NURS1201 Assessment 1 CRC PDF

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Clinical reasoning cycle assessment 2019...

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NURS1201 Assessment 1 – Clinical Reasoning Cycle Question 1: Clinical reasoning involves clinicians using their own critical thinking, judgement and intuition in order to solve the challenges they face when treating and caring for patients. It involves 8 stages: look, collect, process, diagnose, plan, act, evaluate and reflect. LevettJones et al. (2010) examines how a poor understanding and implementation of these stages can and have resulted in failure to recognise and interfere appropriately when patients deteriorate. The effective utilisation of this process relies heavily upon the clinician’s ability to gather the right cues, implement the right action, for the right patient, at the right time, for the right reason. This is known as the ‘five rights’ of clinical reasoning and can have harmful outcomes to patient safety if not exercised. Graduate nurses are commonly linked to critical patients’ incidents (NSW Health, 2006). This can be attributed to novice nurse’s inexperience in processing large amounts of complex information in crucial situations and their ability to discern the urgency of the clinical condition of their patient. Therefore, it can be determined that clinical reasoning skills are detrimental in maintaining safe nursing practice when identifying and managing at risk or deteriorating patients. Question 2: Nurses gain a preliminary impression of the patient and their situation in the initial stage of the Clinical Reasoning Cycle (CRC), consider the patient situation. It includes describing the person, context, objects and facts involved in the preliminary clinical setting (Levett-Jones, 2018). This is a vital step in establishing the basis for the subsequent stages of the CRC. For example, Mrs Williamson is a 76-year-old woman admitted to the Orthopaedic ward, through the Emergency Department following suspicions of a left foot metatarsal bone fracture after falling over at home. Question 3: 3a) In the second stage of the CRC, nurses are required to collect relevant cues and information related to the patient and their situation. It involves reviewing the current information (e.g. Patient history, reports, charts, previous nursing/medical assessments, etc), gathering new applicable information via assessments, and recalling any medical knowledge that could be relevant to the situation. This stage should not be undervalued, as missed cues can very easily result in adverse patient incidences (Levett-Jones, 2018). Therefore, therapeutic communication plays an important role in this stage as possibly sensitive and/or vital information may only be disclosed by the patient if they feel comfortable and safe with the nurse caring for them. 3b) ➢ History of Hypertension and is on Avapro (150mg/day) ➢ Blood pressure on admission 145/90 mm Hg ➢ Temperature on admission 36.8⁰C ➢ Pulse rate on admission 110 beats/min ➢ Respiration rate on admission 18 breathes/min ➢ Oxygen saturation on admission 95% ➢ Initial dose 1000mg Panadol in ED 3hrs ago – ongoing order 1000mg Panadol PRN 6 hourly ➢ Pain & redness in right foot has increased despite analgesia ➢ Current pain level 8/10 ➢ Orientated and alert but worried as alone at hospital ➢ Husband passed away 12 months ago ➢ Not attending local

church or bowling club since husbands passing ➢ States she ‘does not want to be in hospital” and asks when she can go home 3c) ➢ Pain Assessment (PQRST) Due to her high pain score on admission to the orthopaedic ward, assessment should be repeated to confirm pain management is not working and alternative may need to be requested (Applegarth, J. 2015). ➢ Mobility Assessment Due to previous history of falls and suspected left foot metatarsal fracture, mobility should be assessed to prevent any further injury while moving around in hospital. (Bellchambers, H. 2015). ➢ Mental Health Assessment Due to her husbands recent passing, lack of social activity and attitude towards being alone in hospital, a mental health assessment should be undertaken to ensure Mrs. Williamson is getting the appropriate care (Bellchambers, H. 2015). Question 4: 4a) Process information is the third stage of the CRC. It involves interpreting, discriminating, relating, inferring and matching the cues collected and then predicting an outcome. In this step, nurses are required to distinguish between which cues are normal or abnormal. In order to successfully interpret the information, they have collected, nurses must call upon their range of previous clinical practices and foresee possible complications depending on what course of action is taken (Levett-Jones, 2018). 4b) ➢ Current pain level of 8/10 This is abnormal, as the ideal pain score is 0 – 3 as per the SAGO chart (CEC). A PQRST pain score above 7 is considered severe and therefore requires immediate attention (Levett-Jones, 2018). ➢ Pain & redness in right foot has increased despite analgesia 3 hours ago Panadol is used for mild to moderate pain which is classed as 0-6 on the pain scale (Health Direct, 2018). Due to the continuous and increasing pain this cue is considered abnormal and Mrs Williamson should be assessed by the doctor for a stronger pain medication (Applegarth, J. 2015). ➢ Blood pressure on admission 145/90 mm Hg Although Mrs. Williamson is hypertensive, this BP is still abnormally high considering she takes Avapro. Bellchambers (2015) confirms a normal blood pressure is below 120/80 mm Hg. ➢ Pulse rate on admission 110 beats/min

