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Integrated Nursing Practice

Introduction to Clinical Reasoning and Decision-Making

Clinical reasoning and decision-making are the mechanisms of thought and techniques that the nurses use to interpret knowledge and distinguish between options to recognize medical issues in consideration for medical diagnosis and evaluation of findings and treatments in clinical practice (Hawkins et al., 2019). In the given essay two case studies of different patients of different age have been discussed who is suffering from some health conditions and similar symptoms. The nurses use clinical reasoning and decision-making to address the health condition of the patient that is an imbalance of fluid and electrolytes. Excessive quantities of fluids in the body or dehydration may result from an excess of fluids and electrolytes. Mostly as a consequence of a transition in body processes, serious illness, certain drugs, or an underlying disease, this will occur. Electrolytes control the work of nerves and muscles, moisturize the bloodstream, regulate acidity and pressure in the blood, and then further repair weakened tissue (Paz, 2019).

Both the patients Poppy Sutherland who is 4-year-old and Mary Smith who is 85-year-old in the given study have normal temperature respiration rate, oxygen saturation levels. The heart rate of the child Poppy is also stable while the other patient heart rate is irregular showing the HR at 108 beats per minute. Both the patients are undergoing pain and abdominal cramping. Low blood pressure is when your blood pressure reading is lower than 90/60 mm Hg. Both the patients are showing the signs of dehydration as their lips are pale, the tongue is dry and showing a capillary refill > 1 sec. There is been no urine output in the patient for the past 8 hours. The most common cause of reduced urine production is dehydration. Dehydration usually happens when an individual becomes sick with diarrhea, vomiting, or another disease, and may not recover the fluids that person loses. When this happens, human kidneys retain as much fluid as possible. The ingestion and release of fluid and electrolytes usually take place in the intestine (Takada et al., 2020). A stable human, for example, drinks with much less than two liters of fluid per day. Approximately seven liters are attributed to saliva and body fluids from the throat, pancreas, and liver, allowing a maximum of around nine liters which reach the intestinal tract each day. There, the villi progressively absorb fluids and electrolytes and the crypts of the intestinal epithelial cells secrete them (Hegyi et al., 2018). Two-directional water flow and electrolytes from the gastrointestinal tract and the bloodstream is caused by this. Although fluid absorption is usually greater than the secretion of fluid, fluid absorption is the net effect. Approximately 90% of the liquid that enters the gastrointestinal tract is normally drained, meaning only one liter exits the lower intestine. Some more absorption takes place there, with just 100 to 200 milliliters of fluid excreted in shaped stools per day (Kotloff, 2017). Each shift in the two-directional distribution (i.e. enhanced secretion, decreased absorption, or even both) of fluid and electrolytes in the intestinal wall leads in either decreased net absorption or net secretion and allows an enhanced amount of fluid to reach the large intestine. Diarrhea happens as this reaches its minimal absorptive ability (Walton, 2016).

The pain is assessed by the observational pain scale in the child as the child is not able to understand the other assessment methods. The observation pain scale in the child Poppy showed the pain 4/10 while in the other patient Mary the pain was self-reported as 6/10. The blood pressure of both the patient Poppy and Mary is low showing a reading of 88/50 and 105/60 respectively. Due to a drop in blood flow, dehydration can cause low blood pressure. Blood volume refers to the amount of fluid in the veins and arteries that are flowing. It is essential to maintain regular blood flow for blood to be able to enter all of the body's tissues properly. The amount of blood will reduce when a person is quite dehydrated, leading to a decline in blood pressure. The organs won't get the oxygen and other nutrients they require when blood pressure falls too much (Rust & Ekmekcioglu, 2016). Possibly, a patient may go into trauma. A proxy disorder for serious dehydration is a diarrhoeal disease, a serious public health problem for children and adults worldwide. Recent studies have investigated the relationship between diarrhea in childhood and BP, taking advantage of established cohorts in developed countries. Dehydration may lead to increased BP in infancy, that could be maintained into adulthood, by various pathways. Elevated BP is closely linked to stroke, particularly hemorrhagic stroke, in adulthood. Blood pressure can also be caused to decline by a reduction in blood flow. Significant blood loss due to serious injuries, vomiting, or extreme internal bleeding lowers the amount of blood, leading to a severe decrease in blood pressure. A reduction in the amount of blood can result in a potentially harmful decline in blood pressure and even shock. Through drinking lots of water, one can avoid dehydration. If you're sick, in a warm climate, or physically involved, this is very important (Fortes et al., 2015).

