NRSG370 Clinical Integration

Introduction:

The professional practice by the nurses is associated with a varied range of different skills including clinical judgment, clinical decision making, clinical reasoning, problem solving and critical thinking in order to provide safe and effective care to the patients. Clinical reasoning cycle established by Tracy Levett Jones as a model framework allowing the nurses to implement safe and effective practice along with utilizing all the above mentioned skill and at the same time be able to learn from their practice experience (Dalton, Gee & Levett-Jones, 2015). As mentioned by Hur and Roh, (2013), the nursing professionals with a positive critical analytical skills and reflective skills have positive outcomes on the health and wellbeing status of the patient. Similarly, the nursing professionals that fail to implement adequate critical analytical skills in the professional practice are associated with diminished health and safety outcomes. Hence, the importance of the clinical reasoning cycle is extreme to help the nursing professionals implement practice in a manner that is inclusive of clinical reasoning and decision making skills. This essay will attempt to explore the steps of clinical reasoning cycle to evaluate and analyze a real world care scenario taking the assistance of a perioperative case study.

Considering the patient situation:

The selected case scenario represents a perioperative case involving the patient Candace Evans, a year old patient who had been admitted to the health care facility to undergo elective lower uterine caesarean section or LUCS who had been diagnosed with spinal anaesthesia. This is the first step of the cycle which involves exploring the current situation or condition of the patient and what information is needed to be collected in the very next step (Hur & Roh,). In this case scenario, the patient had undergone a LUCS giving birth to a healthy baby boy and was shifted to the PACU with intraoperative blood-loss being 150ml, which is alarming. However, while in the PACU, the vaginal blood loss of the patient had been extreme with her pad being soaked with frank blood and also some clots indicating signs of extreme blood loss due to her placenta previa (Silver, 2015).

Collection of information:

The second step of clinical reasoning cycle is the elaborative assessment of the patient where the nurse is required to gather all information available about the patient including past medical history, current issues, treatment plan, observational data, investigative results, handover reports and previous medical records (Smith, Loftus & Levett-Jones, 2013). In this case the past medical history of the patient includes gestational diabetes, anxiety and post natal depression, which can have a significant impact on her health, hence past medical data should be adequately collected and documented. Followed by that, the nurse should also take a thorough head to toe assessment and document her vital signs to understand her present condition.

Processing the information:

In order to complete the patient assessment procedure successfully, the very next step of the clinical reasoning cycle is associated with processing the gathered information and compare and contrasting the data with best available evidences to interpret, discriminate, relate and match the available data to predict care outcomes for the patient. In this case, the past medical history stated that Candace had gestational diabetes, anxiety and post natal depression, which is needed to be considered with respect to the blood loss and related complications she is facing. Furthermore, gestational diabetes is also reported to enhance the risk of placenta previa (Kassem & Alzahrani, 2013). The vital signs of the patient include heart rate of 88, which is lower than normal along with a low blood pressure at 104/76, indicating signs of bradycardia which can be caused by extreme blood loss and exhaustion from the surgery. Her body temperature is also slightly elevated at 36.9° Celsius, hence, he patient is also slightly febrile. However, the major concerns regarding the patient is the blood loss and frank haematuria due to her placenta previa. The presence of rose coloured urine is validating the presence of postpartum haemorrhage (Räisänen, Kancherla, Kramer, Gissler & Heinonen, 2014).

Identification of problems:

After the nurse is finished with complete patient assessment and processing of the information collected, the clinical reasoning cycle encourages the nurses to engage in discovering the acre cues or nursing problems presented by the patient so that adequate care can be provided to the patient. In this case, the nursing problems faced by Candace includes:

• Postpartum haemorrhage with clots and fresh blood loss leading several complications due to placenta previa
• Low heart rate due to blood loss and exhaustion (Räisänen, Kancherla, Kramer, Gissler & Heinonen, 2014)
• Hypotension or low blood pressure due to the consistent blood loss
• Risk of infection due to consistent heavy vaginal bleeding with clots
• Complete lack of pain which can be due to high block of anaesthesia
• Discomfort, anxiety and grief due to the complications and post natal depression (Woolhouse, Gartland, Perlen, Donath & Brown, 2014).

