Clinical Reasoning: A Case Study

Peter is a 47 year old male, with severe learning disabilities who lives in a community setting with other residents. He requires the assistance of his carers to meet his needs. Peter has asthma which is controlled by inhaled medication, he has a history of depression, he has a grade 2 pressure ulcer to his sacral area, and his body mass index (BMI) is 31. He is visited twice daily by the district nurses (DN)who administer Peter’s insulin, because he has been newly diagnosed with type 2 diabetes, following a recent hospital admission. Peter has also experienced complications with his diabetes as following his diagnosis; he has been admitted acutely into hospital twice following a hypoglycaemic episode.

This paper will discuss three theories of decision-making that can be adopted in nursing practice, additionally how decision-making theories are able to be implemented and used. Decision-making in nursing is adopted through the critical thinking process that provides each nurse a model to make the best choices, solve problems and to meet goals in clinical practice (Berman & Kozier 2018, pp. 199-200; Levett-Jones & Hoffman 2013, pp. 4-5). Effective decision-making in nursing is a vital component and part of the role of a registered nurse; each year a substantial number of patients die due to medical errors and poor decision-making (Levett-Jones & Hoffman 2013, pp. 4-5; Nibbelink & Brewer 2017, p. 3). Through the use of

It is widely known that early recognition of a deteriorating patient can contribute largely to a successful outcome, through recognising and taking action on the deteriorating health status of the patient (National Consensus Statement, 2010). This report will explore the ways in which deteriorating patients and clinical reasoning are used in the public health care system in New South Wales (NSW).

The purpose of this paper is to conduct an in depth exploration of the nursing care considerations of patients in a specific clinical area. Through the synthesis of prior knowledge, clinical experiences and skills, evidence based best practices, and care of patients a comprehensive care and teaching plan will be composed. Integration of critical thinking and clinical reasoning skills, combined with evidence-based research will provide confirmation of nursing process comprehension. The inclusion of reviewed literature will further support knowledge and understanding.

Alfaro-LeFevre, R. (2013). Critical thinking, clinical reasoning, and clinical judgment : A practical approach (Fifth ed.).

The first step is to ensure that the patient is on a proper diet by making sure that the patient's cupboards are well stocked with food. This will be followed by taking her medicine plus make sure that she is taken out twice a week to visit her children as well as to visit the German association members (Planning Nursing Care, 2017). Moreover, she will be going to local church on Sundays. This will ensure that she maintains her touch with the society as well as reduce depression. Also, her house will always be clean at all times, to ensure she stays in a clean environment. Finally, physical exercises will be made possible through some guidance to try to slow down the illness.

160) Knowledge elevates the power of critical thinking. Critical thinking is very essential to work in areas such as Intensive Care Units, Emergency Care Units. Assessment, diagnosis, planning, implementation and evaluation are best done by a BSN than an ADN because of the power of critical thinking. The skills of critical thinking, better problem solving, and development of clinical judgment are important for increase patient acuity. Since BSN is better in critical thinking and evidence based practice, they lower mortality rate significantly. (Aiken, 2003)

Clinical reasoning is embedded in nurses’ thinking for patient care (Levett-Jones 2013). It is a spiral, continuous mental process, underpinned by critical thinking theory and a sound body of nursing knowledge (Levett-Jones 2013). The clinical reasoning cycle includes considering patient’s situation, collecting cues, processing information, identifying problems, establishing goals, taking action, evaluating outcomes and reflecting on the process undertaken (Levett-Jones 2013). Nursing practice for registered nurses is guided both by the National Competency Standard (Nursing and Midwifery Board of Australia 2006) and the Nursing Practice Decision Flowchart (Nursing and Midwifery Board of Australia 2010) to ensure patients’ safety and to optimise care by challenging medical assumptions and facilitating evidence-based practice. The clinical reasoning framework, therefore, allows nurses to prioritise the most time sensitive and specific information, to recognise deteriorating patients and to manage complex clinical situations (Levett-Jones & Bourgeois 2011). This paper will focus on processing information and identifying the two major problems in the case study of Mr. Brown, a 74-year-old man, who was admitted to hospital after a ‘fainting’ episode with chief complaint of dizziness.

