NRS82005 Clinical Reasoning Cycle to Use Critical Analysis for Patient Care Case Study B Assessment Answer
Assessment 2: Case Study B
PART 1: Collecting the Clues
Clinical reasoning cycle is a conceptual framework with the help of which clinical experts collect cues about the patient. Processing the information collected from the cues help them to understand the patient’s medical condition and they further plan and implement suitable medical interventions for the patient (Levett-Jones et al., 2010). The clinical reasoning approach is used by nurses to evaluate and monitor the condition of a patient and ensure appropriate and high-quality care for patients (Hunter & Arthur, 2016). The assessment aims to apply the concepts of the clinical reasoning cycle to use critical analysis to consider various aspects of patient care. It also deals with Mrs X’s case study (patients name is kept confidential following the privacy and confidentiality of the patient) analysis for planning person-centred care for her. Mrs X is suffering from cancer and other comorbidities associated with it and require immediate medical attention due to worsening health condition.
Consider the patient
The patient is Mrs X is a 48-year-old-female. She is suffering from Sigmoid Adenocarcinoma Stage IV. The patient has a past medical history of dark and bloody stools and she has been dealing with this over the last two months. The patient was admitted to the hospital after she suffered bloody diarrhoea and stomach cramps, on the recommendations of her professional general practitioner (GP). She also underwent a colonoscopy a week earlier. The colonoscopy examination suggests that Mrs X has a lesion of the sigmoid colon and laparoscopic sigmoid colectomy. In addition to this, she had mild hypertension and hyperlipidemia. Mrs X’s father died by cancer at the age of 64 and the origin of cancer was unknown. She is married and has 2 children. Her children are aged 20 and 23. She does not live with her husband now as she is separated from him. The patient is complaining of immense pain and her bowels did not open from last three days.
The body assessment by the nurse is made with acute observation and care. In the case of Mrs X her vital sign shows that she has a temperature of 37.6, pulse rate 74, blood pressure is 170/80 and respiration rate is 24. Her blood test results shows that her CEA> 27ng/ml, CA is 19-9> 120 U/ml, neutrophils are <500/mcl and Hb is 89. Mrs X blood pressure is found to be elevated as the normal blood pressure of the healthy individual is 120/80 mmHg (Edelman et al., 2017). The standard range of temperature is 37 degree Celsius and hence Mrs X has normal body temperature (Boron & Boulpaep, 2016). Also, Mrs X pulse rate is normal as it falls in between 60 to 100 pulses per minute (Ignatavicius & Workman, 2015). Mrs X respiration rate shows unstable ranges (normal range of RR is 12 to 20 breaths per minute) (Jeong et al., 2016). She has severe pain as it is 8/10 on the pain scale (Meyer et al., 2018). According to Jeong et al. (2016), the patient may have cancer is he/she has elevated CEA levels and also 19-9 CA levels are attributable to the cancerous condition. Further, Hb levels are very high which indicates anaemia (Ugwu, 2018).
Process the information
Mrs X has Stage IV Sigmoid Adenocarcinoma, but there is an increased co-prevalence of cancer and hypertension, as these disorders bear the same risk factors such as unhealthy lifestyle, stress, unemployment, alcohol intake, and poor diet (Watson & Preedy, 2019). Also, Mrs X has high blood pressure due to medicines used in cancer treatment such as erythropoietin, corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) as well as cervical radiotherapy trauma to the carotid bar receptor may also have boosted blood pressure (Souza et al., 2015). Due to poor pneumatic core inputs, the irregular breathing rates increase the inspiratory time, enabling tidal volume to increase. The apneustic centre activates the neurons of the medulla and the expiratory neurons are blocked. The over-stimulation of this region produces long, coughing inspirations that are insufficiently interrupted by intermittent expirations (Whited & Graham, 2018). CEA is a type of oncofetal glycoprotein released by the cells of the mucosa. It is up-regulation that can be more often correlated with colorectal cancer attributable to a certain range of tumours (Asad-Ur-Rahman & Saif, 2016). Also, she is neutropenic.
