Background of the Case
Question:
Discuss About The Deepening Quality Clinical Reason Decision?
The focus of the assignment is on the clinical care and analysis of a 67 year old woman, Ms. S.B., who experienced a hypoglycemic condition and the care, provided using “clinical reasoning cycle” method. It is important for a healthcare provider and nurse to have very good clinical reasoning and decision making skills, so that in times of clinical emergency like hypoglycemia, quick service and risk management can be arranged by healthcare providers in the facility (Sedgwick, Grigg & Dersch, 2014). The process of clinical decision making is a relative, progressive, and mounting process, where it is important to gather, interpret, and evaluate the clinical data for successful selection of plan of action based on the evidence (Groves, 2014). It involves drawing conclusion based on critical thoughts and clinical interpretation (Robert, Tilley & Petersen, 2014). This assignment aims to talk about an emergency case of Hypoglycemia, when I was undergoing my clinical rotation and to practice the clinical rotation cycle. The assignment consists of the background of the condition, reflective perspective in the assessment of Hypoglycemia using Gibb’s cycle and followed by a recommendation that would help develop nursing professional conduct.
Individuals with diabetes face the condition of Hypoglycemia very often which has the potential to cause life-challenging difficulties (Round et al., 2014). The condition is best described as having an unusually lowered glucose levels in blood (Holt, 2011). It is observed that people with type 2 diabetes have rare but harsh episodes of hypoglycemia in comparison to people with type 1 diabetes (Lim, Munshi & Sharon, 2015). In Al Ain, UAE, a study was conducted in 2004 which revealed that the annual diabetic treatment expense increased five folds of 1,605$ when compared to patients with hypoglycemia than without the condition (Al-Maskari, El-Sadig & Nagelkerke, 2010).
The process of gathering information, processing the found data to understand the clinical condition as well as planning and implementing intervention to evaluate efficiency and reflective learning of the outcome of the concerned health issue is termed as clinical reasoning cycle (Meissner, 2010). The importance of Clinical reasoning cycle is that it can derive a positive end result of the clinical procedure based on the patient’s health condition and way of living (Levine, 2014). It also helps a nurse in prioritizing the involvement by understanding the immediate plan of active to be devised and delayed action that can be used to manage complications (Chamberland et al., 2015). Implementation of clinical reasoning cycle is based on the skill of cognition, presence of mind and critical analysis (Rochmawati &Wiechula, 2010). Clinical reasoning errors can arise due to biased thinking, stereotypical notions and influence of social stigma, which needs to be avoided during clinical (Burbach, Barnason & Thompson, 2015). Clinical reasoning cycle includes eight stages; observation, collection, processivity, decision making, planning, action, evaluation and reflection. I have discussed in detail about an incident that I came across during one of my clinical rotation duties.
Clinical Reasoning Cycle and its Importance
The initial step of clinical logic is to familiarize with the patient’s medical history, so I got acquainted with the patient, her medical history and recognized her main issue and tried to analyze the situation.
I checked with the nurse who was in her night shift when the patient was admitted. I was handed over the medical account in the morning, mentioned that Ms. S.B. was a 67-year old woman with known history diabetes, taking insulin, had hypertension and end stage of renal disease (ESRD). The patient regularly underwent dialysis for three times in a week. Ms. S.B. was found to have a blockage in her AV fistula on the left arm the day she went to the dialysis unit to get her usual session and was referred to the emergency unit. She was found to have high potassium in her blood, 6.1 mmol/L and underwent femoral central venous access to complete her session and avoid ventricular fibrillation (Budovich, Blum & Berger, 2014). She was referred to my ward due to this and she was assigned to Dr. R.A. to perform thrombectomy (removal of blockage in fistula) that day. She was prescribed complete bowel rest for six hours before her procedure from breakfast until lunchtime at 1200p.m. The patient’s vital symptoms were as follows: tympanic temperature- 36.6ºC, heart rate- 78, blood pressure- 121/62 mmHg, respiratory rate- 16 br/min, SpO2 levels- 99% and blood glucose levels (BGLs) at 0600 read 4.2 mmol/L.
