Clinical Decision-Making - Information Processing on the Patient and the Situation, and Identifying Issues - Case Study Example

Can you please just send a message if you need anything. Thanks! Clinical Decision-making Case Study Background Alterations in fluid status are common but in elderly patient showing rapid manifestation and numerous comorbidities, fluid or electrolyte imbalance can be fatal . In these circumstances, the accuracy of clinical decision is critical particularly in delivering care and monitoring developments in patient’s condition. For instance, each clinical situation must be carefully evaluated and confirmed through observations and measurements, analysis, review of the most recent clinical data. This is because in order to arrive in an accurate and sound clinical decision, the nurse should acknowledge her limitations and avoid prejudices and biases resulting from use of intuition and assumptions as sole source of clinical decision . For this reason, the aims of this paper include critically exploring the clinical decision made in the following case study, understand how decisions were made and the contributing factors that made these decisions possible. The case study exploration and analysis are guided by clinical reasoning model developed by . The following scenario focuses on 72-year-old Mr. Mike Anderson who was already suffering from colon cancer. He went to the clinic to consult and seek treatment of his bleeding rectum. Mr. Anderson told the doctor that he noticed some changes in his bowel movements and experiencing constipation and diarrhoea sporadically. Further doctor questioning reveal that he was anaemic and had a history of bowel cancer in the family and therefore subjected to digit rectal examination. However, despite absence of obvious rectal mass, the doctor suggests that he should see a gastroenterologist and undergo a colonoscopy. He was later scheduled for surgery as the colonoscopy suggests that he has left sided colon cancer and a bowel resection. The operation was successful and Mr. Anderson was handed over for care in about 9:00 AM. Clinical Reasoning a. Information on the patient and the situation Based on the report, the patient assigned in Room 101 is a 72 years old male diagnosed with bowel cancer, partial colectomy, and colostomy formation. The patient showed no sign of complications and was stable since surgery. He has Patient Controlled Analgesia or PCA to be able to dispense pain medication (morphine) whenever he needs one and fluid challenge (administration of IV or Intravenous) running at 84 mls per hour. His blood pressure is reported low due to sleeplessness and the recommended diet is for type 2 diabetic as he is on 4th hourly BGL. He is also under oxygen therapy at six litres per minute and enduring the mask well. His IDC or Indwelling Urinary Catherer, a soft flexible tube placed on his bladder to drain urine, is a bit low and is set on hourly measures. His bellovac, a urinary drainage system, already drained 300mls since surgery while the dressing in his wound due to the operation remains intact. Mr. Anderson’s wife already passed away and he is expecting his daughter to visit him soon. b. Collect cues and information Based on the current report, it may be necessary to collect some useful cues and information about Mr. Anderson such as temperature, pulse rate, respiratory rate, blood pressure, oxygen saturation level, hourly urine output, and BGL. In the current observation, his temperature is about 37 degrees with a pulse rate of 112 per minute. His respiratory rate is recorded at 22 and his blood pressure registered at 90/50. His BGL or Blood Glucose Level on the other hand is about 4mmol/L/. His current urine output shows an hourly rate of 26ml with 97% oxygen saturation level. c. Information Processing Based on the report and information taken from current observation, some useful cues may be useful in assessing Mr. Anderson’s present condition. However, this endeavour requires recalling some related knowledge such as the recorded low urine production or oliguria- the presence urinary tract obstruction. Another is the decline in glomerular filtration rate that according to is associated with age but this can caused by some abnormalities such as progressive of renal function that often occurs due to kidney damage. Another is the possibility of antidiuretic hormone secretion which according to are activities of the antidiuretic hormone that causes of hyponatremia, a disorder associated with the presence of impermeant solute other than sodium circulating in high concentration in plasma by excessively retaining water. d. Identify problems or Issues By careful analysis, these cues may be interpreted correctly by comparing normal values against abnormal ones and become more familiar with signs and symptoms shown by Mr. Anderson. For instance, his temperature is about 37 degrees centigrade, which by comparison is normal. According to , body temperature is the balance between heat produced and heat lost and in a healthy individual, this could be as low as 98.6 degrees Fahrenheit or 37 degrees centigrade. In fact, a body temperature in range from 