Using The Clinical Reasoning Cycle To Identify Two Care Priorities

Identified care priorities

Use the clinical reasoning cycle to identify two care priorities and design a curated intervention plan to address the care needs.

This essay will use the clinical reasoning cycle to identify two care priorities and design a curated intervention plan to address the care needs identified with detailed link to underlying pathophysiology and clinical manifestation expressed by the student. The case study focuses on Beryl, a 50 year old woman suffering with hypertension attending a healthy heart workshop in the local community health centre. The blood pressure of the patient was 160/95 and she was obese at 105 kg body weight with 150 cm of height. She expressed to the care provider that she has an extremely stressful life with her executive management job. She drinks 3 glasses of wine every night and eats a lot of take away food because she doesn’t have time to cook for herself. She had three school-aged children and she also mentioned that she really exercises due to have lack of time. She has also mentioned that she forgets to take of hypertension medication which has also contributed to exacerbation of her health conditions. Both her blood pressure and her cholesterol levels were extremely high hence the care priority selected for the assignment are hypertension and hyperlipidemia.

According to the standard 1 of NMBA registered nurse practice standards, the nursing professionals are accountable for accessing, assessing and evaluating the patient needs and issues and designing a culturally safe and effective care plan to address the care needs identified. On a more elaborative note, as per the standard 4, the nursing assessments are needed to be holistic and culturally appropriate (Nursingmidwiferyboard.gov.au., 2018). According to the standard 5, the care plan development will need to be based on the critical and evidence-based assessment data, underlying pathophysiology and best available literature evidence. Hence, it can be concluded that the registered nurse practice guidelines can be effectively met by utilizing the steps of the clinical reasoning cycle. This cycle begins with accurate and extensive patent situation analysis and collection of cues that collects all the relevant data regarding the patient. In this case, the patient was Beryl, a 50-year-old woman with severe hypertension, the patient situational analysis and collection of cues revealed that she had blood pressure at 160/95 and had been obese with 105 kg weight. Her total cholesterol was 6 mmol/L, Low-Density Lipoprotein 3.1 mmol/L, and High-Density Lipoprotein 0.8mmol/L. Beryl was a single mother of 3 children and lived a very stressful life. On further assessment, the patient revealed forgetting to take medication and being an active smoker and drinker. Beryl also informed the care professional that she forgot to take her daily medications with the extremely stressful life that she lived. Processing the information, it can be mentioned that the patient had been suffering from two major problems, hypertension, and hyperlipidemia. Hence she will require a detailed nursing management and interventions for both of the identified care priorities.

Hypertension

In order to understand the patient care needs, identification of care priorities and determination of the interventions, as per the clinical reasoning cycle, understanding the pathophysiology and related factors is imperative. Hypertension is a very chronic health condition that targets a vast population, especially those belonging to the age group of 50 and over. Hypertension has been reported as one of the major public health priorities affecting almost 35% of the total population and contributes to close to 42% of the total cardiac disorder burden of the Australia. Elaborating more on the disorder, hypertension is a long-term medical condition that causes a persistent elevation of the blood pressure levels in the arteries (Head, McGrath, Nelson & Stowasser, 2012, pp 144). This particular condition paves way for more complicated health disorders such as the coronary artery disease, stroke, heart failure, atrial fibrillation, peripheral vascular disease, vision loss, chronic kidney disease, and dementia. High blood pressure usually goes unnoticed by the patient generally due to lack of any distinct clinical manifestation or symptoms. However, with prolonged hypertension, it can give rise to symptoms such as headaches, shortness of breath, light-headedness and even nosebleed. In this case, the patient presented to the healthcare facility with light-headedness, shortness of breath (especially after exertion). Hence, it can be stated that Beryl had been suffering from hypertension issue for a prolonged period of time (Mehta, Herrmann, Williamson & Nathan, 2013, pp 4). From the assessment data of the case study, first and foremost, it has to be discussed that the blood pressure of the patient had been 160/90. Now according to Ruilope (2018), the normal blood pressure levels are 120/80 mmHg, any elevation from the above mentioned levels are considered to be hypertensive. As per the Gee, Pickett, Janssen, Johnson, and Campbell (2013) pp 6, the higher systolic pressure between 140 to 160 mmHg and the lower systolic pressure between 90 to 99 mmHg refers to the stage one hypertension, as Beryl’s blood pressure levels fall within this range it can be mentioned that she had been suffering from stage 1 hypertension. However, it has to be mentioned that as per the case study, Beryl’s Heart rate had been 94 with regular rhythms, exploring the underlying pathophysiology for the assessment data, it has to be mentioned that in most of the general hypertension cases, the increase in the blood pressure levels does not cause an increase in the cardiac output. According to the Maraj, Makaryus, Ashkar, McFarlane, and Makaryus (2013) pp 2-7, the stage 1 hypertension is caused by the structural narrowing of small arteries and arterioles, however, the reduction of number or density of capillaries can also lead to stage 1 hypertension in the patients. According to the patient assessment data for the case study, that patient and also been suffering from shortness of breath as well (RR 22). Now it has to be mentioned prolonged hypertension has been known to lead to pulmonary hypertension as well. In this case, the high blood pressure in the loop connecting the network of vessels between the heart and the lings of the patients causes excess fluid back up. It has to be mentioned in this context that the impact of pulmonary hypertension is very high in the left ventricle of the heart which handles the most of the blood pumping load. As a result, the heart is not able to clear the pulmonary circulation which in turn affects breathing pattern of the patient leading to shortness of breath (Nguyen, Odelola, Rangaswami & Amanullah, 2013, pp 2-6).