Understand the patient’s problem
The problems and issues of the patients are exhibited by the signs and symptoms of the patients are considered in this stage (Simpson et al., 2016). The major nursing issues, in this case, includes the assessment of high blood pressure, CEA, Hb, CA, and respiration rate that is regular monitoring of vitals. Also, there is a need for pain management for Mrs X. Thirdly she has lost weight 6 kg in the last two weeks so she needs patient education on diet management (Peter et al., 2015). The three priority nursing issues following the assessment data would be pain management, monitoring of vitals and patient education including diet modification. Using pharmacotherapy all these can be maintained.
PART 2: Planning Care and Evaluating Outcomes
Plan and implement interventions
The goals developed in the nursing practice aims to be “SMART” i.e. they should be “specific, measurable, attainable, time-bound and realistic” (Aghera et al., 2018). The first goal will be the monitoring of vitals. All tests are frequently checked to maintain patient safety, blood testing and blood pressure. In order to assess early signs and symptoms of clinical deterioration, it is of crucial importance to perform continuous monitoring of vitals (ACSQH, 2019). This can be addressed by regulating the respiratory rate, blood pressure and pain level (Steinfeld et al., 2016). For managing blood pressure she will be administered with perindopril as prescribed by the doctor. Perindopril is an effective ACE-inhibitor which helps in maintaining high blood pressure and improves the condition of heart failure (Elliott & Bistrika, 2018). According to Finnerup et al. (2015), severe pain could be a reason for severe discomfort, restlessness, high blood pressure and sleeping problems. Assess the incision and monitoring for unusual bleeding or scar infection as a nurse is essential.
The second priority is to maintain the patient's pain condition and discomfort as it ranges 8/10 on the pain scale (Meyer et al., 2018). This state of the patient can be managed by providing medications, as recommended by the physician. The medications recommended are drugs such as antibiotics that help relieve the pain and distress of the patient (Coppini, 2016). Focusing on the pain management of the person is an important priority for the nurse (Finnerup et al., 2015). Complications such as decreased exercise, psychological disorders, decreased dialysis compliance worsen unless the pain is controlled (Raouf et al., 2017).
The third priority will be patient education that includes describing the anatomical changes, explaining the toilet position, exercises and assuring that improvements will be attained to minimize stress and overcome sleeping problems. Also, she has lost weight in the last two weeks so it is crucial for nurses to provide her education on diet. Patient education regarding diet would be crucial as Mrs X is suffering pain and her blood test results show abnormal values of CEA, CA, and Hb that can be modified by taking adequate diet to maintain the immune system and to respond to infections. Also, to maintain her body weight education on diet is of primary importance this can be done using the teach-back method to ensure that the patient understands all the important information given by the nurse (Peter et al., 2015).
Pursuant to Standard 5 of nursing and midwifery standards, registered nurses are expected to record, assess and amend their procedures according to the patient's needs and situation (NMBA, 2017). In Mrs X’s condition, several modifications can be noted. When her bowels opened she felt less pain and was able to sleep well. Also, Mrs X started eating properly and her blood test results were also improved. After nursing interventions and chemotherapy, her CEA, CA and Hb results are modified and positive outcomes can be seen.
Following standard 1 of nursing and midwifery standards, it is important for the nurse to reflect on their experiences in order to enhance their future practices and learning from them (NMBA, 2016). Mrs X’s condition was very serious and she was suffering from pain more than normal also she was very weak and facing this from the last few weeks this made me compassionate and caring towards her. I used effective communication skills using non-verbal and verbal cues which made the patient comfortable in expressing her individual needs. Also, interventions set by me improved her condition and her chemotherapy improvement is seen in her vital signs, blood test reports and also pain scale. Other interventions can be provided for the betterment of the patient if the priority nursing strategies do not provide effective results.
For efficient decision making in nursing practise "clinical reasoning cycle" is a reliable approach. The application of critical analysis and logical reasoning skills increases patients' quality of treatment. To address the clinical deterioration faced by the patient, all the steps of CRC were implemented. Strategy for controlling the pain and monitoring of vitals and blood test reports were followed, and a reflection by the nurse was performed to relate to the learning's gained by the nurse.