3807NRS Advanced Clinical Decision Making

Introduction

Registered nurses needs to be flexible in the in the decision making approach and to ensure a continuity of care. In order to provide a safe and a high quality of care, they should possess the ability to judge, think and reason. Clinical reasoning is a complex process that utilizes the formal and informal reasoning strategies for gathering and the analyzing the patient reasoning. This process is reliant on the health care professionals and the individual client circumstances. In this assignment, the Levett Jone’s clinical reasoning cycle has been used as a tool for the registered nurses to make appropriate decisions. Furthermore the recommendations has been proposed in the light of the three competency standards for the registered nurses by the Nursing and Midwifery Board of Australia (NMBA) .

Consider the patient situation

A 45 years old male patient named James had been admitted to the ED with the clinical manifestations of Pneumonia. The patient had been admitted with productive cough and shortening of breath. The patient has been suffering from the respiratory tract infections for the last five days. A local General practitioner had been managing the respiratory illness was referred to the emergency department on the exacerbation of the respiratory distress. After admitting the patient in the emergency department, the patient was subjected to chest x-ray, which displayed a consolidated lungs that indicated towards the occurrence of pneumococcal infections. I was allocated as the nurses for taking care of this patient.

Collect cues/information

This is the second stage of the clinical reasoning cycle where nurses are accountable to review the current information of the patient based upon the diagnostic tests. On arrival to the emergency department vital signs of James were taken and recorded. The recorded temperature was 38.8 degree Celsius. Heart rate was observed to 110beats per minute, respiratory rate 26 per minutes, blood pressure was recorded to be 100/72 and oxygen saturation level was found to be 91 %. The doctored ordered for an hourly monitoring of the breathing, LOC and the neurological status. James was initially admitted with an oxygen saturation level of 91 % which decreased with time and was reduced to 87%, with increasing respiratory distress. Right after an hour of admission the patient exhibited high fever with increasing respiratory problem. The current PaO₂ level was observed to be 50mmHg. One of the main concern for James is the increasing respiratory distress and the decreasing oxygen saturation level. The blood pH was recorded to be 7.45. I have recorded all the observations and reported the abnormal signs to the registered nurse, who gave the order of reporting to a doctor.

Process information

Processing of the information is the third stage of the clinical reasoning cycle where all the displayed signs and the symptoms are linked to the underlying pathophysiology, pharmacology and the pharmacodynamics. The normal vital signs are compared with the abnormal. Pneumonia is an acute form of respiratory tract infections that affect the lung parenchyma and oxygenation of the lungs. The clinical manifestations are mainly monitored by a chest x-ray (Singh, 2012).

The primary symptoms of Pneumonia involves coughing with a phlegm or a pus, difficult breathing. High fever and symptoms of dehydration following the admission of the patient is an important indication towards pneumococcal infections (Driver, 2012). Interpretation of the arterial blood gases are extremely crucial in case of pneumonia patients. PaCO₂ is low as the standard range of the PaCO₂ is 35-45 (Alwadhi, Dewan,  Malhotra, Shah & Gupta, 2017). PaCO₂ can be an effective marker in measuring the severity of community acquired pneumonia.

The PaO₂ is also much low, whereas the normal value is between 80-100. PaO2 might be low due to the mucous displacing the air in the alveoli affected by pneumonia. The pH is also on the lower of the normal range that indicated towards a compensated respiratory acidosis (Singh, Khatana & Gupta, 2013).Troubled breathing can be explained by the increased respiratory rate as the heart has to pump more effectively to meet up the oxygen demand. Arterial hypoxemia is mainly caused by the persistence of the pulmonary blood flow to the consolidated lungs causing an interpulmonary shunt. Hypoxemia can be also be caused due to the intrapulmonary consumption of oxygen by the lungs at the time of the acute phase. Respiratory failure in pneumonia affects the lungs such that it cannot remove carbon-dioxide from the blood (Singh, Khatana & Gupta, 2013). A low oxygen level and low carbon-dioxide level occurs at the same time in the blood. Hypoxia is related to high respiratory rate as the an abnormally low content of oxygen in the blood triggers troubled breathing to meet up the oxygen demand in the tissues and the organs (Kushwah, Verma & Gaur, 2018). It has to be remembered that pneumonia is an infection that is mainly caused when there is an inflammation in the airsacs of the lungs. Fever is an autoimmune mechanism displayed by the body against any kind of infections. In a retrospective study high rate of mortality was found in the elderly patients with pneumonia and no fever in comparison to the ones with pneumonia and fever (Walter, Hanna-Jumma, Carraretto & Forni, 2016).Tachypnea in the patient that is an increased respiratory rate can be probably caused due to the fever due to pneumonia. Tachypnea can be termed as the voluntary or the involuntary response to anxiety, pain or fright or abnormal breathing pattern due to increased temperature.