In fluids in the body, electrolytes are present. In a child or adult, dehydration may disrupt the fragile balance of electrolytes. Because of their small size and quick metabolism, children are extremely susceptible to dehydration, which allows them to replace fluids and electrolytes at a higher pace than adults. A disease that induces extreme vomiting, diarrhea, and high fever, as well as taking medicine that triggers prolonged urination, raises the risk of fluid and electrolyte damage. The risk of dehydration may also be raised by profuse sweating from strenuous exercise (Koziolek et al., 2018). In children with a severe underlying medical disorder, fluid and electrolyte disruptions are normal. For example, children with chronic kidney disease, a disorder that inhibits these organs' capacity to sustain sufficient amounts of fluid and electrolytes, are at risk. Substances called electrolytes in your blood, including potassium, sodium, calcium, and magnesium, help activate and execute your heart's electrical impulses (Rust & Ekmekcioglu, 2016). Electrolyte levels can increase or too low will influence the electrical impulses of your heart and lead to the production of arrhythmia.

Setting large nursing priorities makes it possible for them to be subject to interpretation. The SMART structure is used to set patient goals and to fulfill them as soon as possible. When establishing their objectives, SMART is an acronym for the criteria nurses can use. Nursing goals can often be long-term, and how you view the target they set through alter your atmosphere and personal opinions (Lewis et al., 2016). In certain situations, the stage of development will alter the action and reaction of a drug, a distinction in pharmacodynamics that depends on age. Concerning both the desired action and adverse incidents, this may be valid.

S-The patient will show a decrease in the amount of vomiting and diarrhea after 4 hours of medical intervention.

M- Note the stool and nausea frequency and report it. Properties, quantity, and precipitating factors. Promote patients' bed rest.

A- Have bedside toilet seat, recognize nutrition and hydration that precipitate diarrhea, resume oral hydration levels progressively. Provide transparent liquids on an hourly basis to prevent cold fluids.

R- Rest reduces intestinal microbiota and decreases the rate of metabolism. Cramping and stomach pain can be avoided by gradual intake of fluids. Intestinal rest is facilitated by eliminating intestinal irritants.

T- After 4 hours of nursing intervention, the patient was able to report a reduction in the frequency of stools.

Both in and out of the cell, human body cells are covered in liquids. The water inside constitutes one-half to two-thirds of the mass of an average human. Intracellular fluid (ICF) is considered liquid within the intracellular and tissue fluid (ECF) is called fluid outside the cells. Water and soluble solutes and proteins are found in intracellular fluid. The substances are electrolytes, which play a major role in the processes of the physiological body. Water and electrolyte imbalance can lead to increased quantities of fluid or deficiency throughout the body. As a result of a shift in body processes, chronic illness, certain drugs, or an intrinsic disorder, this may occur (Sherwood, 2015).

Patients who vomit can quickly become dehydrated and have stomach cramps. Electrolytes, urine performance, and the mental state of patients should be regularly monitored. The nursing interventions for both the patients are to make them drink fluids this intervention can be managed at home for both the patients. To prevent dehydration, it is important to drink plenty of fluids. To avoid dehydration, an Oral Rehydration Solution (ORS) should be used. It is possible to have traditional home alternatives such as boiled rice water, brined yogurt beverages, vegetables, and chicken soups with salt. It includes drinking water, specifically potassium and sodium, with moderate quantities of sugar and salts (Moghazy et al., 2016). If symptoms worsen, it is advised to delay the procedure for 10 minutes and then resume it slowly. It functions by increasing the absorption of sodium by glucose and thereby watering the digestive system. The other nursing intervention is to monitor the infusion rate of parenteral fluids closely. The nurses might have to use an infusion pump, as necessary because the patient is small and aged. The nurses can use infusion pumps as both the patients Poppy and Mary are extreme age. the rapid fluid bolus or prolonged excessive administration can potentiate volume overload and risk of cardiac decompensation (Gorski, 2017). So, this intervention has to be closely monitored and performed by the nurses themselves. In certain situations, the stage of development will alter the action and reaction of a drug, a distinction in pharmacodynamics that depends on age. Concerning both the required outcome and adverse incidents, this may be valid. In addition, medication may also change progress, permanent or temporary, and solely for fetal life and childhood.