I had gathered information about the patient, thorough medical and nursing history by noting the patient’s clinical records and other accessible cues during the second stage of the clinical reasoning cycle. It had been more than 10 years; Ms. S.B. was diagnosed with diabetes mellitus and hypertension. She had been taking dialysis for three years after she was diagnosed with ESRD. Five years ago she underwent a cholecystectomy surgery. She was prescribed a regular dose of insulin aspart and insulin glargine for diabetes and amlodipine and Prazosin for hypertension.
- Gather new information
The next step of the clinical reasoning cycle was collection fresh information and related data for an ailing patient by setting up a questionnaire with the patient, with their family members and other health practitioners or nurses assigned to the patient. In the morning at 0820 am, the patient rang a bell to which my teacher and I heeded and she complained “I feel drowsy, dizzy and very hot”, for which we examined her body temperature which read normal, 36.6 ºC. We examined her BGL after this which read, 3.2mmol/L; speculating problem, we asked whether she had meal or not, to which she replied due to her fatigue and sleepiness, she had skipped breakfast and remained empty stomach since last night’s dinner. The assigned nurse from the night before failed to address that fact and informed us that the patient had breakfast. This was troublesome as the patient was instructed to have only 6 hours of NPO before the procedure.
- Recall knowledge
It is essential to gather more knowledge apart from current record and medical history so I had searched for further information related to the condition by using newest facts based application and observing the patient’s state in various scenarios. I concluded that due to the fact that the patient was unfed for such a long time, her BGL lowered vastly and she started to perspire, palpitate, starve, confuse, nauseous, feel drowsy and could not speak (Holt, 2011). These were the obvious reasons for Ms. S.B.’s distress.
Errors in Clinical Reasoning Cycle
Analysis of the found data is the next step in clinical reasoning and looking for any abnormality. It was abnormal for Ms. S.B. to have such low level of BGL, in accordance with the National Institute for Health and Care Excellence (NICE) the threshold BGL for people with type 2 diabetes is from 4 to 7 mmol/L prior to meals and post meals level is 8.5mmol/L (Oldroyd, 2011). Ms. S.B. is an elderly woman with diagnosed renal issues and had been starving for more than 8 hours, so these factors can taken for consideration for the cause of lowered BGL in Ms. S.B. A study in the United States studied the number of people with medical benefits in elderly people, which suggested that age is a common factor which elevates the risk of Hypoglycemia. About 1.2% of oral hypoglycemic medicine users and 2.8% of insulin users above the age of 65 years suffer this condition (Ligthelm, Kaiser, Vora & Yale, 2012).
- Discriminate
The found data will be compiled by me on Ms. S.B., by stating that her potassium level is a little elevated 6.1mmol/L, but this is not to be pondered about. The concerning was her BGL of 3.2 mmol/L.
- Relate
A step in clinical reasoning called “connecting the dots” means that at this step I had gathered the data jointly to understand the associations and analyze logically. Therefore, Ms. S.B’s lowered BGL could originate from the starvation or due to the renal illness. Hypoglycemia is common in people with chronic kidney disease (CKD) (Kong et al., 2014). This happens because, inhibition of glucose discharge and insulin expulsion by kidney, distorted drug interaction, dialysis related issues, albuminuria and under nourishment (Alsahli & Gerich, 2014).
- Infer
This step allows me to deduce results that I had followed rationally by interpreting symptoms, considering secondary options and end results. It can be concluded that, Ms. S.B. could have undergone cues and manifestations of hypoglycemia.
- Predict
I had needed to deduce conclusion basing on the every data that I collected. So, if Ms. S.B. was left with her current the BGL condition, she would have faced further complications as a result of hypoglycemia like, losing sense, seizures, or fatal end (Feinkohl et al., 2014).
- Match
This step required me to relate the condition with the previous state and this patient’s issue with other patients. It is observed that patients with known history of kidney disease show lowered levels of BGL when they do not intake proper food intake for long time.