Identify the Problem/Issues

The fourth stage is the proper identification of the issues. It is evident from the case scenario that James was displaying low oxygen saturation, high temperature, signs of dehydration, tachypnea, low PaO₂ and low pH. All the arterial blood gas values and the vital signs indicated towards the occurrence of pneumonia. The decreased urinary output of James indicated towards severe dehydration (Prina, Ranzani & Torres, 2015). Dehydration is caused in pneumonia due to fever. Excessive sweating and cough is an important symptom of pneumonia. Excessive sweating in pneumonia might lead to water loss leading to dehydration (Kang et al., 2013). Low oxygen saturation level is the symptom of hypoxemia arising due to pneumonia (Alwadhi, Dewan,  Malhotra, Shah & Gupta, 2017). This can probably compromise the function of the different organs such as brain and heart(Pinciroli, Mietto & Berra, 2013). For acute cases oxygen supplementation is necessary. Pneumonia in this patient should be managed properly as severe pneumonia might lead to septic shocks, lung abscesses, pleural effusions, emphysema and pleurisy (Pinciroli, Mietto & Berra, 2013). On severe cases renal failure and respiratory failure can also occur. In order to control that there is a need for the rapid assessment of the conditions, followed by proper goals and a proper action plan for achieving the goals.

Establish goals

Establishment of proper goals is extremely necessary to carry out the treatment in a proper and systematic way. The goals can be stated as follows;-

• To mitigate the respiratory distress and the restoration of the normal breathing pattern.
• Restoring the oxygen saturation level to about 97% in James, by giving supplementary oxygen therapy.

Take actions

Analyzing the signs and the symptoms and linking them to the pathophysiology had helped me to understand the central problem and identify the clinical priority based on which the interventions have to be made. Such analysis helped me to take immediate actions and I called for the registered nurse. Effective airway clearance is the primary step in mitigating the respiratory distress in James. James was held in supine position as doing so would lower the diaphragm that would help in the expansion of the chest, aeration of the segments of the lungs, mobilization and expectoration of the secretions. The patient was educated and assisted to practice deep breathing exercises and was demonstrated with the proper chest splinting and effective coughing (Huang et al., 2015). Effective deep breathing exercise help in lung expansion and opening of the airways. Effective coughing is the natural way to clear secretions from the throat and maintain patient airways (Driver, 2012). Sitting in a supine position normally helps in more forceful coughing. The respiratory distress of James was getting reduced with more time. The RN ordered to assess the rate and depth of respiration in James, as shallow respirations and asymmetric chest movement may be caused if the patient experiences some discomfort present in the chest wall (Prina, Ranzani & Torres, 2015). The registered nurse ordered to maintain 2-4L/minnasal prongs. The prime purpose of the oxygen therapy is to maintain the PaO₂ above 66mmHg (Fealy et al., 2016). I made sure that the oxygen level is tolerable to the patient. The arterial blood gases, neurological signs and the vital signs were monitored at an interval of every two hours.

Evaluate Outcomes

Evaluation of the outcomes is the seventh stage of the clinical reasoning cycle that proves that the actions taken have met the goals successfully or not. The outcome in case of James had been positive, specifically in terms of the oxygen saturation level and the respiratory rate. The oxygen saturation level in James finally rose to 96%, which is within the normal value and display enough oxygen level in the blood. Naturally, the respiratory distress in James was lowered to a considerable extent. The PaO₂ value is also restored to a normal level, ensuring an improved ventilation and oxygenation of the tissues within the acceptable range (Singh, Khatana & Gupta, 2013). James was finally able to take part in the actions to maximize oxygenation. Airway clearance was demonstrated by positive changes in the depth and the rate of the respiration. Tachypnea was found to be under control and ABG values were found to be normalizing gradually.

Reflection

Reflecting on the experiences and understandings is the final stage of the clinical reasoning cycle. According to Levett Jones et al.(2011), clinical reasoning cycle helps the health care professionals to identify a specific health problem and facilitates the thinking behind the plan of management. It has to be remembered that medical decisions are complicated and based on different internal and external parameters. Hence it is the need of the health care professionals to follow a particular decision making tool. Such a clinical reasoning has allowed me to understand the clinical predisposing factors and the contributing factors of James’ illness. Learning from such a case, has allowed me to gain competency in particularly three nursing competency standards as per the NMBA standard . According to standard 1 of the registered nurse standards for practice, an RN accesses, uses and analyses the available evidences for practicing a safe quality nursing (NMBA ,2016). I have brainstormed through some nursing articles in order to gain an insight to the underlying pathophysiology of James. Hence I believe that I have used the best possible evidences to identify the actual condition of James. Evidence based information has also helped me to chalk out the essential goals for better outcomes in patients.

