Application of Clinical Reasoning Skills

APPLICATION OF
CLINICAL REASONING
SKILLS FOR CLINICAL
PATIENT SCENARIO

Table of Contents
CASE STUDY.................................................................................................................................1
1.1 Pathophysiology of Angina..............................................................................................1
1.2 Physical Nursing Assessments.........................................................................................2
1.3 Nursing Interventions for improving physiological outcomes ........................................3
1.4 Analysis of administration of sublingual Glyceryl Trinitrate...........................................4
1.5 Abnormal findings needed to be reported immediately...................................................6
REFERENCES................................................................................................................................7

CASE STUDY
1.1 Pathophysiology of Angina
Cardiovascular disease is the prime cause of deaths in Australia. Annually, more than
353,000 Australians are affected by this disease and nearly 72,000 hospitalized (Suzanne
Albrecht, 2013). Angina or angina pectoris is a type of predictive heart condition that arises
when the heart is not able to supply sufficient amount of oxygen and blood to myocardium for
meeting its needs (Boden and et.al. 2012). It is caused by myocardial ischaemia or emotional
stress and exertion. Coronary arteries are responsible for supplying oxygen and blood to heart
muscles, in case these arteries narrow down, the heart muscle is unable to function properly
leading to development of fatty plaques in the walls of arteries. This phenomenon is known as
'Atherosclerosis' (Economou and et.al,2015). A patient can experience stable or unstable angina,
however, it should not be confused with a heart attack as the former is only temporary in nature
and does not damage one's heart muscles. In the given case scenario, Jon Edwards has been
diagnosed with Angina condition for last 3 years. Symptoms of Angina include chest pain with a
feeling of squeezing, pressure or tightness, pain in arm, shoulder, neck or back, unable to breathe
properly, fatigue, sweating, dizziness and nausea. Jon's past history shows that he has been a
regular smoker consuming 20 cigarettes per day for 25 years until now with fairly healthy eating
habits and regular consumption of red wine (four times) per day.
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Risk factors of angina – Out of 90% Australians, at least one has risk factor for heart
diseases. These risk factors associated with this disease are both modifiable and unmodifiable in
nature including tobacco use, diabetes, high blood pressure and blood cholesterol, older age, lack
of exercise, stress and obesity.
Preventive strategies
 Thus, in terms of preventative pharmacology, Jon has been suggested to quit smoking
which he has recently and in order to reduce stress he walks his dog daily.
 Some of the preventative measures that can be adopted by a patient of such disease
include quitting smoking, maintaining a healthy diet, reducing stress, limit alcohol
consumption, regular check-ups and increased physical activities (Harskamp and et.al.,
2013).
 Since he is 64 years old, his condition cannot be treated completely although it is
preventable.
 Angina can be treated through medication and surgery as well as adopting healthier
lifestyle choices.
 Medication usually includes nitrates that dilate blood vessels and increase blood flow to
heart. Jon is prescribed Aspirin that helps in preventing clots in narrowed arteries, he
should reduce alcohol consumption and include additional exercise to treat high blood
pressure and stress.
1.2 Physical Nursing Assessments
Assessment is a crucial part of nursing practice regulated by Nursing and Midwifery
Board of Australia (NMBA). A physical nursing assessment helps in obtaining complete
assessment of the patient. These assessment includes history, observation and inspection,
palpation and auscultation (Jukema and et.al., 2012). As chest pains can be false alarms it is
important to confirm angina by assessing other symptoms that trigger it. Typically, angina shows
sign of discomfort or pain in chest, arms, shoulders with tightness and burning sensations.
ECG – The most important diagnostic tool to evaluate angina is ECG. However, ECG
cannot be used in isolation to fully evaluate the left ventricle's posterior, lateral and apical walls.
Jon has been hospitalized with cellulitis and has a medical history that shows signs of
alcoholism, smoking, hypertension, hypercholesterolemia and Angina for past 3 years. A
standard 12 lead-ECG or Electrocardiogram report is a medical test that can help in diagnosing
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any kind of severity in Jon's heart condition in the past three years by mere comparison of
current and previous ECG reports.
As far as observation or monitoring is concerned, electrocardiograph findings may not be
detected through this assessment (Kemp and Conte, 2012). On the other hand, observation
assessment can be helpful to determine the mental health of Jon to see whether he is depressed or
overstressed as high stress levels can be a trigger to angina attacks too. This can also be done
through stress testing using a bicycle or a treadmill for patients that are allowed to exercise.
Additionally, a nurse can assess the weight of Mr. Edwards to ascertain whether he is obese or
not as these factors will help in verifying his high blood cholesterol levels and blood pressure.
Another assessment that can be carried out for Jon involves imaging coronary arteries through
CT Scan – Computed Tomography (CT) scans (Latsios and et.al., 2013). As mentioned
earlier, narrowing of coronary arteries results in angina pectoris, a CT scan of the arteries
without contrast injection can help in finding a correlation between coronary calcification and
degree of luminal narrowing. If the patient tends to have a high risk of uncontrollable
cardiovascular outcome, angiography must be recommended. Also, lifestyle habits of Jon should
also be monitored by keeping him under a strict diet with low or no consumption of alcohol and
increased physical activities incorporated in it. This is because smoking and alcoholism are
strong and independent risk factors that contribute to increased blood pressures, obesity and
possibility of developing Type 2 Diabetes.
Chest X- ray – This includes the criteria to take images of heart and lungs which is
helpful to observe enlarged hearts to determine situation of angina which can be used in case of
Jon in order to analyse the same.