- Identify the problem / issue
Compilation of all the data that have been gathered to construct the diagnostic evaluation of the patient is the fourth stage of the clinical reasoning cycle. Ms. S.B. is elderly woman, with kidney syndrome who starved since the night before from 0600 p.m. till 0820 a.m. Consequently, Ms. S.B. experienced a hypoglycemic incident.
- Establish goals
I had placed a precise conclusion for Ms. S.B after my intervention in the fifth step of the clinical reasoning cycle. The short term goal I placed for Ms. S.B. to replenish her threshold BGL 4-7mmol/L after one hour, and the long term goal I placed for her by preventing future hypoglycemic episodes.
- Take action
The Incident during Clinical Rotation
I had devised a plan that needed awareness, clinical vocation, effective patient engagement skills and clinical reasoning aptitude as well in the sixth stage of clinical reasoning. Consequently, we summoned the practitioner and she instructed 10% dextrose solution and we provided it. However, SEHA hospitals says that in accordance with the Health Authority for Abu Dhabi (HAAD) if any patient is influenced by NPO and undergoing a vitally low BGL,10% dextrose solution is the standard dose to control the BGL to normalize the level (Baynouna, Nagelkerke, Al Ameri, Al Deen & Ali, 2014). Additionally, other articles hold up this intervention and affirm that when a patient with diabetes has hypoglycemia and they are unable to consume any fluid or if, external fluid needed, the ideal remedy is to inject venous dextrose, because it contains water with various amounts of sugar (Pham & Borno, 2012) which dissolves in blood. Whilst, most the articles add up the administration of dextrose for these patients the dosage is vastly variable in compliance with the patient’s condition (Coats & Marshall, 2013).
- Evaluate
I had evaluated the efficacy of the planning in this stage. We calculated a capillary BGL at the beginning of signs to affirm the hypoglycemic condition and then we constantly checked at 10–15 minutes interval of the dextrose administration (Lim, Munshi & Sharon, 2015). At 0930 the dextrose administration was completed 10 minutes before, so we examined the BGL and it stabilized at 5.2mmo/L. hence her BGL was in stable threshold currently, but we were required to check frequently.
- Reflect
Reflection is closing step of the clinical reasoning cycle and it consists of two segments, the first one being retrospection, meaning what learning experience you got from this course of action and flash forward which is devising what could have been done another way. Utilizing the Gibbs reflective cycle I employed it, to figure up the clinical reasoning cycle in this step (Lewis, 2015).
Gibbs reflective cycle is a documented scaffold of reflective thinking that contains six segments to concur one cycle and these segments are descriptive, emotion, evaluate, analyze, conclude and act management (Ritchie, 2012). I had discussed the condition first for starting the cycle. Throughout the service of Ms. S.B. rang the bell at 0820 am and she said “I feeling drowsy, dizzy and very hot” so we examined her vitals and she was fine, then we examined the BGL and it read 3.2mmol/L. However, she had undergone NPO and we were not supposed to give her anything orally, so the practitioner instructed dextrose for her and following one hour the patient’s BGL stabilized at 5.2mmol/L. Also I remembered sitting beside the patient trying to calm her during her distress.
I described my feelings in the second segment where I was thinking throughout the condition. I was concerned regarding the patient due to the fact that she was lonely and frightened.
In the evaluation segment, I felt sad when my teacher just observed me while I was injecting the dextrose and just stepped out from the ward. I helped the patient calm down because she did not have her family to comfort her.
The Clinical Reasoning Cycle in Action
In the analytical segment, we did the correct intervention for Ms. S.B., my teacher and I examined the BGL and let the assigned practitioner know. The doctor instructed the amount of fluid that needed by the patient. After that my teacher and I injected it and evaluated the efficacy of the intervention. I provided emotional support for Ms. S.B when my teacher was engaged with other patients. We faced inaccurate clinical reasoning when the assigned nurse for the previous night shift did not make sure whether the patient had her breakfast and we were not sure until she met with the episode. We faced a mismanagement of clinical reasoning which occurred due to the fact that there was inefficiency while gathering all the important data in making a discrepancy examination that resulted in noteworthy end result being overlooked (Chamberland et al., 2015).
