Clinical Reasoning and Its Application to Nursing - Case Study Example

CASE STUDY ASSIGNMENT Name: Grade Course: Tutor’s Name: 5th April, 2011 Introduction Nurses have a very important role to play in caring for patients to ensure positive outcomes. In acute care settings, patients have complex problems some of which if not taken care of, lead to the patient getting into a critical condition. Nurses have to ensure that the cues they collect about the patient are right, the actions taken are right and they should be taken at the right time. This is known as clinical reasoning and according to Levett-Jones and others; clinical reasoning is a process of collecting relevant information about patient condition, analysis of the information to find out the problem, development of appropriate action plan, taking the right action and evaluating the outcome. The nurse has to have knowledge which will help in indenification of the problem and has to have the ability collect the right cues and make the right decision (Levett-Jones et al, 2010, p. 515). This paper aims at assessing the knowledge on and importance of clinical reasoning. A case study is provided for analysis (Mr. James Smith’s Complex problem) and questions about clinical reasoning and how it can be applied in the case study are asked. The case study is provided in a different paper and the questions to be answered are C and D. Below are the answers to the questions. C. According to Levett-Jones and others, at risk patients are not always identified or managed properly (Levett-Jones et al, 2010, p. 515). The case provides a perfect example of poor management or lack of identification of patients at risk for appropriate management. As Levett-Jones and others indicate, warning signs may be evident but the health care practitioners fail to identify the patients at risk or even if identified, they fail to properly manage them. The 52 year old patient (James Smith) has a history of 30 years of smoking, which according to the records, there is no indication of him having stopped. The patient has COPD and has had symptoms showing advancement of the chronic disease. His age is another factor that puts him at risk of becoming critically ill. The symptoms are such as more apparent breathlessness, persistent cough, development of hypertension which may be due to stress, and frequent visits to his GP. The patient has been experiencing chest pains for the last six months, has had heart failure as a problem for the last two years and is stressed by his condition. These are all symptoms of advancing COPD or deteriorating health due to COPD (Medifocus, 2011, p. 49). From the case study, there are three problems; poor management, lack of effective communication and lack of identification of the patient as at risk. The patient is a heavy smoker and no action was taken to prevent this based on his medical records. This could also be the cause of hypercholesterolaemia (Mariani, 2000, p. 40) that he has. It is most likely the cause of COPD (99% based on his smoking period) that he has (Schriber, 2009). The patient’s medical history shows that he needed advanced COPD nursing care which was not identified at the right time. Poor management is evident in the actions taken, for example, the doctor in the emergency department prescribes 24% oxygen for the patient while his oxygen sats show 88%. This is not well taken by the nurse who seeks a medication review from the pharmacist. This is a clear show of poor communication, a characteristic of poor management. Poor management is also shown on the lack of identification of the urgent need to manage the patient’s condition. Haig, Sutton and Whittington (2006, p. 168) and Woodhall, Vertacnik and McLaughlin (2008, p. 314), indicate that lack of a communication’s structure, lack of a team leader to guide the patient’s management, lack of standardized communication system and differences in communication style are factors that cause communication difficulties hence poor management. In order to change that and ensure effective management, the health care center should implement a structured communication system. This system should enable understanding among nurses, physicians and other health care practitioners so that patient safety is ensured. A model already proposed is the SBAR, meaning; Situation, Background, Assessment and Recommendation. It is a standardized approach to hand off communications among care givers and is meant to promote a culture of safety. It supports honest and open communications for information sharing, providing suggestions and asking questions. There should be a leader, like the chief nurse officer (Haig, Sutton and Whittington, 2006, p. 168) How the Nurse should be aware of early warning signs In order to rescue patients, nurses have to be competent. Competency in nursing apart from other skills, involves clinical reasoning which according to Banning (2004, p. 177) is what characterizes an expert nurse. The nurse has to able to identify the facts about the patient’s situation, review current information about the patient including patient history, analyze the information to understand the disease or patient’s condition, identify the problem, establish appropriate action, take action and evaluate the outcome (Levett-Jones et al, 2010, p. 517). This is what is known as clinical reasoning. Early warning signs guide the nurse in decision making to rescue the patient since the nurse will have the knowledge of the disease and its status. According to Clarke (2004, p. 67), rescuing a patient involves two phases; examination and identification of possible dangers in time, and development of an effective rescue response. Note the statement in the first phase ‘identification of possible problems in time’. It means that with clinical reasoning (by use of the right clinical reasoning strategy) the early warning signs can be identified and any adverse effects avoided and well managed. In the case study, the nurse failed to make use of appropriate clinical reasoning or just did not know how. Clinical reasoning is affected by different factors such as knowledge, expertise, anxiety, confidence and time pressures (Levett-Jones et al, 2010, p. 517). It is not easy to tell which factor represents the nurse’s action but the cues were evident yet the nurse