1.3 Nursing Interventions for improving physiological outcomes
Nursing interventions include treatments and actions performed by a nurse to help a
patient attain goals that are set for them using critical thinking skills, knowledge and experience.
There are three types of Nursing interventions namely independent, dependent and
interdependent actions (Lippi and et.al., 2012).
 Independent actions are those that a nurse is able to carry out independently such as
health promotion.
 Dependent actions require permission from another healthcare provider such as a
physician or a doctor and cannot be carried out solely by a nurse.
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 Interdependent actions need participation of a number of members of health care team.
In the context of given case scenario, the nursing interventions that would help in
improving physiological outcomes for Mr. Jon Edwards suffering from Angina pectoris would
include instructing Jon to stop all activities and take rest in a semi-Fowler's position and
administer his nitro-glycerine sublingually. Semi- Fowler's Position helps in reducing pain,
nausea and provides comfort, especially to cardiac patients, by inclining the patient's bed at angle
of 30 to 45 degrees. As Jon is experiencing severe chest pain, a semi-Fowler position will help in
reducing tightness around the chest and keep him from fainting due to severe nauseousness. A
diagnosis would be carried out for calculating death anxiety levels and stress to explore its
implications on the illness on the basis of which important preventing measures will be listed for
Mr. Edwards. Since depression and stress have a direct effect on heart, emotions and mental
health of an individual it is important to prevent progression of such variables to extremity
(Moreno and Clancy, 2012). Apart from this, a review of assessment findings through ECG tests,
CT Scans, Stress Testing help in identification of extent to which Jon's pain was caused. This
will help in planning his daily activities for reducing future probability of experiencing an angina
spasm.
 While angina is caused due to shrinkage in coronary arteries, it is important that proper
activity plans must be enforced including Mr. Edwards family and pets to ensure proper
balance is maintained between his oxygen demand and supply by following such
activities.
 These may include incorporating treadmill routine in his lifestyle along with healthy
meals comprising fruits, vegetables and whole grains along with low-fat dairy products
like skim milk, low sodium-level foods, chicken,fish and beans.
 These staples will help in keeping blood pressure controlled to 130/180 and HbA1c as
well as blood sugar at recommended levels which will ultimately reduce cholesterol,
diabetes and obesity.
1.4 Analysis of administration of sublingual Glyceryl Trinitrate
Sublingual Administration pertains to placing a drug under patient's tongue to dissolve
to assure that the drug is absorbed in the patient's blood through underlying tissues present near
tongue(Hochgruber and et.al., 2014).
Benefits of Glyceryl Trinitrate (GTN) in angina
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 Glyceryl Trinitrate (GTN) is a medication that belongs to the 'nitrates or vasodilators'
category of medicines that helps in relaxing muscles surrounding blood vessels and
enables an increase in supply of blood and oxygen to reach heart.
 It is also used to control blood pressure while performing surgical procedures (Radico
and et.al., 2014).
 GTN provides immediate relief to a patient during an angina episode.
 Mr. Jon has been experiencing an episode of angina pectoris, with a low BP of 110/90
and irregular pulse rate of 110 bpm, a sublingual GTN tablet will provide immediate
release of pain in the chest area.
Risks to use Glyceryl Trinitrate (GTN) in angina
 If a person has problems related to functioning of liver and kidneys then GTN is not
appropriate.
 If patient has problem of low blood pressure then GTN should be avoided.
 If a person has an issue of underactive thyroid and eye condition called glaucoma then it
use of GTN is risky.
To ensure proper administration of sublingual Glyceryl Tri-nitrate (GTN), Mr. Edwards
must sit upright otherwise it could lead to accidental inhalation of medication. It should be taken
at the first sign of an angina attack and must dissolve under Jon's tongue in 5 to 10 minutes since
oral swallowing of GTN tablet would not act fast to relieve the pain as it will be absorbed
through digestive system rather than blood. If the chest pain does not reduce in 15 minute period,
Jon would be given 1 tablet every 5 minutes to relieve the pain.
As mentioned earlier, a physical nursing assessment was carried out on Mr. Edwards that
included ECG tests, making Mr. Edwards sit in Semi-Fowler's position and administering
nitroglycerin sublingually.
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The rhythm strip above shows a regular tracing with constant intervals except once where
there has been a considerable drop in the tracing. An irregular pulse rate of 110 bpm shows
approximately 14 boxes divided into 1500 going low at Biphasic P wave then retracing back to
its normal level (Shu and et.al., 2012). The U wave has become a flat line and has even dropped
before forming R wave showing a huge drop in the pulse rate with a flat-line. This shows that the
angina attack was rather severe for Jon but he was able to stabilize his heart rate with uniform
intervals in PQRSTU Waves.
1.5 Abnormal findings needed to be reported immediately
An abnormal Electrocardiogram (ECG) usually indicates variations in heart rhythms or
signals any medical emergency in relation to presence of myocardial infarcation or heart attack,
or arrhythmia. Jon underwent a standard 12-lead ECG test, the abnormalities in ECG findings
include contraction of heart muscle due to electrical depolarisation of cells in Sinus Node located
in right atrium of myocardium (Tarkin and Kaski, 2013). Also, the heart rate has measured up to
110 beats per minute which is higher than normal rate showing that heart is beating at an
abnormally faster rate. Apart from this the Respiratory rate (RR) is recorded at 24 breaths per
minute which is abnormal and Jon must be kept on oxygen mask to ensure restoration of normal
RR between 12 to 20 (Torres-Alba and et.al, 2013).
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REFERENCES
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Online
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Suzanne Albrecht, 2013. [Online]. Available through:
<https://www.uspharmacist.com/article/the-pathophysiology-and-treatment-of-stable-
angina-pectoris>.
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