This cue is abnormal, as the normal range for heart rate for an older adult is between 60-100 beats/min (Bellchambers, H. 2015). 4c) Mrs Williamson current pain level of 8/10 would be the priority in this situation as she was administered 1000mg Panadol three hours prior, which should have decreased her pain level, however it has increased instead. Question 5: 5a) An actual nursing diagnosis refers to the use of supporting evidence/cues and aetiology to identify the patient’s current health problem. It utilises a comprehensive analysis of subjective and objective data (Scully, 2015). Whereas, potential (at risk) nursing diagnosis utilises a nurse’s clinical judgement to identify the possibility of additional health problem that could occur without appropriate action for example infections. Both diagnoses are utilised in the fourth stage of the CRC, identify problems/issues, to process the information and cues collected into one condition that clearly explains the patient’s situation. 5b) When writing a nursing diagnosis, the “related to” section provides the etiologic factors or causes of the actual diagnosis identified (Levett-Jones, 2018). The “evidenced by” section of the diagnosis directly links the identified diagnosis to the “related to” etiologic factors by distinguishing the major defining characteristics showing in the patient. This can include the clinical manifestations, symptoms, signs and observations collected (Scully, 2015). 5c) Acute pain related to possible left foot metatarsal bone fracture evidenced by high pain score; elevated blood pressure 145/90 (hypertensive) and heart rate 110 (Tachycardia). 5d) Possible depression related to husbands recent passing and lack of social activity. Question 6: Actual Nursing Diagnosis Goal: Reduce pain level to under 4 on pain scale within one hour Potential Nursing Diagnosis Goal: Promote social activity by going bowling or to church once a week for the next 2 months Question 7: 7a) Mrs. Williamsons would need her pain re-assessed in order to properly manage the increase in pain since arriving at the orthopaedic ward (Applegarth, J. 2015). Observations should also be retaken in order to confirm this. While Panadol is a slow release drug, it should of have improved her pain within three hours since administration (Health Direct, 2018). 7b) Mrs. Williamson will need to be educated on the significance of identifying increases in her pain level and the importance of requesting pain medication before the pain is too intense. Applegarth (2015) discusses how elderly individuals struggle to acknowledge and vocalise their pain as they don’t want to be a nuisance.

7c) A clinical review will need to be requested to reassess the validity of the pain medication she is currently on. Due to her high pain score, these medications will need to be reassessed and possibly changed or increased to manage her pain (NSW Health, 2013) 7d) In order to care for Mrs. Williamsons with her current pain, her left leg should be elevated and iced to help reduce the pain and swelling until the Doctors can reassess her pain management plan. Nurses should routinely monitor Mrs. Williamson comfort and ensure she knows to call out if pain increases before reassessment (Scully, 2015). Question 8: The evaluation of nursing actions is crucial in assessing the success of the CRC process. It involves the nurse re-examining the data to review how effective the interventions undertaken have been and if the issue improved or not. In this step, the ability to recognise and critically analyse the critical reasoning skills employed, provides the experience and knowledge to improve future actions in similar clinical situations (Fagan, Levett-Jones, 2015). This evaluation will allow nurses to determine whether they continue with their planned course of action, or if they need to change these interventions due to patient unchanging or deteriorating condition. This is the point in the CRC where it is determined if the method has worked or it needs to be repeated from the start due to possible missed information (Levett-Jones, 2018).

Question 9: In finishing this assignment, I have gained a better understanding of how the clinical reasoning cycle operates and feel I have established a good basis to continue improving my clinical reasoning skills. For me, I struggled most with the sixth stage of the CRC, take action, however I feel that as I continue to go through the CRC for different situations, my ability to recommend actions and intervention will improve as my experiences grow. This assessment has also shown me the importance of therapeutic communications in collecting relevant data to establish nursing diagnosis’s and how easily missed cues can impact the overall progression of the CRC.

References: Applegarth, J. (2015). Chapter 48: Pain Management. In A. Berman, S. Snyder, T. LevettJones, T. Dwyer, M. Hales, N. Harvey, …D. Stanley, Kozier and Erb’s Fundamentals of Nursing (3rd Aust. ed., Vol 3, pp. 1293-1333). Melbourne, Vic.: Pearson. Bellchambers, H. (2015). Chapter 31: Health Assessment. In A. Berman, S. Snyder, T. Levett-Jones, T. Dwyer, M. Hales, N. Harvey, …D. Stanley, Kozier and Erb’s Fundamentals of Nursing (3rd Aust. ed., Vol 3, pp. 631-713). Melbourne, Vic.: Pearson. Fagan, A., Levett-Jones, T. (2015). Chapter 13: Diagnosing. In A. Berman, S. Snyder, T. Levett-Jones, T. Dwyer, M. Hales, N. Harvey, …D. Stanley, Kozier and Erb’s fundamentals of nursing (3rd Aust. ed., Vol 1, pp. 234-245). Melbourne, Vic.: Pearson. Health Direct: Paracetamol, (2018, August). Retrieved from https://www.healthdirect.gov.au/paracetamol Levett-Jones, T. (Ed). (2018). Clinical reasoning: Learning to think like a nurse. Frenchs Forrest, NSW: Pearson Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S., Noble, D., Norton, C., . . . 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. Nurse Education Today, 30(6), 515-520. doi:10.1016/j.nedt.2009.10.020 NSW Health, 2006. Patient Safety and Clinical Quality Program: Third report on Incident Management in the NSW Public Health System 2005–2006. NSW Department of Health, Sydney. Retrieved from https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2005_608.pdf NSW Health. (2013) Standard Adult General Observation Chart. Retrieved from safety/between-theflags/observation-charts Scully, N. (2015). Chapter 11: Critical Thinking and the Nursing Process. In A. Berman, S. Snyder, T. Levett-Jones, T. Dwyer, M. Hales, N. Harvey, …D. Stanley, Kozier and Erb’s fundamentals of nursing (3rd Aust. ed., Vol 1, pp. 197-206). Melbourne, Vic.: Pearson....