Clinical Reasoning Cycle and Patient Care
Question:
Discuss about the Diagnosis and Treatment of Rare Complications.
Critical reflection has become a necessary element in nursing practice to engage in effective decision making for the safety of patient. The clinical reasoning skill of nurse contributes to positive outcome in patient (Hunter & Arthur, 2016). This essay looks at the process of reflective decision making in nursing practice by analysis of the case scenario of Mr. H.S, a 23 year old admitted to the hospital after a motor vehicle crash (MVC). The interpretation of patient situation, treatment needs and evaluation of outcome is done by the use of clinical reasoning cycle. Clinical judgment and decision making is a necessary component on nursing practice and use of tools like the clinical reasoning cycle guides the nurse to systematically process and interpret patient’s information for planning and delivery of care (Kuiper, Pesut & Arms, 2016). The main aim of this essay is to critically discuss about the methods used to identify patient issues and engage in reflective decision making for the recovery of patient. Based on the challenges faced in deciding the best care for patient, it also proposes recommendation for nursing professional development.
In the first stage of the clinical reasoning cycle I start to be able to know about the patient situation, patient information, and the chief complaint then start to think about it. We have Mr. H.S. a 23-year old male was referred from al Ruwais hospital after being involved in MVC. Patient arrived to ER hypotensive, normal heart rate, RR and saturation. He was complaining of pain in the left upper chest, neck, lower back, pelvis and left ankle. Patient come with report of CT trauma which was positive for pubic rami fracture with retroperitoneal pelvic hematoma. XR show left ankle fracture with hairline fracture of calcaneus. Hypotension improved after IV fluids administration. Patient admitted in the surgical ward after doing Open Reduction Internal Fixation (ORIF) for left medial, malleolus. Patient is non-know of allergy. He has wound 40×7.5 cm on lateral aspect of foot with degloving of dorsal skin with macerated edges, all other systems are normal and The vital signs of Mr. H.S. are oral temperature 36.8 degC, blood pressure 144/86 mmHg, heart rate is 92, respiratory rate 18 br/min, oxygen saturation level is 100%.
During the second stage of the clinical reasoning cycle I will start to gather the patient information throughout the medical and nursing noted patient’s clinical documentation and other available cues. The review of CT trauma of patient showed that M. H.S had sustained pelvic fracture and ankle fracture post MVC. His vital parameters are at normal range except blood pressure. Apart from his presenting information, his past medical history was also reviewed. This showed that Mr. H.S had no past medical or surgical history and he does not use any medication at home, his mother known of diabetes mellitus type 2 and hypertension.
The following stage of the clinical reasoning cycle is to gather new and relevant information for a particular person at a particular point in time by asking the patient, his family and other health care providers. At 0920 am the patient ring the bell and when I replay he said “I have severe pain”, so we ask him about the severity of pain in scale of 0-10 he said “6/10”, then we give him Perflgan as Dr order. Hence, the new information gathered at this stage was that Mr. H.S was currently struggling with pain. After gathering this information, another decision making priority was to critically reflect on the parameters that will be affected by high pain score in patient. Information related to medication provided to student post admission was also reviewed.
Case Scenario of Mr. H.S.
Based on current and new information collected about the patient, the aim at this stage was to recall all knowledge gathered during nursing education program and find those informations that can be effectively linked to the patient’s problem. Post admission to the hospital, the patient was found to be hypertensive although other vital signs were normal. This is obvious because patient came with report of CT trauma and hypertension is most commonly seen in patient after blunt trauma. CT report revealed pubic rami fracture which meant he sustained a type of pelvic ring fracture. Analysis of evidence based research on complications found in patient with pelvic fracture revealed that such kind of fracture occurs in patient when they have multiple organ injuries. Hence, such kinds of injuries lead to hypertension in patient.