Nursing management

Nursing management:

Nursing diagnosis	Nursing goal	Nursing intervention	Rationale	Outcome measurement
Hypertension	The blood pressure of the patient will be reduced to normal levels (less than 140 mm Hg systolic and less than 90 mm Hg diastolic) and the patient will be relieved of the light-headedness and shortness of breath.	The independent intervention for Beryl by the nursing professional in order to reduce the blood pressure of the patient to normal levels include administration of drug therapy. The nurse will have to take informed consent appropriately informing the patent regarding the medication and the benefits it will have on her recovery and overall health. The patient will be given a diuretics such as lasix or furosemide   (Nguyen, Odelola, Rangaswami & Amanullah, 2013, pp 2-6). The nurse will have to ensure that Beryl understands the need for administering the medications and consents to taking the medication.  The nurse will have to monitor the patient diligently to track the progress of the medication and any possible drug interaction (Stewart, Carrington, Swemmer, Kurstjens & Jennings, 2013, pp 955). The nurse will have to strictly adhere to the dosage requirements and monitor drug interaction and onset of possible side effects as well. The medicine will need to be swallowed by the patient and the gap between will need to be 6 to 8 hours. The drug can interact with desmopressin, ethacrynic acid, lithium hence the patient will need to be asked whether she had been taking dietary aids or NSAID drugs.  The side effects include dizziness, lightheadedness, headache, or blurred vision. For management of these side effects the patient hould be encouraged to move slowly and should be helped with getting in and out of bed. The next intervention administered by the nurse will include a collaborative practice with a dietician in order for the patient to follow a weight management plan or routine. The nurse will first explain to the patient about the harmful impacts of her obesity on her present health conditions and the risk to cardiac disorders and diabetes in the future followed by which the nurse will have to coordinate the equal participation of the patient and the dietician along with herself for the most suitable and achievable DASH diet. .	It has to be mentioned that according to the registered nurse practice standards and National Safety and Quality Health Service Standards, it is crucial for the nursing professional to perform medication safety while independently administering the medications. On a more elaborative note, the healthcare professionals are accountable for planning and implementing systematic strategies for safely dispensing and administering appropriate medication to the informed patients (Reis et al., 2018 pp 2-6). Hence the nursing professional will need to take informed consent from the patient before administering the medication to the patient (Cunningham, 2013, pp 4-5). The mechanism of action of Lasix is promoting sodium and water excretion, reduce plasma volume, decrease sodium in the arteriolar walls, and reduce the vascular response to catecholamines. (Stewart, Carrington, Swemmer, Kurstjens & Jennings, 2013, pp955). The dosage will 20-80 mg depending on the severity of the condition. It has to be mentioned that for the patient to incorporate a collaborative lifestyle change, the nurse will have to include a dietician perspective to ensure safe and effective collaborative practice. The DASH or Dietary Approaches to Stop Hypertension will help the patient in-pharmacologically and effectively reduce her blood pressure and along with that will provide an effective and long-term solution to the issues (Juraschek, Miller III, Weaver & Appel, 2017, pp 2841-2848). .	The blood pressure of the patient reduces and the patient is relieved from the light-headedness as well. There is no noticeable adverse reaction to the medication. The patient understands the impact of her diet choices on her hypertension agrees to the dietary changes and participates in the care planning.