Establishing goals:

In this step of the cycle the nurse is required to discover and analyze the care problems identified with detail and with the help of patient assessment, available best practice evidence and personal critical analytical thinking and decision making skills recognize care priorities that need immediate clinical attention to protect health and safety of the patient under consideration (Hur & Roh, 2013). In this case the primary concern for the patient is the extreme vaginal blood loss due to her placenta previa. Now, as per the assessment data the greatest concern that the patient had been facing is the extreme vaginal blood loss to the placental anomaly. And as this anomaly has no direct cure, the nursing goal for the patient would be to minimizing the blood loss and cure the post-partum haemorrhage.

Take action:

First and foremost, the nurse must begin with the five ‘R’s of Clinical reasoning cycle and also take informed consent from the patient before progressing with the care interventions (Levett-Jones et al., 2010). For the blood loss, the nurse will need to help the patient with a fresh vaginal pad with adequate cleaning and hygiene maintenance to ensure infection control. Along with that, the nurse will require to provide complete and comfortable resting position for the patient and preferably encouraging her to keep one leg elevated to help with the blood clotting, along with administration of Gonadotropin-releasing hormone agonists (Abdel-Aleem, d’Arcangues, Vogelsong,  Gaffield & Gülmezoglu, 2013). The post-partum haemorrhage is a grave concern for the patient and the nurse must take into consideration uterine fundus massage which will help in uterine contraction and will also help in reducing the bleeding, preventing and eliminating the post-partum haemorrhage (Matsubara et al., 2013). The nurse with the collaboration of the midwife will also need to instruct Candace to breast feed her baby boy which will also facilitate uterine contraction and reduce bleeding.

The next care priority for Candace is the complete lack of pain which can be facilitated by high spinal block anaesthesia as evidenced by the dermatome level T3 in the patient. The nursing intervention in this case should be to check the sensory levels with ice or blunt needle via pin prick sensation test. If the levels are higher than expected, the nurse will need to position the patient sitting straight up which will stabilize the blood volume and will help in washing out the anaesthesia from the blood. The aid of goal directed fluid therapy might also help in regaining heamodynamic stability of the patient (Xiao et al., 2015).

The third care priority for the patient is her discomfort, anxiety and depression. The nurse should be providing a warm and comfortable stay in the facility and encourage fluid intake to help her regain strength and help her feel better (Wetta et al., 2013). The patient will also need antidepressants and antianxiety pills such as Selective serotonin reuptake inhibitors to help with her anxiety and depression. For a new mother, being able to hold her new born child and interact with the loved ones help extremely in accelerating the recovery (O’hara & McCabe, 2013). The nurse, in collaboration with the midwife, will need to let Candace’s baby boy and husband interact with her to help uplift her mood and help her recover.

Evaluation and reflection:

In the last step of the clinical reasoning cycle, the nurse is expected to evaluate the outcome of the care interventions or actions implemented and reflect on the entire experience (Dalton, Gee & Levett-Jones, 2015). In this case, the periodic vaginal cleaning and infection control helped the patient overcome her discomfort. The hormone therapy had also been helpful in reducing the excessive heavy bleeding along with elevating the legs. However, wearing the support hose had been very difficult for the patient and she soon complained of extreme discomfort and became very anxious. In this case, taking informed consent while clearly explaining to her about the hose could have been more beneficial and could have enhanced comfort for Candace (Hur & Roh, 2013). Although, letting her hold her baby boy and talk to her husband had distinct positive impact on her mood and with the antidepressant pills in effect, her anxiety and depression was adequately managed. Within next 24 hours the bleeding reduced with no visible clots along with her bradycardia; her blood pressure also improved and she looked visibly better.