Over the past 30 years nursing has evolved from a task-oriented to a logical and systematic approach to care, using theories and models to guide practice. According to Jasper (2007, p117) theories of decision making in medicine tend to favour logical, precise analytical models which are held to be testable, unambiguous and repeatable, therefore satisfying scientific principles. These represent important ideas of certainty and rationality that are intended to provide a sense of security and reliability. When used correctly a nursing model should give direction to nurses working in a particular area, as it should help them understand more fully the logic behind their actions. It should also act as a guide in decision-making and so reduce conflict within the team of nurses as a whole. This in turn should lead to continuity and consistency of the nursing care received by patients according to Pearson et al (1999,p ).

Underlying both the clinical decision-making process and the nursing process is the skill of critical thinking. Critical thinking has been described as the ability to gather and process data in such a way as to arrive at the best conclusion using the filters of prior knowledge, experience and external resources to overcome personal emotions, biases, and assumptions. (This description was developed during NUR/300 class, University of Phoenix, S. Colorado, March 16, 2006) Note that critical thinking is described as a

Clinical Reasoning is an essential part of the assessment, treatment and evaluation process in occupational therapy (Neistadt, 1996). This reasoning is the skill set that the occupational therapist draws from when working with clients in related to function and performance. Neistadt (1996) suggested that clinical reasoning is the combination of five interacting components (Ward, 2003). This will be explained in the following essay and applied to a case study about a girl named Maria.

The development of the nurse’s ability to clinically reason and take appropriate and timely action can, in time, become an instinctive and automatic process. Reflective practice by the nursing professional will highlight the areas in which further improvement is needed. Essentially, it is the responsibility of the individual nurse to identify the need to develop this ability, and the skill to effectively communicate the patient’s condition to the other members of the healthcare team to produce positive patient outcomes.

Clinical reasoning can be defined as, ‘the process by which nurses (and other clinicians) collect cues, process the information, come to an understanding of a patient’s problem or situation, plan and implement interventions, evaluate outcomes and reflect on and learn from the process’ (Levett-Jones & Hoffman 2013, p.4). It requires health professionals to be able to think critically and ensures better engagement and results for the patient (Tanner 2006, p.209). The Quality in Australian Healthcare Study (Wilson 1995, p.460) discovered that ‘cognitive failure’ resulted in approximately 57% of unfavourable clinical events involving the failure to produce and act correctly on clinical information. It also recognises that often nurse’s preconceptions and assumptions can greatly affect patient care and by going through such a process, one can take into account the holistic nature of the patient and provide the best, most appropriate care.

Johnny Obrien aged 79 years, presented to the Emergency Department after a fall at the RSL, resulting in a laceration on his left elbow which required 3 stitches. He lives by himself with no family close by, and has a history of hypertension and alcohol addiction. Clinical reasoning is a cyclic process, where cues are collected and their data processed to come to a conclusion of the patient situation so that appropriate interventions can be implemented and evaluated through reflective practices which allows for further learning (Levett-Jones 2013). Applying these clinical reasoning skills in practice is important as it has a positive impact on patient outcomes, resulting in less adverse effects due to the detection of patient deterioration throughout this process to ensure safe and effective care (Levett-Jones 2010).Subjective data is information from the patient’s point of view, including their feelings, perceptions and concerns, whereas objective data is information that is observable or measurable (Delmar Cengage Learning 2015).

Critical thinking and clinical reasoning are similar in the fact that each term represents a set of methods that guide the nurse to reliable evidence-based practice while delivering care. Critical thinking and clinical reasoning are centered on knowledge base that is associated with the discipline of nursing. With each concept, the nurse must have an existing developed knowledge base in which to apply each concept to. Nurses apply critical thinking and clinical reasoning skills when patient care decisions are made. With both critical thinking and clinical reasoning, information about the patient is collected and examined. They work together to produce clinical judgment. They both direct nursing care to meet patients’ needs resulting in higher quality of care and better patient outcomes.