In the conclusive step, the constructive outcome from this incident was that I learned how to provide proper emotional support to a suffering patient. The negative outcome was that my senior just observed me whilst I’m injecting the IV solution then she stepped out when the previous assigned nurse gave us wrong information and my senior did not question her. Besides, I educated myself from this incident that when I will become a registered nursing staff, I will endow with time management and good patient engagement skills with the patients and I will pay heed to their requirements. Additionally, I also learned that I should crosscheck the patient data with the patient and their family to avoid complication and miscommunication.
The final step of the Gibbs reflective cycle is having a plan of action. I will be prepared for the next time I encounter similar case, I will he a ready plan of action to avoid any complication and quick care service can be provided to the patient. Another clinical trick I learned was that not just plain sugar but a 10% solution of dextrose can help lowering the BGL of the patient and not just by oral administration. I learned to provide care of the patients in an all rounded approach to provide the best care service. Lastly, I learned to be more aware of the policies that my working healthcare facility has and also the state laws regarding patient safety.
Wellness service providers and especially nurses must have enhanced indispensable application skills such as medical interpretation, analytical thinking and decision making, via studying, discussion and proof related application to include world class service (Groves, 2014). I would recommend future nursing students to carry out complete evaluation of the patients, gather adequate data and question patients and not to hold back information from the next assigned nurse to avoid unpacking principle error (Groves, 2014). Furthermore, I would recommend the current nursing staff to make patient involvement a proper practice, elucidate the care plan to them and inform them. In special cases where the patient has critical condition and is undergoing NPO instructions like in this incident by following the infirmary policies (Rochmawati & Wiechula, 2010).
Collection of Information
Conclusion
The process of Clinical reasoning cycle is a well-versed judgment making technique that is gaining a wide influence in the health care service sector that requires effective staff communication to provide best service for the ailing patients and meeting their demands (Meissner, 2010). All the same, being a patient activist nurse having to support and maintain patients in care plan is important (Groves, 2014). Ensuring wellbeing and healthy life is important and can be maintained by engaging the patient the care plan and letting them known about their current condition and how it can be handled, like in this case, educating the woman might help her check her disease condition. (Holt, 2011).
References
Al-Maskari, F., El-Sadig, M., &Nagelkerke, N. (2010).Assessment of the direct medical costs of diabetes mellitus and its complications in the United Arab Emirates. BMC Public Health, 10679.doi:10.1186/1471-2458-10-679
Alsahli, M., &Gerich, J. E. (2014).Hypoglycemia, chronic kidney disease, and diabetes mellitus. Mayo Clinic Proceedings, 89(11), 1564-1571. doi:10.1016/j.mayocp.2014.07.013
Baynouna, L. M., Nagelkerke, N. J., Al Ameri, T. A., Al Deen, S. Z., & Ali, H. I. (2014). Determinants of diabetes and hypertension control in ambulatory healthcare in Al ain, United arab emirates. Owoman Medical Journal, 29(3), 234-238. doi:10.5001/omj.2014.58
Budovich, A., Blum, S., & Berger, B. (2014). Daptomycin-induced hyperkalemia in a patient with normal renal function. American Journal Of Health-System Pharmacy, 71(24), 2137-2141 5p. doi:10.2146/ajhp140081
Burbach, B., Barnason, S., & Thompson, S. A. (2015).Using ‘Think Aloud’ to Capture Clinical Reasoning during Patient Simulation. International Journal Of Nursing Education Scholarship, 12(1), 1-7 7p. doi:10.1515/ijnes-2014-0044
Chamberland, M., Mamede, S., St-Onge, C., Setrakian, J., Bergeron, L., & Schmidt, H. (2015). Self-explanation in learning clinical reasoning: the added value of examples and prompts. Medical Education, 49(2), 193-202 10p. doi:10.1111/medu.12623
Coats, A., & Marshall, D. (2013). INPATIENT HYPOGLYCAEMIA: A STUDY OF NURSING WOMANAGEMENT. Nursing Praxis In New Zealand, 29(2), 15-24 10p.