In order to understand the patient care needs, identification of care priorities and determination of the interventions, as per the clinical reasoning cycle, understanding the pathophysiology and related factors is imperative. Hyperlipidaemia can be defined as the condition facilitated by high cholesterol leading to high blood pressure and various other cardiac complications in the patient. According to the review report it has to be mentioned that high cholesterol has also been commented as one of the most common health adversities as well (Khera & Plutzky, 2013, 72-78). The desirable cholesterol levels for adults is less than 5.2 mmol/L. The range between 5.2 to 6.2 mmol/L is considered are borderline high cholesterol and cholesterol levels higher than 6.2 mmol/L is considered to be high. From the patient assessment data that has been discovered that the patient had 6 6.2 mmol/L cholesterol with low-density lipoprotein at 3.1 mmol/L and high-density lipoprotein at 0.8 mmol/L. Hence as per the data, it can be concluded that the patient had been suffering from borderline high cholesterol. Now considering the underlying pathophysiology of the high cholesterol on the patient, the most important reason behind the high cholesterol in the patient includes food habits involving saturated fat, and Trans fats. It has to be mentioned that Beryl had been surviving on takeaway food on a regular basis as she could not cook with her highly stressful and hectic lifestyle. Along with that, it has to be mentioned that Beryl had been extremely obese as well, which is contributed by the unhealthy dietary pattern, sedentary lifestyle and acute professional as well personal stress. Obesity and hyperlipidaemia are associated with one another; high cholesterol represents extensive impact on the high BMI of the obese individuals as well. Along with that, the patient had been going through extreme stress which, given her hypertension and hyperlipidaemia, can easily lead to anxiety and stroke. Hence, the patient will require extensive care intervention for her high cholesterol levels in order to revert back to normal cholesterol levels (Katz & Leiter, 2012, 667-677).

 Care plan:

Nursing diagnosis	Nursing goal	Nursing intervention	Rationale	Outcome measurement
Hyperlipidaemia or high cholesterol	The high cholesterol of the patient will reduce and Beryl will feel more energetic. Her breathlessness will also subside.	The nursing professional will independently administer drug therapy including cholesterol- and triglyceride-lowering medication like Fluvastatin or lescol  (Vodnala et al., 2011,pp 14) However, before administering the medication to the patient the nurse will again have to take informed consent of the patient. The nurse will have to monitor the patient diligently to track the progress of the medication and any possible drug interaction. The nurse will have to strictly adhere to the dosage requirements and monitor onset of possible side effects as well. The dosage for lescol for the patient will need to be 40 to 80 mg oral dose per day.  For the patient 2 40 mg capsules will be given with or without food. The most common side effects are headache, dyspepsia, myalgia, abdominal pain and nausea. The drug can interact with Cyclosporine, Fluconazole, Concomitant lipid-lowering therapies, Glyburide, Phenytoin, and Warfarin and coumarin derivates. Hence the patient will need to be asked for any recent usage history of these drugs. In order to manage the side effects the patient can be mild pain relief and comfortable resting position. The nurse will educate the patient regarding the impact of her lifestyle, excessive stress and obesity. The nurse will educate the patient with the aid of an occupational therapist and fitness expert for an exercise regimen fit for her (Kinjo, 2018, pp 201-213)	According to the nursing practice standards and standards for quality and safe practice, for nurses that are practicing independent medication administration, the nurses will need to perform a detailed consent procedure so that Beryl can get the basic idea if the need for the medication and how it will help her (Safetyandquality.gov.au. 2018). As drug interactions are a very common source of medication errors and exacerbations, diligent monitoring and accurate administration procedure will help with avoiding the possibility of side effects or complications (Suksaranjit et al., 2015, pp 33). According to the second standard of registered nursing practice, the nursing professionals will need to establish a therapeutic partnership with the patient in order to enhance their quality of life and promote recovery (Vodnala et al., 2011,pp 14). In this case, the nurse will engage in collaborative practice with the aid of allied health professionals such as an occupational therapist and fitness expert for an exercise regimen that will help her with her weight managements and will help in reducing he blood pressure non-pharmacologically (Tada & Kobayashi, 2016, pp 4).	The respiratory rate of the patient is reduced and the patient feels comfortable. The patient understands the impact of her lifestyle choices and stress on her present health conditions. The patient consents to lifestyle changes including exercise regimen and participates in the planning procedure with the rest of the care professionals

Conclusion:

Nursing care can be considered as one of the most important facts associated with the care that the patients receive in order to be relieved from the health adversities that the patents had been facing. However, it has to be mentioned that illness is a complex construct and in order for the nursing workforce to be able to provide a care service that is effective and efficient and addressing each and every care needs and preferences expressed by the patient, there is a need for a strategic practice framework. This assignment gave a perfect opportunity for applying the clinical reasoning cycle and different practice standards to discover two care priorities and adequate nursing management, both independent and collaborative. Hence, it can be hoped that it will serve as a great lesson for me and will guide me through my future practice

References:

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