (DiCenso et al., 2014). It demands a practical ability to figure out the relevance evidence behind the knowledge and how it is going to be applied for a particular patient. It is unfortunate that in spite of having an abundance of knowledge, physicians are still limited to using their own judgment while making clinical decision for e.g. is a cold caused by virus or bacteria? Should administration of antibiotics is required or should be withheld? The solution lies in knowing when it is right to be choosy with the testing and which cases requires a no-hold-barred knowledge.

A Practical Guide to Clinical Medicine. (2016). Meded.ucsd.edu. Retrieved 13 August 2016, from https://meded.ucsd.edu/clinicalmed/thinking.htm

Chugh, C., Nyirjesy, S. C., Nawalinski, K. P., Sandsmark, D. K., Frangos, S., Maloney-Wilensky, E., … & Kumar, M. A. (2015). Red blood cell distribution width is associated with poor clinical outcome after subarachnoid hemorrhage: A pilot study. Neurocritical care, 23(2), 217-224.

DiCenso, A., Guyatt, G., & Ciliska, D. (2014). Evidence-based nursing: A guide to clinical practice. Elsevier Health Sciences.

Felten, S., & Cydulka, R. K. (2015). ASTHMA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, AND PNEUMONIA. Emergency Medicine Secrets, 177.

Gee, T., Dalton, L., & Levitt-Jones, T. (2015). Using Clinical Reasoning and Simulation based education to flip the enrolled nursing curriculum. InSustainable Healthcare Transformation: International Conference on Health System Innovation.

School of Nursing, Midwifery and Social Work – The University of Queensland, Australia. (2016). Nmsw.uq.edu.au. Retrieved 13 August 2016, from https://nmsw.uq.edu.au/

UNE Moodle. (2016). Moodle.une.edu.au. Retrieved 13 August 2016, from https://moodle.une.edu.au/

University of Tasmania, Australia | World-class study, research, and lifestyle. (2016). Retrieved 13 August 2016, from https://www.utas.edu.au/