Feinkohl, I., Aung, P. P., Keller, M., Robertson, C. M., Morling, J. R., McLachlan, S., & … Price, J. F. (2014). Severe hypoglycemia and cognitive decline in older people with type 2 diabetes: the Edinburgh type 2 diabetes study. Diabetes Care, 37(2), 507-515 9p.doi:10.2337/dc13-1384
Groves, W. (2014).Professional practice skills for nurses. Nursing Standard, 29(1), 51-59 9p. doi:10.7748/ns.29.1.51.e8955
Holt, P. (2011). Taking hypoglycaemia seriously: diabetes, dementia and heart disease. British Journal Of Community Nursing, 16(5), 246-249 4p.
Kong, A. S., Yang, X., Luk, A., Cheung, K. T., Ma, R. W., So, W. Y., &Chan, J. N. (2014).Hypoglycaemia, chronic kidney disease and death in type 2 diabetes: the Hong Kong diabetes registry. BMC Endocrine Disorders, 1448.doi:10.1186/1472-6823-14-48
Levine, D. (2014). The importance of clinical reasoning in the training of all medical practitioners. Journal Of The Royal Society Of Medicine, 107(5), 178.
Lewis, G. (2015). A critical reflection into a perioperative death and the use of the WHO Safer Surgery Checklist team briefing and debriefing using Gibb’s reflective cycle. Operating Theatre Journal, 14-15 2p.
Ligthelm, R. J., Kaiser, M., Vora, J., & Yale, J. (2012). Insulin Use in Elderly Adults: Risk of Hypoglycemia and Strategies for Care. Journal Of The American Geriatrics Society, 60(8), 1564-1570 7p. doi:10.1111/j.1532-5415.2012.04055.x
Lim, H. C., Munshi, L. B., & Sharon, D. (2015). Persistent Hypoglycemia in Patient with Hodgkin’s Disease. Case Reports In Oncological Medicine, 2015820286. doi:10.1155/2015/820286
Meissner, V. G. (2010). Exploring Indigenous health using the clinical reasoning cycle: A student paper. Contemporary Nurse: A Journal For The Australian Nursing Profession, 37(1), 82-89 8p. doi:10.5172/conu.2011.37.1.082
Oldroyd, J. (2011). Care implications of the NICE quality standard for diabetes. Practice Nursing, 22(8), 417-422 6p.
Pham, A. Q., &Borno, L. T. (2012).Severe hypoglycemia from patient misuse of insulin glargine pen. Journal Of Pharmacy Technology, 28(1), 33-35 3p.
Ritchie, M. (2012). Critical reflective entry: postnatal depression. British Journal Of Midwifery, 20(5), 369-371 3p.
Robert, R. R., Tilley, D. S., & Petersen, S. (2014). A Power in Clinical Nursing Practice: Concept Analysis on Nursing Intuition. MEDSURG Nursing, 23(5), 343-349 7p.
Rochmawati, E., &Wiechula, R. (2010).Education strategies to foster health professional students’ clinical reasoning skills. Nursing & Health Sciences, 12(2), 244-250 7p. doi:10.1111/j.1442-2018.2009.00512.x
Round, E., Engel, S., Golm, G., Davies, M., Kaufwoman, K., & Goldstein, B. (2014). Safety of Sitagliptin in Elderly Patients with Type 2 Diabetes: A Pooled Analysis of 25 Clinical Studies. Drugs & Aging, 31(3), 203-214 12p.doi:10.1007/s40266-014-0155-7
Sedgwick, M. G., Grigg, L., &Dersch, S. (2014). Deepening the quality of clinical reasoning and decision-making in rural hospital nursing practice. Rural And Remote Health, 14(3), 2858.
Shih, C., Wu, Y., Lo, Y., Kuo, S., Tarng, D., Lin, C., & … Chen, Y. (2015). Association of hypoglycemia with incident chronic kidney disease in patients with type 2 diabetes: a nationwide population-based study. Medicine, 94(16), e771. doi:10.1097/MD.0000000000000771
Order an Essay Now & Get These Features For Free:
Turnitin Report
Formatting
Title Page
Citation
Outline
