|Date published:||24 Sep 2018|
Nursing practitioners with effective reasoning skills always have a positive impact on the patient’s outcome. Conversely, nurses with poor clinical reasoning skills have a high potential of failing to detect the impending patient deterioration either from drug-body interactions or normal “failure to rescue.” These issues have resulted in increased number of escalating healthcare complaints in the ever expanding population of seniors (Levett-Jones & Bourgeois, 2014). According to Alfaro-LeFevre (2009), there are three primary reasons for the adverse patient outcomes experienced in almost all health care provider institutions. These reasons are: the failure to properly diagnose, the failure to institute appropriate medication and treatment and application of inappropriate management strategies of the presented complications (Alfaro-LeFevre, 2009). All these factors are directly related to the poor clinical reasoning skills. For that reason, Rubenfeld & Scheffer (2006) suggests that education system must promote the recognition and management of deteriorating patients. Furthermore, nursing practitioners must be in a position to utilize different communication channels, a collaboration of inter-professional teams and escalation systems in order to achieve accurate and quality service delivery to patients (Rubenfeld & Scheffer, 2006). One way of attaining this is by implementing the clinical Reasoning cycle (Levett-Jones & Bourgeois, 2014). While putting this information in mind, this paper will utilize the Clinical Reasoning Cycle in reviewing and planning care for a patient named Mr. Jones.
Consider the Patient
According to Levett-Jones et al. (2014), considering the patient is the stage of the Clinical reasoning cycle. In this stage, the nurse encounters the individual who is the recipient of the care and starts to gain an initial impression (Levett-Jones et al., 2014). According to Tanner (2006), this may happen as a result of hearing a report [handover] or by a notice when the patient is first observed (Tanner, 2006). Therefore, while conducting the first impression on Mr. Jones, it is critical noting that prior preconceptions and assumptions may have influenced some of the information in this stage. Furthermore, at this stage, the patient condition is viewed against the background of their historicity and within the institutions of care ability.
Now, Mr. Jones 86 years of age was bought to the hospital after he was found wandering up and down his streets by a close neighbor. Furthermore, his limping and has a favoring in his left side. Blood strains are evident in his socks and paints. A skin tear is also visible in his left shin. Following this, he has been placed on bed rest for later assessment using X-ray to ascertain whether he has any fractures because he thinks that he fell over, but he is not certain about that. In relation to this, the patient complained of pain of pain originating from his left hip spreading down to the leg where he has a laceration following the fall.
Collect Cues and Information
This stage involves collecting relevant information regarding Mr. Jones. Furthermore, it will involve reviewing patient’s information that is available in his documented history, nursing notes, clinical documentations and handover reports. From the reports, Mr. Jones is under medications such as Irbesartan 150mg PO daily. According to Drugs.com (2017), Irbesartan is mostly used in the treatment of high blood pressure (Ace Inhibitors) (hypertension). With this medication, it is clear that Mr. Jones has a history of hypertension.
Additionally, he came in with Metformin 1000mg PO Daily. This drug is used in improving blood sugars and mostly in individuals having type 2 diabetes. For that reason, there are increased chances that Mr. Jones has type 2 diabetes. Also, he had Salbutamol metered dose inhaler 1-2 puffs every 4-6 hours and which is mostly used in preventing and treating bronchospasm in patients with bronchitis, lung related diseases, emphysema, and asthma. Based on the presence of these drugs more scrutiny is needed to define whether he actually suffers from any of that disease.
Additionally, Mr. Jones had Symbicort Turbuhaler 160/4.5mcg 2 inhalations BD, a drug that is mostly used in preventing bronchospasm in patients with chronic obstructive pulmonary disease or asthma. Therefore, while combining the presence of Symbicort Turbuhaler 160/4.5mcg 2 inhalations BD and Salbutamol metered dose inhaler 1-2 puffs every 4-6 hours there is higher likelihood that Mr. Jones has a respiratory related disease. Finally, he complained hip and leg pain and which gives the reason why there are Paracetamols in his drug list. Paracetamols are mostly used as pain and fever relievers; therefore, there are increased chances that Mr. Jones may be feeling some pain on different body parts.
Apart from this data, new information gathered from observations of Mr. Jones shows that: He 177 cm tall and has a weight of 125 kgs translating to a BMI of 39.9, Blood Pressure 165/95 mmHg, T 37.9C, P 105 bpm and R 24 breathes per minute. Additionally, Mr. Jones has a Pain score of 7/10, location located at left hip and leg. Other than these, he has three skin tear, a Waterlow score of 16, High fall score risks of 17 and GCS 14 having normal power in the right leg, mild weaknesses in the left leg. Finally, his pupils are equal and reacting in a sluggish manner. However, he has not opened his bowels for the last two days (BNO x Day 2).
