Clinical reasoning may be described as the process that is utilized by nurse professionals to collect cues, analyze information, and acknowledge the patient's situation or concern along with planning and implementation of appropriate interventions (Dickison, Haerling & Lasater, 2019). Furthermore, the process of clinical reasoning is principally dependent on the critical thinking disposition, and as such, the procedure is potentially influenced by an individual's preconceptions, philosophical perspective in addition to the individual's attitude (Guerrero, 2019). Therefore, it is imperative to note that the clinical reasoning process is not linear; however, it is conceptualized as a spiral or sequence of either ongoing or linked clinical encounters that involve health care practitioners particularly RNs (Registered Nurses) with the clients (patients) (Guerrero, 2019). This paper presents a scenario-based handout that promotes a robust discussion concerning the use of clinical judgment as a sequential involving an outcomes-based dynamic process of clinical reasoning to attain the needs of the patient.
Description of the Clinical Situation:
One of the clinical scenarios where I applied an outcome-based cycle sequence of clinical reasoning involves a previous initial encounter on a Monday morning shift with a 67-year-old post-operative male patient called Mr. Jack diagnosed with colorectal carcinoma. When the patient's GP (General Practitioner) questioned him, he reported changes in his bowel habits with occasional diarrhea as well as infrequent constipation. After Jack's GP noted that the patient was anemic along with a family history including bowel cancer, he conducted a digit rectal evaluation. Even though the GP was unable to palpate a rectal mass, he referred Mr. Jack to who subsequently scheduled and performed a colonoscopy. The colonoscopy disclosed left-sided colon carcinoma and a bowel resection procedure was scheduled the following day. After 24 hours following Mr. Jack's operation, I was issued a handover report at 0900 hours during the morning shift to offer care for the patient.
The report indicated that Jack had bowel cancer, and as such, he had a partial colectomy procedure along with the construction of a colostomy. He was under the care of Dr. Mike. Even though the patient's surgery was uneven, Jack was stable throughout the procedure. Mr. Jack was given PCA (Patient-controlled Analgesia), including morphine given through the IV (Intravenous) route and running at 84 milliliters every one hour. Additionally, Mr. Jack had trouble with sleep following his surgical procedure along with a drop in his BP (Blood Pressure) and required two-fluid challenges each containing a volume of 300 milliliters. An ICD (Indwelling Urethral Catheter) procedure was performed on Mr. Jack, which measured drainage on an hourly basis; however, the drainage was still quite low. The patient had a bellovac drain, and as such, the report indicated that Mr. Jack had only drained 300 milliliters following his surgery. His wound appeared intact and dry and had a drainage bag above his stoma which appeared did not contain any drainage. The report also indicated that Jack's oxygen therapy was due again at 1000 hours, even though his saturation levels were okay. The patient's obstetrics procedure was scheduled at 0900 hours.
Additionally, the report showed that the patient's BGLs (Blood Glucose Levels) required to be monitored on an hourly basis and as such the next check was scheduled at 0900 hours. Jack also had a controlled diet and his BGLs were acceptable. The patient also lived alone following his wife's passing and his daughter was scheduled to visit him later in the day.
The Internal and External Cues and Hypothesis
After reviewing Mr. Jack's current information on the report, I hypothesized that the elderly patient was dehydrated and hypovolemic and as such, he had a fluid imbalance. In support of this hypothesis, I had to apply my physiologic education concerning hypovolemic and dehydration conditions. Most fundamentally, the post-operative state is frequently associated with the activation of the HPA (Hypothalamic-Pituitary-Adrenal) axis as well as the RAA (Renin-Angiotensin-Aldosterone) systems in addition to the non-osmotic production of vasopressin hormones that induce renal retention of sodium and water, to compensate for external losses during a surgical procedure (Rafat et al., 2015). The resulting outcomes include a hypovolemic state and dehydration.
After reviewing Mr. Jack's report, the identified external cues include the report that the patient lives alone following his wife's death, Dr. Mike's report that the patient was anemic and had an uneven surgical procedure, the report that the patient's family has a history of bowel carcinoma, and the colonoscopy report indicating left-sided colon cancer. Jack's internal cues were determined following the assessment of his systems. After the assessment, I discovered the following vital cues required for action: The patient's state of oral mucosa involved a dry mouth with a furrowed tongue; his oral intake behavior involved sips of minimal quantities of fluids; his
His cognitive state included anxiety and restlessness;
and his level of thirst was extreme.
Outcomes-Based Iterative Cycle of the Applied Clinical Reasoning
This section of the paper will illustrate the outcomes-based iterative process in which clinical reasoning was applied in the case scenario. The illustrates cycle involves eight phases of the cycle including considering the patient's situation, collection of information or cues, processing of the information, identifying the concern or problem, establishing objectives, taking action including interventions, evaluating the actions, and reflecting on the cycle and establish new best interventions.
