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This essay entails reflection of a case study and development of medical management in practice of nursing by implementing clinical reasoning cycle. As a nurse it is vital to implement the clinical reasoning cycle in our daily practice for ensuring better outcomes. According to Gummesson, Sunden & Fex, (2018), The 8 stages of the clinical reasoning cycle involve, “considering the patient’s situation; Collecting information; Process the information; Identify the problem; Establish goals; Take action; Evaluate outcome and reflection.”
The first of CRC as a nurse is to appreciate the impact of understand patient’s need in the clinical practice. It requires laying emphasis on the crucial details which help in concluding the need or the requirement of the patient (Gummesson, Sundén, &Fex, 2018).” Upon close appearance Mr Hardden looked flushed and anxious. He has been severely fatigued and had trouble breathing and speaking together. On actively listening to the patient he revealed that the main his main concern is anxiety and chronic worsening of his symptoms. Hadden is a 63-year-old male who having discharged 3 weeks ago from the hospital due to Left lower lobe pneumonia, presented to the GP 4 days ago for a viral infection which caused exacerbation of his COPD symptoms. According to the NMBA standard of Nursing (2016), it is my duty as a nurse to provide a safe practice to obtain the desired treatment outcomes in the patients. I realized that I must counsel the patient to be calm and check the medical history of the patient and assess him further to develop a goal in which we can work on collaboratively to improve his present condition.
Stage two involves assembling the relevant data of the patient. Such as personal history; past history as a part of assessment. I also observed her charts. The past medical history of the patient stated that he is mildly hypertensive for which no medication has been prescribed to him. He also has obstructive sleep apnea or OSA for which he uses CPAP (continues positive airway pressure). It was also found that he has a positive smoking history of 40 years and is a current smoker, which interprets as 20 cigarettes per day. Mr Hadden stated that he is taking his prescribed medications daily except that he continues to smoke daily as well. His medications include bronchodilators, corticosteroids and antibiotics. He also stated that he cannot take the oxygen out of his house as it makes other people stare at him and he feels awkward about it. His vitals were such as blood pressure, heart rate, and respiratory rate were normal but he had poor oxygen concentration of 92% SPO2.
Stage three is comprised of using the obtained information and processing in into clinically useful data based on medical knowledge. As it was found that the patient is a smoker, I recalled that it could be the main cause in exaggeration of his symptoms and may act as a hurdle in the process of recovery in COPD and related complications (Heath, n.d). The patient was on Corticostroids, this is also adding to the risk of drug interaction leading to adverse situations such as aggravating the feelings such as nausea and vomiting (Moro et al, 2013).
The low level blood oxygen in the patient suggested his hypoxemia (Levett-Jones, 2010; Cope et al, 2013). As per the information, it seems has not been compliant with smoking cessation and modifications required in his daily activities. I was connecting the dots here regarding the association of COPD to smoking which I studies in the lectures. I was making mental notes regarding referring the patient for psychology consult. I made a note to discuss it with my supervisor, because as per NMBA, 2016, it is important that the nurse practices within their scope of practice.
Stage four is comprised of recognizing the issues or concerns which in the given case study is anxiety and dyspnea. The problems identified with the patient are the smoking habit (Ohno et al, 2020). Being over-weight and having high blood pressure is also another problem which needs immediate medical attention. As the patient is suffering from chronic bronchitis, it is vital that the patient is educated about the condition and implications that it may have on his health. During the hospital stay it was noted that patient was not irritated with loud noises; it was also noted that the patient did not like to have any visitors and just wanted to lie on his bed and spend time alone with himself. He was mostly quiet and did not talk to anyone or read anything.
According to the NMBA standard of Nursing standard 6.4, “It is the duty of the nurse to provide timely directions and supervision so that care is safely delivered to the patients. The term COPD refers to narrowing of the airways die to collection of sputum in them which restricts the entry of the oxygen to the blood. It causes spasm in the airways, reducing the capacity of the elasticity which is required to exchange the blood gases between the atmosphere and the body. The role of bronchodilators is to re-establish the elasticity of the airways in order to have effective flow of blood gases and optimize the flow of oxygen into the lungs. Smoking causes further constriction of the airways of the lung and hence known to exaggerate the symptoms of dyspnea.
