Clinical Reasoning Essay

In today’s society, there is a focus on excellent healthcare services delivery as a result of increasing incidence of poor patient health outcomes in Australia as well as the whole world (Stempsey, 2009). Acute health care settings have recently catered to a larger proportion of patients with complicated health conditions who become gravely ill during their hospital stay (Charlin, Lubarsky, Millette, Crevier & Audetat, 2012). At the forefront of these dynamic health systems are nurses who provide direct care to patients. Experienced nurses are able to rise to the ever-changing patient conditions and challenges. On the other hand, novice nurses have a difficult time coping with these complex health situations (Pinnock & Welch, 2014). In the
perspective of less experienced nurses, the expert nurses’ abilities seem to be instinctive and innate. However, these are merely misconceptions because experienced nurses have developed a well-practiced skill in dealing with health conditions. This is termed as Clinical Reasoning. They had honed this skill over the years of service and continuous update of their knowledge base (Alfaro-Lefevre, 2012).
According to Delany and Golding (2014), Clinical Reasoning is a systematic and logical method by which nurses gather cues, analyze information, understand a patient’s condition, create plans and implement interventions, evaluate results, and exercise reflective practice.
Because of its continuity, Clinical Reasoning does not happen in a linear manner but remains to be cyclical (Marcum, 2012). Nurses who exhibit good clinical reasoning skills have the capacity “to collect the right cues and to take the right action for the right patient at the right time and for the right reason” (Levett-Jones, Hoffman, Dempsey, Yeun-Sim Jeong, Noble, Norton, Roche & Hickey, 2010). In contrast, nurses with less developed clinical reasoning skills usually fall short in detecting imminent deterioration of patient’s status. Flaws in clinical reasoning continue to account for majority of patient mortality and morbidity despite the sophisticated technology and evidence-based practices. Hence, it is vital for nurses to develop effective clinical reasoning skills (Norman & Eva, 2009). This can be done through practice and constant feedback in the way they think and address patient problems. The guidance of expert nurses and teachers is critical in cultivating clinical reasoning skills of novice nurses (Salminen, Zary, Bjorklund, Toth-Pal and Leanderson,
2014).
To further illustrate the clinical reasoning cycle, this essay will discuss the case of Mr. J, a 75-year-old, post–laparoscopy patient who experienced hypoxemia. Using the clinical reasoning cycle, the student nurse will present how she was able to recognize cues of Mr. J’s impending condition, plan and implement appropriate interventions, evaluate outcomes and prevent further deterioration of Mr. J’s condition. To provide an understanding of Mr.
J’s health problem, it is important to use the clinical reasoning cycle. According to Levett-Jones, et al. (2010), the first step is to describe and consider the patient’s situation. Mr. J was admitted to the hospital due to acute abdominal pain, increased abdominal girth and general weakness. He had been diagnosed with COPD five years ago. He underwent laparoscopy to determine the cause of his abdominal pain and was then transferred to the Recovery Room. The second step is collection of information and cues (Levett-Jones, et al 2010). The student nurse received a handover from the operating room nurse that Mr. J tolerated the surgery well and his observations were stable. However, when she checked his oxygen saturation it was 88% in room air. Reviewing his previous vital signs charts, Mr. J’s oxygen saturation sits between 95%-97% in room air. She checked Mr. J’s fingers if they were too cold and she also rechecked the functionality of the pulse oximeter but it was working properly. She then assessed Mr. J’s breathing. It was shallow with mild nasal flaring. Upon chest auscultation, she heard wheezing over both lung fields. Recalling her previous readings, the student nurse remembered the risk factors of hypoxemia and realized that Mr. J had most of them. Ehrenfeld, Funk, Van Schalkwyk, Merry, Sandberg and Gawande (2010) stated that patients who have increased age, obstructive lung disease, raised intra-abdominal pressures (e.g. after
laparoscopy) and following anesthesia are at risk for hypoxemia after surgery. The third step of the cycle is processing information (Levett-Jones, et al 2010). Mr. J’s oxygen level is low and it is a cause of concern. His underlying lung disease, age and recent anesthesia led to his respiration problem. It must be corrected because if not then it can lead to acute respiratory failure, a medical emergency (Froese, 2014). The fourth step is identifying the problem (Levett-Jones, et al 2010). In Mr. J’s case, it is hypoxemia. In the fifth step, the goals for his care (Levett-Jones, et al 2010) were improving his respirations and maintaining his oxygen saturation about 95% or more, respiratory rate between 12-14 breaths/min, clear airways with no wheeze, and without signs of respiratory distress as stated by Gallagher, Haines, Osterlund, Mullen and Downs (2010). The sixth step is taking actions (Levett-Jones, et al 2010). The interventions done by the student nurse were administering oxygen therapy at 100% via bag and mask, continuous monitoring of patient’s observations, informing the anesthetist/physician of Mr. J’s problem, anticipating and carrying out medical orders such as administering bronchodilators or other drugs and adjustments to any pain medications, and giving emotional support to Mr. J as stated by Hare and Kavanagh (2010). The seventh step involves evaluation of actions taken (Levett-Jones, et al 2010). Mr. J’s oxygen saturation had improved to 95-97% and his respiratory rate is 13-14 breaths/min with clear airways, regular breathing pattern and no nasal flaring. The last step is reflecting on the process and gaining new learning (Levett-Jones, et al 2010). The student nurse realized that timely assessment and appropriate interventions can definitely avert critical events. It is also important to consider Mr. J’s background as they significantly impact his condition after surgery.
In conclusion, the clinical reasoning cycle is a useful and effective tool for novice nurses such as student nurses in providing safer and more competent nursing care to patients. Although it takes time to master the said skills, constant practice and feedback from mentors can definitely hone such skills in less experienced nurses. Ultimately, the goal of excellent health services delivery in Australia and across the globe will be achieved with the nurses’ practice of clinical reasoning.