36.1 to 37.2 degrees centigrade can be considered normal (p.315). Another is the recorded pulse rate of 112 per minute, which in normal resting value is a bit greater than normal. The patient’s pulse rate and rhythm according to is between 60 to 100 beats per minute and it can rise to 5 to 10 bpm for each degree of fever. In contrast, pulse rate that is below 60 bpm requires medical evaluation (p.14). These facts suggest that Mr. Anderson may need more rest and not with fever as his temperature is normal. The respiratory rate of Mr. Anderson, which is recorded at 22 breaths per minute beyond normal breathing. For instance, the normal respiratory rate is between 12 and 20 breaths per minute and those that are over this rate is considered as case of tachypnoea , an abnormally fast respiratory rate than can be a sign of respiratory distress . Moreover, IV or the administration of fluids, nutrients, and medication through a vein may be due to fluid lost and maintain fluid and electrolyte balance or just to administer IV medications. However, fluid replacement is often associated with losses due to haemorrhage, vomiting, and diarrhea . At this stage, Mr. Anderson may be suffering from hypovolaemia and dehydration, symptoms that closely linked to absolute losses, low urine output, and reduction in blood pressure . Hypovolaemia is also associated with treatment aimed at retaining sodium and monitoring electrolyte levels . More importantly, hypovolemia is associated with renal failure or impaired renal blood flow and subsequent drop in circulatory volume resulting to acute haemorrhage or dehydration. This according to is common in cancer patients with inadequate fluid intake and according to , cancer account for the majority of cases involving small-bowel obstruction leading to loss of massive amounts of intravascular volume responsible for hypovolemia and dehydration. e. Establish Goals The main goals for Mr. Anderson’s condition are to restore euvolemia or maintain normal body fluid volume, prevent further hypovolemia and dehydration, and maintain normal electrolyte balance. For this reason, the short-term goal at this time particularly for Mr. Anderson receiving IV fluid as his sole fluid and nutritional intake will be to have his urine output monitored and ensure reduction of electrolyte abnormalities, and renal failure . f. Select a course of action In relation to the health issues identified and goals that must be achieved, the following actions are taken. Reassure Mr. Anderson and facilitate client cooperation – this is to avoid anxiety, restlessness, and maintain psychosocial wellbeing. Monitor his vital signs and oxygen saturation level – this is to ensure adequate oxygen delivery and identify improvement or deterioration in patient’s condition. Check that the IV cannula is not blocked – this is to ensure that fluids are administered correctly. Check that the urinary catherer is in good condition – this is to ensure that urine is flowing smoothly. Monitor his input and maintain hourly urine measures Monitor his drain, stoma, and wound Monitor colour and condition of the skin Monitor his level of consciousness and cognitive status Provide regular oral care Notify the doctor of his current condition Administer fluid challenge as ordered by doctor Document observations and actions properly g. Evaluate the effectiveness of the action The doctor order Mr. Anderson’s fluid challenge and IV rate increased to 125 mL per hour and after two hours, his monitored signs and symptoms are as follows. Cognitive Status : Calm and cooperating Level of Thirst : Patient says he is a bit thirsty Pulse : 90 Urine Output : 36mL/hr Oral mucosa : Dried mouth and furrowed tongue Oral intake : Tolerate sips of water BP : 110/70 Colour of Skin : Pale Skin condition : Skin turgor is poor As indicated above, his cognitive status improves along with his urine output that is now 10ml higher than previously recorded. However, there are still signs of dehydration as evidenced by dried mouth and furrowed tongue. Oral fluid intake may be developing as the patient showing tolerance to water. His pulse rate is now lower at 90 per minute, which is within the range of normal pulse rate (60 to 100 pulses per minute). Similarly, his blood pressure improves, as it is now 110/70 compared to previously registered 90/50. However, his pale skin and poor skin turgor suggest that he is still suffering from severe dehydration. h. Identify and explore potential clinical reasoning errors that may have been involved in the case scenario Potential clinical reasoning errors in this case scenario may be divided into two dimensions such as cognitive and interactive. It may possible that errors in cognition occur when the practitioner exaggerated on findings that are relevant to existing hypothesis or ignoring other information that do not conform to hypothesis. Errors are also possible when the nurse concentrate too much on the presence or absence of specific patterns and overlook potential important information in the process. Interactively, the health care professional can make errors related to inauthentic implementation of best practices, ignoring the