The fifth stage involves establish goals for the patient. The first goal is to exercise lifestyle modification such as exercise and smoking cessation. It is also important that the Mr Hadden is put into pulmonary rehabilitation for a certain duration of time to improve his endurance capacity (Rutter & Harrison, 2020). Apart from this medical management also plays a very important role in management of COPD. Mr Hadden must use CPAP as and when necessary. He must be counselled to use CPAP also while going out.
The sixth stage involves taking action. It was conveyed to the patient that she will have to quit smoking as it is a serious health risk factor for patients with COPD and respiratory problems such as pneumonia and OSA. I also encouraged the patient to use Nicotine patches and cut down daily count of cigarettes gradually, in order to avoid withdrawal symptoms due to sudden cessation of smoking. I also encouraged the patient to exercise and walk which also helps in reducing stress (Bainbridge et al, 2015) and advised to take care of diet which is essential in controlling high blood pressure. I also provided few educational hand-outs regarding “how to control high blood pressure” and “how to stop smoking”, and gave useful exercise and dietary videos to the patient. Extensive oxygen therapy along with increase dose of bronchodilators was advised after discussing with my supervisor.
In the seventh stage of evaluating the patient outcomes, it was noted that there was a significant level of improvement in patient’s blood glucose levels and her blood pressure was also between the flags. Improvement was also seen in weight loss and improved enthusiasm in the body activities. Patient was also able to regularly monitor her blood sugar levels. It shows that the medicinal education had been useful as well as effective. It was also noted that the patient was feeling happy and he smiled more often. Patient’s mood was elevated on presentation; it indicates that the treatment for depression was working and that his depression was under control or being well-managed.
The eight stage comprises of reflecting upon the entire situation, I learnt that taking care of the person’s needs. During the medical management of the patient, I realised the importance of educating the patient regarding his condition. I improved compliance. Applying the principles of clinical reasoning cycle has helped me in gaining holistic approach in nursing practice. I believe that in future, this will help me to understand and relate with the patients of aboriginal or Torres Strait background come to the hospital and understand the reason for them having suffering panic attacks and anxiety.
1. Bainbridge, R., McCalman, J., Clifford, A., &Tsey, K. (2015). Cultural Competency in The Delivery of Health Services for Indigenous People. Retrieved from https://www.aihw.gov.au/getmedia/4f8276f5-e467-442e-a9ef-80b8c010c690/ctgc-ip13.pdf.aspx?inline=true
2. Cope, S., Donohue, J. F., Jansen, J. P., Kraemer, M., Capkun-Niggli, G., Baldwin, M., ... & Jones, P. (2013). Comparative efficacy of long-acting bronchodilators for COPD-a network meta-analysis. Respiratory research, 14(1), 100.
3. Gummesson, C., Sundén, A., &Fex, A. (2018). Clinical reasoning as a conceptual framework for interprofessional learning: a literature review and a case study. Physical Therapy Reviews, 23(1), 29-34.
4. Heath, S., (n.d.). How Patient Education Tools Improve Chronic Disease Management. Retrieved from https://patientengagementhit.com/news/how-patient-education-tools-improve-chronic-disease-management
5. 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.
6. Nursing and Midwifery Board of Australia. (2016). Standards for Practice: Enrolled Nurses.
7. Ohno, Y., Iwasawa, T., Seo, J. B., Koyama, H., Takahashi, H., Oh, Y. M., ... & Sugimura, K. (2020). Multi-Center Study for Clinical Stage Classification of Smoking-Related COPD: Oxygen-Enhanced MRI vs. Quantitatively Assessed MDCT.
8. Rutter, P. M., & Harrison, T. (2020). Differential diagnosis in pharmacy practice: Time to adopt clinical reasoning and decision making. Research in Social and Administrative Pharmacy.
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