According to Alfaro-LeFevre (2017), it is important for the nursing practitioner in a change to recall some knowledge from Law, therapeutic, cultural context, physiology, and pathology in relation to the patient (Mr. Jones case). First, Mr. Jones wife died two months ago. This may be related to depression and stress resulting in lack of the ability to eat hence lowered bowel movements. Blood Pressure and hypertension are linked to the fluid status in the patient’s body (Alfaro-LeFevre, 2017). Additionally, Mr. Jones lives in a single Story House and which has two steps at the entrance. Therefore, due to the pain in his hip and leg, it may be related to the event where he was found wandering up and down his street by the neighbor.
In the ward where Mr. Jones is hosted before an X-ray is conducted, there are standing orders that must be followed by the patients and the relatives or any individual connected to the patient. Before anything is done on the patient’s body, his children must visit the hospital, listen to the consent files and accept whether they agree on the procedures that the nurses and doctors aim to use on their father. Additionally, the nurse must inform the patient on all the possible medical procedures that will be taken to ascertain the real cause of the challenges and problems he is facing. These standing laws are to be observed as they will save the hospital from any possible law suits originating from human rights or family members.
According to Levett-Jones et al. (2014), all the cues and patient data collected in the above phase are carefully analyzed. Any aberration from the normal is identified and highlighted. Furthermore, cues patterns and clustered are recognized, inferences created and hypotheses generated (Levett-Jones et al., 2014). Simply, the patient’s situation is compared with previous clinical presentations thereby giving the nursing practitioner an opportunity to anticipate possible outcomes with regard to the available course of action. According to Alfaro-Le Fevre (2009), thinking ahead or rather predicting outcomes helps in knowing possible results of understanding certain procedures.
Analyze the cues/Data to come to a stable understanding of Mr. Jones Signs and Symptoms. [Comparing the normal vs. Abnormal]
Normal blood pressure should not go over 120/80 and 140/90. Therefore, it is clear that Mr. Jones has high blood pressure. Furthermore, his skin tear is placed under category three where the skin flap is completely absent. Therefore, while following this information, the blood stains on his leg and pants may have originated from this skin tear. Also, Mr. Jones score 16 in Waterlow and which places him under high risk of developing pressure sores. With a fall risk score of 17, it means that Mr. Jones is susceptible to falls and therefore there is need to check the x-rays for any potential fractures. Mr. Jones has a GCS 14 with normal power in his right leg and mild weakness in the left. His pupils are equal however they are reacting sluggishly. A score of 14 implies that he is a having a mild dysfunction. This implies that his conscious state as a person has mild dysfunction.
Mr. Jones is 177 cm tall and Weighs 12kgs. This means that his BMI is actually 39.9. According to World Health Organization, individuals with a BMI of 30 and over are classified as observed obese. In most cases, senior individuals and who are obese and hypertensive have a higher chance of having diabetes, eye problems and hear problems. Therefore, Mr. Jones BMI index opens a clearer path to securitizing some of the co-morbidities that he is currently suffering from. While still connecting Mr. Jones age of 86 with his BP 165/95 mmHg. Additionally, the patient had, T 37.9C, P 105 bpm, R 24 breathes per minute. Because the normal blood pressure is less than or equal to 120/80 mm Hg, then Mr. Jones is above the normal with 165/95 hence labeling him as hypertension. While looking at the textbook, the normal temperature is between 36 to 38, Mr. Jones’s temperature stands at 37.9 and which labeled as high temperature. On the other hand, the Pulse for adults should stand at an average of 70 (60-100). Mr. Jones pulse rate stands at 105. This implies that his pulse is way before normal. Finally, from the textbook, an older adult should have an average of 16 in his or her respiratory rate. While comparing his respiratory rate  and what is highlighted in the textbook, he may be suffering from tachypnea a condition where an individual suffers from faster respirations.
This involves distinguishing relevant from the irrelevant information. Furthermore, it involves recognizing the inconsistences in the data in order to narrow down the information to levels where the gaps in the cues is collected. Based on Mr. Jones age, his temperature is up but, the nursing practitioner is not too worried about it. However, more concern is directed towards the Blood Pressure and the Pulse. For that reason, it’s good to check oxygen sats in the blood as well as the urine output. The text on the urine output will be to measure the glucose output. This information will help in correlating the GCS 14 his individual level of consciousness.