I have learnt that planning is an important part of the nursing practice. This is also an important standard of nursing, standard 5 (NMBA ,2016).  Patient specific agreed plans are developed in collaboration with the peers and are generally based on the approval of the registered nurses. I had been mindful in giving an emergency call to the registered nurse, on observing the drastic drop in the oxygen saturation level. I have properly assessed all the nursing cues and the available evidences to develop the plan. All the goals and the action plan was approved from the registered nurse in charge.In this case any misses or delayed recording would have brought adverse outcome in the patient or the patient would have been died. Hence, I ensured that each time the arterial blood gases and vital signs are measured, they are recorded systematically. My final reflection is based on the standard 6 that states that nurses are liable to practice in accordance to the relevant guidance, regulations, standards and legislations (NMBA ,2016). I was mindful about my scope of practice and hence approved each and every steps that has to be done, from the registered nurse. I made sure that my performance complies with all the nursing guidelines related to patient safety, oxygen administration and medication administration.A registered nurse can provide appropriate care to the patient by using their clinical reasoning skills. By using the above clinical reasoning cycle, a timely diagnosis and management was done in case of James. However reflecting through the application of the clinical reasoning cycle and relating them to the NMBA nursing standard has helped me to develop three main recommendation for nursing practice- evidence based practice based on researches, proper assessment and correct recording and being accountable to the duties.

References

Alwadhi, V., Dewan, P., Malhotra, R. K., Shah, D., & Gupta, P. (2017). Tachypnea and other danger signs vs pulse oximetry for prediction of hypoxia in severe pneumonia/very severe disease. Indian pediatrics, 54(9), 729-734. https://doi.org/10.1007/s13312-017-1163-6

Driver, C. (2012). Pneumonia part 1: pathology, presentation and prevention. British Journal of Nursing, 21(2), 103-106. https://doi.org/10.12968/bjon.2012.21.2.103

Fealy, N., Osborne, C., Eastwood, G. M., Glassford, N., Hart, G., & Bellomo, R. (2016). Nasal high-flow oxygen therapy in ICU: a before-and-after study. Australian Critical Care, 29(1), 17-22. https://doi.org/10.1016/j.aucc.2015.05.003

Huang, L., Zhang, W., Yang, Y., Wu, W., Lu, W., Xue, H., … & Liu, L. (2018). Application of extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome induced by avian influenza A (H7N9) viral pneumonia: national data from the Chinese multicentre collaboration. BMC infectious diseases, 18(1), 23. DOI 10.1186/s12879-017-2903-x

Kang, C. I., Song, J. H., Kim, S. H., Chung, D. R., Peck, K. R., Thamlikitkul, V., … & Carlos, C. C. (2013). Risk factors and pathogenic significance of bacteremic pneumonia in adult patients with community-acquired pneumococcal pneumonia. Journal of Infection, 66(1), 34-40. https://doi.org/10.1016/j.jinf.2012.08.011

Kushwah, M. S., Verma, Y. S., & Gaur, A. (2018). Clinical predictors of hypoxemia in children with WHO classified pneumonia. International Journal of Contemporary Pediatrics. https://doi.org/10.1016/j.aucc.2018.05.003

Levett-Jones .,Hoffman, K., Dempsey, J., T., Noble, D., Hickey, N., Jeong, S., … & Norton, C. (2011). The design and implementation of an Interactive Computerised Decision Support Framework (ICDSF) as a strategy to improve nursing students’ clinical reasoning skills. Nurse Education Today, 31(6), 587-594. https://doi.org/10.1007/978-94-010-0462-6_8

NMBA (2016). Standards for practice: competency standards for registered nurses. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Pinciroli, R., Mietto, C., & Berra, L. (2013). Respiratory therapy device modifications to prevent ventilator-associated pneumonia. Current opinion in infectious diseases, 26(2), 175-183. doi: 10.1097/QCO.0b013e32835d3349

Prina, E., Ranzani, O. T., & Torres, A. (2015). Community-acquired pneumonia. The Lancet, 386(9998), 1097-1108. https://doi.org/10.1016/S0140-6736(15)60733-4

Singh, V., Khatana, S., & Gupta, P. (2013). Blood gas analysis for bedside diagnosis. National journal of maxillofacial surgery, 4(2). 10.1097/QCO.0b013e32835d3349

Singh, Y. D. (2012). Pathophysiology of community acquired pneumonia. Supplement to JAPI, 60, 7-9. Retrieved from: https://japi.org/january_special_2012/03_pathophysiology_of_community.pdf

Walter, E. J., Hanna-Jumma, S., Carraretto, M., & Forni, L. (2016). The pathophysiological basis and consequences of fever. Critical Care, 20(1), 200. https://doi.org/10.1186/s13054-016-1375-5