 The instructions would be given to the carer to evaluate the efficacy of the interventions. The family members can keep a check on the urine output of the patients. A track on Measure of fluid losses can be done through this method. The urine output for the child and adult will vary in normal conditions. The child urine output will be more than 1 ml per kg per hour and the adult urine output will 5 ml per kg per hour. The need for fluid substitution is focused on the adjustment of existing deficits and continuing losses. Hypovolemia may be demonstrated by reduced urinary production, inadequate renal perfusion or polyuria may be established, requiring more vigorous fluid replacement (Langston, 2017). Skin and mouth care must be given to patients. Due to various vasoconstriction and diminished intracellular water, the skin and mucous membranes are dried with reduced elasticity. Bathing daily can increase dryness. Weigh the patient regularly and measure the intake and production for 24 hours. Although intravascular volume does not accurately represent hydration levels and fluid gain greater than output, these measures provide valuable information for decision making.

Conclusion on Clinical Reasoning and Decision-Making

In certain situations, the stage of development will alter the action and reaction of a drug, a distinction in pharmacodynamics that depends on age. Concerning both the desired action and adverse incidents, this may be valid. Drug programming is often a phenomenon that is almost unique to early life, i.e. lasting effects arise from stimuli, often in fetal or neonatal life, introduced at a vulnerable point in development ('critical window'). Independent pathophysiology, different causes of illness, separate pharmacodynamics, separate site reactions, and numerous adverse drug events may all clear why some children's medications behave differently. However, by deciding how information from adult human and animal models can help guide study and practice for kids, we, therefore, need to examine ways to avoid post-inventing the cycle. This brings up the question as to whether the use of the similar characteristics between children and adults in basic biochemical, cellular, and organ processes to help shorten the studies needed to move a drug from design to bedside.

References for Clinical Reasoning and Decision-Making

T., Chinda, D., Mikami, T., Shimizu, K., Oana, K., Hayamizu, S., & Makino, H. (2020). Dynamic analysis of human small intestinal microbiota after an ingestion of fermented milk by small-intestinal fluid perfusion using an endoscopic retrograde bowel insertion technique. Gut Microbes11(6), 1662-1676.

Fortes, M. B., Owen, J. A., Raymond-Barker, P., Bishop, C., Elghenzai, S., Oliver, S. J., & Walsh, N. P. (2015). Is this elderly patient dehydrated? Diagnostic accuracy of hydration assessment using physical signs, urine, and saliva markers. Journal of the American Medical Directors Association16(3), 221-228.

Gorski, L. A. (2017). The 2016 infusion therapy standards of practice. Home Healthcare Now35(1), 10-18.

Hawkins, D., Elder, L., & Paul, R. (2019). The Thinker's Guide to Clinical Reasoning: Based on Critical Thinking Concepts and Tools. Rowman & Littlefield.

Hegyi, P., Maléth, J., Walters, J. R., Hofmann, A. F., & Keely, S. J. (2018). Guts and gall: bile acids in regulation of intestinal epithelial function in health and disease. Physiological Reviews98(4), 1983-2023.

Kotloff, K. L. (2017). The burden and etiology of diarrheal illness in developing countries. Pediatric Clinics64(4), 799-814.

Koziolek, M., Grimm, M., Schneider, F., Jedamzik, P., Sager, M., Kühn, J. P., & Weitschies, W. (2016). Navigating the human gastrointestinal tract for oral drug delivery: Uncharted waters and new frontiers. Advanced Drug Delivery Reviews101, 75-88.

Langston, C. (2017). Managing fluid and electrolyte disorders in kidney disease. Veterinary Clinics: Small Animal Practice47(2), 471-490.

Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems, Single Volume. Elsevier Health Sciences.

Moghazy, A. M., Adly, O. A., Elbadawy, M. A., & Hashem, R. E. (2016). Evaluation of who oral rehydration solution (ORS) and salt tablets in resuscitating adult patients with burns covering more than 15% of total body surface area (TBSA). Annals of Burns and Fire Disasters29(1), 43.

Norsk, P., Asmar, A., Damgaard, M., & Christensen, N. J. (2015). Fluid shifts, vasodilatation and ambulatory blood pressure reduction during long duration spaceflight. The Journal of Physiology593(3), 573-584.

Paz, J. C. (2019). Fluid and Electrolyte. Acute Care Handbook for Physical Therapists E-Book, 16379.

Rust, P., & Ekmekcioglu, C. (2016). Impact of salt intake on the pathogenesis and treatment of hypertension. In Hypertension: from basic research to clinical practice (pp. 61-84). Springer, Cham.

Sherwood, L. (2015). Human physiology: from cells to systems. Cengage learning.

Walton, S. (2016). Gestational hypoxia and programming of disease. The University of Queensland. https://doi.org/10.14264/uql.2017.42

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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