Relating the Cues
At this sublevel, the nursing practitioner is expected to discover new relations within the information and cues. It also helps in identifying the relationships that exist between the data. For instance, Mr. Jones high respiratory rate, pulse and blood pressure may result in the experienced GCS 14. Furthermore, with a category three of the wound, the blood paints have a higher possibility of originating from this site. Also, all the medications that Mr. Jones came with to the hospital prove the fact that the mentioned co-morbidities of Asthma, Type 2 diabetes, Hypertension and Arthritis are evident. Finally, the fact that Mr. Jones bowels have not opened for 2 last days may be linked to two main factors. First, Mr. Jones wife died a few months ago, therefore, he may be suffering from loneliness and stress and which have a possibility of halting his digestion ability. Additionally, based on his current age, his digestion may be weak to digest the take away and frozen meals that he has been depending on. For those reasons, the bowel movements problems are more likely to be associated with these factors.
This involves making deductions while forming opinions that follow the logic by interpreting the subjective and objective cues. For instance, in Mr. Jones case, his pulse rate and respiratory rate could be higher based on the tension and stress that he has been exposed to in his old age. Furthermore, the wound may be breeding from lack of attendance. Finally, his blood pressure could be low due to the amount of blood lost through the wound. The fact is that his pants were wet with blood.
According to World Health Organization, elderly individuals are at risk of suffering from hypertension, diabetes and difficulties in bowel movement. For that reason, some of the challenges facing Mr. Jones are connected. Furthermore, as individuals get older, their body muscles become weaker and which exposes them to risks of fractures or falls. For that reason, the pain that Mr. Jones is experiencing in his hip may be originating from either a fall he experienced a few days ago. Following the fact that he’s old, there are increased chances of losing memory and which means that he has a potential of forgetting what happened in his life.
Predicting the Outcomes
Based on the nature of Mr. Jones, if he is not taken for X-ray scans, there is higher chance that the case of the pain in his hip may deteriorate. Furthermore, based on his condition, if he is not placed on fluids, there are increased chances that he may get a shock. To understand the nature of his bowel movements, Mr. Jones will be given some vegetable dish. The roughage will be focused on checking whether his bowels will open after getting exposed to fluids. Finally, due to his increased pulse rate and respiratory rate, Mr. Jones will be given behavioral therapy that will work in coming down his stress and depression levels. This is because, with hypertension and higher pulse rate, there are increased chances of facing challenges in breathing or even stroke.
Cleaning the wound helps in lowering the bacteria and which works in reducing the pain originating from the wound.
According to Levett-Jones et al. (2014), this stage involves the nursing practitioner re-evaluating the patient’s cues and the current status so as to determine the most effective nursing interventions and whether the patient’s condition has been improved. First, to lower the patient’s pain originating from the wound, lowering the infection has proved to be an effective intervention for the patient. It has initiated the healing process as well as lowering the pain experienced by the patient. After administering narcotics and antibiotics to the patients, another measure of the pain level showed 3/10. This score confirms that the pain has completely reduced. Secondly, offering fluids and treating the wound has worked in lowering the pressure and the blood pressure the patient was initiated exposed. Addition, use of drugs to control hypertension, diabetes and pulse rates were very effective in stabilizing the condition of the patient helping help to adopt a smooth route to healing. The X-ray proved that the patient did not have any fracture; however, the hip bone was somehow dislocated. Therefore, the physicians placed the patient under therapy to return the bones to normal. All in all, the interventions adopted by the nursing practitioners with help from senior doctors, Mr. Jones health status has begun returning to normal
Reflect on Process and New Learning
Levett-Jones et al. (2014) place this last stage as a reflection stage. It offers a suitable opportunity to review the practice. This step provides a chance to refine the processes, change or improve the interventions. In this case, Cognitive Behavior Therapy will be included to improve the healing process of Mr. Jones based on the fact that he is a senior and has a chance of suffering from mental disorders and eating disorders. Next time, while dealing with such a senior patient, the first step will be including their family members into play. This will ensure that the hospital and the senior’s family work in collaboration in dealing with potential challenges that have a possibility of affecting the patient in future. Finally, if I had the skills in Behavior Therapy and Cognitive Behavior therapy, I would have provided therapy to allow the patient to change attitude and emotions following the death of his wife. This would help in improving the healing process of the senior patient.