The main priority at this stage was to carefully look at all the current and past medical information of patient and find immediate clinical care priorities for patient. His vital sign observation included, blood pressure 144/86 mmHg, heart rate is 92, respiratory rate 18 br/min and 100% oxygen saturation rate. His respiratory rate is in normal range as it is within normal range of 12 to 20 breaths per minute. Despite a blunt trauma injury, his heart also falls within normal range (60-100 beats/min). However, his blood pressure value was 144/86 mm Hg compared to normal range of 120/80 thus indicating that patient was hypertensive. Use of several medications and the trauma associated with injury might have increased his blood pressure. Evidence has proved that hypertension is one of the common medical comorbidities in patient after fracture. Hence, taking action to control hypertension at the early stage will be beneficial for patient (Yang, Chen & Wu, 2015).
Although different types of information of patient were analyzed in the stage of collecting cues, however the most important data that should be a focus of attention at this stage is high blood pressure, pain score and his wound at the foot. The wound assessment at the foot showed degloving of dorsal skin with macerated edges. Hence, pain management and wound management is regarded as the most important clinical priority for patient at this stage.
The information gather so far has some links with each other and reflecting on this connection is necessary to understand the mechanism behind complication in patient. As the patient had no history of smoking or alcohol consumption or other disease like diabetes, the rise in blood pressure due to past social or medical history is ruled out. However, link between trauma related fracture/injury and pain and hypertension has been established. As he was found positive for pubic rami fracture with retroperitoneal pelvic hematoma, this increases patient tendency to experience pain. Delayed bleeding can also be linked to pelvic hematoma (Sandri, Regis & Bizzotto 2014).
Based on my inference, I aim to implement specific pharmacological intervention for management of pain and hypertension. Secondly, for his wound at the foot, the aim is to follow all treatment principles required for wound management and decreasing the rate of infection in patient (Armstrong et al., 2014). His blood count report showed low RBC count and this needs to be addressed too. He was also found to suffer from thrombocythemia as his platelet count was higher than usual level (Ramsey et al. 2016).
Stages of Clinical Reasoning Cycle
As Mr.H.S came to the hospital following MVC, he sustained both internal and external wounds. His presenting conditions showed similar patterns of injuries as found in motor vehicle accidents. Platelet count in trauma patient increases and this was matched with patient’s symptoms (Holcomb et al. 2015).
After engaging in the process of collecting cues/ information about patient and processing those information, it can be concluded that the main problem in patient post trauma is thrombocythemia, hypertension, pain and low RBC count.
The short term goal for Mr. H.S is to minimize his pain level and blood pressure. After this, the main clinical priority is to minimize risk of bleeding complication in patient by bringng platelet count and RBC count to normal level. As patient ability to engage in daily life activities will be affected after fracture, supporting patient in activities of daily living (ADL) is a long-term goal (Been?Dahmen et al., 2015).
Based on my nursing goal, I will take action regarding hypertension and pain in patient by assessment of pain in patient after giving the Perflgan medication. Based on reduction or increase in pain level and blood pressure in patient, I will consult physician regarding the appropriate drug need for patient. Secondly, to prevent bleeding complication due to thrombocythemia, I will take the action to minimize further risk of injury. Blood transfusion will also be provided as this is a necessary intervention for management of hemorrhage in patient with pelvic fracture (Godinho et al. 2012).
I engaged in clinical communication with patient to determine the best pharmacological intervention necessary for pain management and controlling hypertension in patient. This provided pain relief and reduced discomfort level of patient. Blood transfusion and taking nursing action to prevent injury minimized chances of bleeding related complication in patient (Jones & Frazier, 2016).
Since the patient was patient with a trauma injury, his condition was critical. Apart from internal injury, the patient was coping with external injuries too. I was anxious initially after seeing the patient condition; however since I had to prioritize care, my approach was to focus on those symptoms which can deteriorate patient condition if treatment is delayed. Hence, this judgment helped me to take the right course of action for the safety of patient. I was also concerned about the low blood count and wound at the foot, however consulting my mentor helped to understand the process needed to prevent risk of infection.