value of input from patient, limited interpersonal communication, and cultural incompetence . In this case study for instance, the nurse may be committing errors in relying too much on the hypothesis that fluid loss is entirely associated with surgery and ignoring the presence of other symptoms. Similarly, relying too much on normal parameters despite evident physical and psychological deterioration and input from Mr. Anderson can lead to clinical reasoning errors. i. Initial Reflection of the process and new learning (Note: this section is based from your sample) The identification of current issues and development in Mr. Anderson’s condition suggest that the short-term goals established and actions taken to achieve these goals were appropriate. The report submitted to the doctor about the current condition of the patient enable effective administration of fluid challenge and IV resulting to improvement in patient’s urine output and further identification of issues associated with dehydration. Moreover, reassuring Mr. Anderson help improved his cognitive status and vital signs such as pulse rate, BP. Reflecting on the process of clinical reasoning suggests that achievement of goals, and improvement in patient’s condition is highly dependent on the accuracy of the identified health problems and issues associated with care. More importantly, recalling related knowledge, compare and contrasting the normal from abnormal and inferring cues collected greatly improve the accuracy of clinical reasoning and the subsequent care. j. Final Evaluation of Outcomes (Note: this section is based from your sample) The nursing intervention is generally successful considering the effective analysis of patient situation from the handover report and important cues collected from reviewing the current patient situation. Moreover, the clinical reasoning was undertaken systematically and verified through recall of related knowledge and understanding of evidence-based practices. This information was processed effectively through comparison leading to clear and accurate identification of the patient’s present condition and required care. The established goals for Mr. Anderson’s care were also valuable and helpful in delivering not only the right care but ensuring recovery from the health effects hypovolemia and dehydration. As indicated by some improvement in Mr. Anderson’s vital signs, the nursing intervention effectively carried out the required problem identification and arrived in a decision most suitable for Mr. Anderson. For instance, as Mr. Anderson was recently arrived from surgery, many fluids can be lost including sodium and potassium thus fluid administration is vital. Similarly, the patient was nil orally for some time thus hypovolaemia is likely and oral care is necessary. Moreover, the noticeable improvement in cognitive status, level of thirst, pulse, urine output, BP, and the unchanged condition of the mouth and tongue, oral intake tolerance, and others are critical as they generally indicate improvement in fluid status. Overall, the outcome of nursing intervention is effective and marked by coherent clinical decisions. k. Final Reflection of the process and new learning Reflecting on clinical decision making process suggest that nursing care involves some amount of uncertainties and new learning particularly in complicated health cases. These include uncertainties about patient actual condition and the need to find facts about the causes of patient condition, the outcome of the intervention, the well-being of the patient over a particular course of time and others. In this case study, a lot of time was spent identifying clinical deterioration, assessing patient’s current and previous condition, and predicting future events. Similarly, arriving in effective clinical decisions requires making a choice between alternatives and weighing up the potential costs and benefits of actions to be taken. However, it is somewhat clear that clinical decisions can be effective if done systematically such as examining the handover report and understanding the patient situation in detail before any conclusion is made. In determining patient’s current condition, collecting cues, recall of related knowledge, and other information significantly contribute to the effectiveness of decisions particularly in planning the most appropriate intervention and care for Mr. Anderson. New learning on the other hand is somewhat is an essential part of nursing intervention as making the right clinical decision is nearly impossible using common nursing knowledge. For instance, the complexity of Mr. Anderson’s condition (an old cancer patient experiencing fluid and electrolyte imbalance that can lead to potentially fatal consequences) requires more facts and accurate assessment. References Britt, L., Peitzman, A., Barie, P. & Jurkovich, G. (2012). Acute Care Surgery, Wolters Kluwer Health Burket, L. W., Greenberg, M. S. & Glick, M. (2003). Burket's Oral Medicine: Diagnosis and Treatment, BC Decker Davey, P. (2012). Medicine at a Glance, Wiley Ellis, J. R., Nowlis, E. A. & Bentz, P. M. (1992). 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