never made use of them. Early warning signs are important in disease management and if never identified poor diagnosis results. The patient should be under advanced COPD management with emergency situations treated first and because the health care center has no standard and structured communication system, this should be developed as proposed above. D. The Five Rights of Clinical Reasoning They are; the right cues, the right patient, the right time, right action and the right reason. The right cues: Cues are the changes experienced by the patient over time and current experiences that are either psychosocial or physiological or; available patient information, the patient’s current assessment and knowledge. The right cues means the right information needed for the right decision about the patient’s condition hence the condition’s management (Levett-Jones et al, 2010, p. 517). In the case study, the right cues include the patient’s medical history, current assessment and knowledge on COPD management and symptoms. With knowledge, the nurse should be able to know that COPD is a chronic disease that advances with time and that hypertension, development of persistent cough, increased cases of breathlessness, heart failure and chest pain are symptoms of advancement of the disease. The nurse should also be able to comprehend the reason for the patient’s frequent visits to his GP. COPD is associated with anxiety and depression, so if the patient frequently visits his GP, it means he was constantly worried. This is a characteristic of anxiety (Schriber, 2009 & Medifocus, 2011, p. 49). Current assessment of the patient also confirms the stage of COPD. The doctor confirmed that his heart failures are due to COPD exacerbations and that he was depressed. Considering hypercholesterolaemia, this is a condition that the patient may have developed due to his smoking habit (Mariani, 2000, p. 40). The right patient: Is the patient at risk of getting critically ill or experiencing adverse effects. In order to determine if the patient will be critically ill, Early Warning Signs’ system can be used to determine the signs which when observed, can alert the nurses and other health care practitioners to start the appropriate management strategies or treatment in time (Levett-Jones et al, 2010, p. 518). The symptoms described in the case study (patient medical history and the current assessment and the changes that have occurred for example persistent cough and increased breathlessness among others) are the early warning signs that if appropriate action is not taken, the patient may fall critically ill. Right time: After identification of the early warning signs, it is appropriate to develop a response plan and take action in time. The early warning signs of COPD’s advancement are clear in the case study and these show that at the time the patient was admitted, he should have been put under advanced COPD management and the symptoms treated or managed. The right time also means taking the right action in the right order (Levett-Jones et al, 2010, p. 518). Hypercholesterolaemia for example, is another disease that is caused by smoking. The cause of these two diseases (COPD and Hypercholesterolaemia) is his smoking although hypercholesterolaemia could be genetic. The drugs used to manage his condition are failing and one possible cause of that may be his inability to effectively use his puffer. His oxygen sats are still at recommended levels, that is, 88%-92% (Gregory & Mursell, 2010, p. 220). This patient requires treatment of threatening symptoms accompanied by monitoring, and then pulmonary rehabilitation. The right action: This is the action taken after judging the patient’s condition. From the case study, the nurse should aim at preventing any critical condition occurrence. This can only happen due to increased heart failures, breathlessness and advancement of other symptoms. To prevent this, the symptoms of the disease should first be managed before managing the disease to stabilize the patient and lift his spirits. The right reason: This is a justification for the decision. It shows why the decision is made to take a specific action for example, for what reason shall the nurse in the above case study decide to treat the symptoms of the disease first other than just dealing with the disease? The patient already showed signs of deteriorating. The reasons behind deterioration have been established. The major one is his COPD which is causing all the problems from hypertension, anxiety, heart failures, breathlessness and depression. The patient however, may go into critical condition if appropriate action is not taken and what may get him into critical condition are the symptoms. The symptoms are first dealt with then other important disease management procedures later. Family support is very important in managing COPD and this should be considered to build the patient’s spirits (Schriber, 2009). References Banning, M 2004, Clinical Reasoning and Its Application to Nursing: Concepts And Research Studies, Journal of Nurse Education in Practice, 8, 177–183. Clarke, S. P., 2004, Failure to Rescue: Lessons From Missed Opportunities In Care, Journal of Nursing Inquiry, 11(2), 67–71. Gregory, P & Mursell, I 2010, Manual of Clinical Paramedic Procedures, John Wiley and Sons, Oxford. Haig, K M, Sutton, S & Whittington, J 2006, SBAR: A Shared Mental Model for Improving Communication Between Clinicians, Journal on Quality and Patient Safety, 32 (3), 167-175. Levett-Jones, T, Hoffman, K, Dempsey, J, Yeun-Sim Jeong, S, Noble, D, Norton, C A, Roche, J & Hickey, N 2010, The ‘Five Rights’ Of Clinical Reasoning: An Educational Model To Enhance Nursing Students’ Ability To Identify And Manage Clinically ‘At Risk’ Patients, Journal of Nurse Education Today, 30, 515–520. Mariani, J J (2nd Ed) 2000, Cracking the boards: USMLE step 2, The Princeton Review, New York. Medifocus, 2011, Emphysema: A Comprehensive Guide to Symptoms, Treatment, Research, and Support, Medifocus.com Inc. Schriber, A 2009, Chronic Obstructive Pulmonary Disease, PubMed Health. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001153/ Woodhall, L J, Vertacnik, L & McLaughlin, M 2008, Implementation Of The SBAR Communication Technique In A Tertiary Center, Journal Of Emergency Nursing, 34 (4), 314-317. Read More