Use of clinical reasoning cycle guided me in systematically processing patient’s information and deciding best nursing intervention for patient. My recommendation after this experience is that all nursing students must focus on building their critical thinking skills as this will help them to handle complex situation in a professional manner (Arnold & Boggs, 2015). Hence, nursing students must focus on this aspect during their professional development. Secondly, they must also learn the skills to therapeutically communicate with patient as this will help nurses to engage patients in decision making too (Sharpe & Hemsley, 2016).
Gathering Patient Information
Conclusion:
The essay gave an insight into the process of reflective decision making and prioritizing and evaluating care of a patient by the analysis of Mr. H.A case. The steps mentioned in the clinical reasoning cycle helped in framing the patient information, processing health information and differentiating the vital information necessary for deciding the best intervention for patient. Collaboration with relevant health care team also support nurse to advocate for the safety of patient and take the best course of action for improving their quality of life. Student nurse who aim to become a registered nurse should focus on critical thinking skills as part of their professional development goal.
References:
Armstrong, D. G., Meyr, A. J., Sanfey, H., Eidt, J. F., Mills, J. L., & Billings, J. A. (2014). Basic principles of wound management. Up to date.
Arnold, E. C., & Boggs, K. U. (2015). Interpersonal Relationships-E-Book: Professional Communication Skills for Nurses. Elsevier Health Sciences.
Been?Dahmen, J. M., Dwarswaard, J., Hazes, J. M., Staa, A., & Ista, E. (2015). Nurses’ views on patient self?management: a qualitative study. Journal of advanced nursing, 71(12), 2834-2845.
Godinho, M., Garcia, D. D. F. V., Parreira, J. G., Fraga, G. P., Nascimento, B., & Rizoli, S. (2012). Management of hemorrhage in patients with pelvic fracture and hemodynamically unstable. Revista do Colégio Brasileiro de Cirurgiões, 39(3), 238-242.
Holcomb, J. B., Tilley, B. C., Baraniuk, S., Fox, E. E., Wade, C. E., Podbielski, J. M., … & Cohen, M. J. (2015). Transfusion of plasma, platelets, and red blood cells in a 1: 1: 1 vs a 1: 1: 2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. Jama, 313(5), 471-482.
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Jones, A. R., & Frazier, S. K. (2016). Association of blood component ratio with clinical outcomes in patients after trauma and massive transfusion: a systematic review. Advanced emergency nursing journal, 38(2), 157-168.
Kuiper, R., Pesut, D. J., & Arms, T. E. (2016). Clinical reasoning and care coordination in advanced practice nursing. Springer Publishing Company.
Ramsey, M. T., Fabian, T. C., Shahan, C. P., Sharpe, J. P., Mabry, S. E., Weinberg, J. A., … & Jennings, L. K. (2016). A prospective study of platelet function in trauma patients. Journal of Trauma and Acute Care Surgery, 80(5), 726-733.
Sandri, A., Regis, D., & Bizzotto, N. (2014). Delayed bleeding and pelvic haematoma after low-energy osteoporotic pubic rami fracture in a warfarin patient: an unusual cause of abdominal pain. Case reports in emergency medicine, 2014.
Sharpe, B., & Hemsley, B. (2016). Improving nurse–patient communication with patients with communication impairments: hospital nurses’ views on the feasibility of using mobile communication technologies. Applied nursing research, 30, 228-236.
Yang, S., Chen, A., & Wu, T. (2015). Association of history of fracture with prehypertension and hypertension: a retrospective case–control study. BMC musculoskeletal disorders, 16(1), 86.
Zong, Z. W., Bao, Q. W., Liu, H. Y., Shen, Y., Zhao, Y. F., Hua, X., … & Chen, H. (2016). Diagnosis and treatment of rare complications of pelvic fractures. Chinese Journal of Traumatology, 19(4), 199-205.
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