Consideration of Mr. Jacks Situation
The first stage of the cycle includes the consideration of Mr. Jack's situation to determine the external and internal cues as well as a hypothesis. The central element to understanding the patient situation involves listing or describing the principle facts, people, objects or the context of the current situation (Guerrero, 2019). Considering Mr. Jacks situation, the following factors were listed: partial colectomy procedure in the previous day; administration of patient-controlled analgesia including morphine through IV route; fluid challenge involving administration of a large quantities of fluids over a short duration under close monitoring to assess Jack's responsiveness; vacuum drainage; the use of indwelling catheter; an opening into Jack's body from the outside by the surgeon; and monitoring of the BGLs.
Collection of Information or Cues
After reviewing the report presented, the cues and hypotheses were determined, as highlighted in the previous section of this scenario-based handout. The current systemic information that was collected includes the following:
System: Temperature: 37; BP: 90/50; BGL: 4 mmol/L; the average hourly urine output: 26mL/hr; Oxygen saturation level measured at 97 %; Pulse rate: 112; RR (Respiratory Rate): 22. New information was gathered along with the presentation of internal as well as external cues, as stated in the preceding section of this paper.
The next phase of the clinical reasoning involved the processing of the gathered information by interpreting cues, discriminating the cues to obtain the essential facts, relating the cues, inferring as well as by predicting (Kuiper, O'Donnell, Pesut & Turrise, 2017) Mr. Jack's potential outcomes. The interpretation reasoning applied in Mr. Jack's situation includes the analysis of the patient's parameters by comparing abnormal versus the healthy factors. As such, Jack's BP (90/50) and Temperature (37C) parameters were within the normal range as opposed to the listed physiological parameters in the preceding section of this paper. Additionally, his SpO2 was okay implying that it was within the normal range of between 95 and 100% (Ramachandran, Thompson, Pandit, Devine & Shanks, 2017). The BGLs were also within the normal range of 4-8 mmol/L.
In discriminating the gathered cues and information, critical cues were selected, including BP, Jack's pulse rate, his condition of the oral mucosa, as well as the patient's low urine output. The next stage of processing the information involved relating the information to determine possible associations between them. In support of this action Kuiper et al. (2017) noted that it is essential to categorize the gathered cues together with the linkages between them to identify the issue at hand. Considering Mr. Jack's scenario, the analysis of information reveals that Mr. Jack is hypotensive due to preoperative bowel preparation. Additionally, the relation analysis indicated that the patient is oliguric because of hypotension. Finally, another vital relation deduced from the cues includes the fact that the patient had tachycardia based on the report that he had had a third space fluid shift.
After analyzing the gathered cues, the identified inferences include tachycardia and oliguria, as well as the afebrile state of Mr. Jack along with hypotension. After making the inferences, the next step of information processing involves predicting the probable patient outcomes (Gummesson, Sunden & Fex, 2018). In the case of Mr. Jack, I predicted what could probably occur; his fluid status not corrected. The predictions included hypovolemic shock, acute tubular necrosis also known as acute renal failure, and the probable worst-case scenario, could be death.
Issue or Problem Identification
This stag if the clinical reasoning sequence necessitates the nurse to combine his or her synthesis to establish a definitive nursing diagnosis. Concerning Mr. Jack's scenario, the correctly nursing diagnosis identified following the synthesis of the cues included dehydration and hypovolemic conditions. This issue was identified based on the fact that the patient experienced external fluid losses after his surgical procedure resulting in activation of HPA axis as well as RAA systems in addition to the non-osmotic production of vasopressin hormones that induced renal retention of sodium and water (Rafat et al., 2015).
Establishment of Goals
Short-term and SMART goals should be established to aid in determining the next best nursing interventions. Considering the case of Mr. Jack, the principal goal established includes the following: To ensure Mr. Jack enters a normotensive state with urine output of at least the range of between 35 milliliters and 40 milliliters every single hour within the next two to four hours. This goal is SMART because of the following reasons:
- Specific: the objective of entering a normotensive state.
- Measurable: a urine output of at least the range of between 35 milliliters and 40 milliliters
- Achievable: normality of the normotensive state can be reached
- Realistic: The objective is not ambiguous.
- Timely: within the next two to four hours
Taken Nursing Actions
The nursing actions are described as the behavior that follows on from either a decision or a judgment (Manetti, 2019). This stage of the clinical reasoning process is associated with the application of communication skills, intellectual actions, as well as the use of practical skills to decide the section of the plan given priority along with the policies and procedures involved in the nursing actions (Kuiper et al., 2017). Based on the SMART objectives identified above, as well as learned experiences including communication, practice, and intellectual skills, I took the following six most immediate and vital nursing interventions:
I notified Mr. Jack's GP concerning his condition, particularly the hyp...
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