Reflecting on the practice, I would like to mention the fact that thus had been an excellent opportunity for me to care for Candace and help her with the post-partum complications that she had been suffering with. Along with that, it gave me opportunity to connect with her and engage with therapeutic communication which not only helped ease her anxiety and distress but also helped her verbalize her issues and wishes better with me. I would like to state that this has been an excellent opportunity to learn how to care for patients with postpartum complications and how to provide safe and effective care.

Conclusion:

On a concluding note, caring for a postpartum woman with various interrelated post-operative complications are associated with many risks. In order to be able to provide adequate care and be able to address each and every issues of the patient requires the assistance of a systematic framework. Clinical reasoning cycle serves as a key model framework providing the nurses with the opportunity to follow all the clinical practice guideline and implement critical thinking and judgment skills with respect to evidence based practice in a simple step by step manner. This assignment has given me an excellent opportunity to implement the clinical reasoning cycle in practice while caring in a real world scenario and be able to implement safe and effective care. This has helped me learn my strengths and flaws and it can be hoped that it will be an excellent help for my gradual professional growth in the future.

References:

Abdel-Aleem, H., d’Arcangues, C., Vogelsong, K. M., Gaffield, M. L., & Gülmezoglu, A. M. (2013). Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Doi:  10.1002/14651858.CD003449

Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based education to’flip’the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, The, 33(2), 29. Retrieved from https://search.informit.com.au/documentSummary;dn=018184224173600;res=IELHEA

Hur, H. K., & Roh, Y. S. (2013). Effects of a simulation based clinical reasoning practice program on clinical competence in nursing students. Korean Journal of Adult Nursing, 25(5), 574-584. Doi: 10.7475/kjan.2013.25.5.574

Kassem, G. A., & Alzahrani, A. K. (2013). Maternal and neonatal outcomes of placenta previa and placenta accreta: three years of experience with a two-consultant approach. International journal of women’s health, 5, 803. Doi: 10.2147/IJWH.S53865

Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y. S., Noble, D., Norton, C. A., … & 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

Matsubara, S., Yano, H., Ohkuchi, A., Kuwata, T., Usui, R., & Suzuki, M. (2013). Uterine compression sutures for postpartum hemorrhage: an overview. Acta obstetricia et gynecologica Scandinavica, 92(4), 378-385. Doi: 10.1111/aogs.12077

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Räisänen, S., Kancherla, V., Kramer, M. R., Gissler, M., & Heinonen, S. (2014). Placenta previa and the risk of delivering a small-for-gestational-age newborn. Obstetrics and gynecology, 124(2 0 1), 285. Doi:  10.1097/AOG.0000000000000368

Sentilhes, L., Vayssière, C., Deneux-Tharaux, C., Aya, A. G., Bayoumeu, F., Bonnet, M. P., … & Dupont, C. (2016). Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR). European Journal of Obstetrics & Gynecology and Reproductive Biology, 198, 12-21. Doi: 10.1016/j.ejogrb.2015.12.012

Silver, R. M. (2015). Abnormal placentation: placenta previa, vasa previa, and placenta accreta. Obstetrics & Gynecology, 126(3), 654-668. Doi: 10.1097/AOG.0000000000001005

Smith, M., Loftus, S., & Levett-Jones, T. (2013). Teaching clinical reasoning. In Educating Health Professionals (pp. 269-276). SensePublishers, Rotterdam. Doi: 10.1007/978-94-6209-353-9_23

Xiao, W., Duan, Q., Zhao, L., Chi, X., Wang, F., Ma, D., & Wang, T. (2015). Goal?directed fluid therapy may improve hemodynamic stability in parturient women under combined spinal epidural anesthesia for cesarean section and newborn well?being. Journal of Obstetrics and Gynaecology Research, 41(10), 1547-1555. Doi: 10.1111/jog.12769

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Woolhouse, H., Gartland, D., Perlen, S., Donath, S., & Brown, S. J. (2014). Physical health after childbirth and maternal depression in the first 12 months post partum: results of an Australian nulliparous pregnancy cohort study. Midwifery, 30(3), 378-384. Doi: 10.1016/j.midw.2013.03.006