Clinical Reasoning Cycle Essay

This essay discusses the implementation of the clinical reasoning cycle in assessment of a patient and planning care taking the case study of a case study.

Running head: CLINICAL REASONING CYCLE ESSAY
Clinical reasoning cycle essay
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CLINICAL REASONING CYCLE ESSAY
Introduction:
With the advancements in the health care industry, the legal and legislative practice
essentials and standards are also continually expanding with more and more complexities
being involved (Koivisto et al., 2016). Hence, not only the nurses have to address each of the
diverse care needs of different patients, they have to adhere to all of the legislative and ethical
code of conduct and professional standards at all times. As discussed by Xiao et al. (2015),
the ever-changing provisions in the ethical and professional standards for nurses and ever
increasing patient demands often tends to confuse and overwhelm the nurses regarding the
extent of their responsibilities and scope of practice. In support, authors have also mentioned
the fact that new nurses that are transitioning into practice face the most challenges while
keeping up with the plethora of job roles and responsibilities. The practice frameworks and
models serve as a buffer to this scenario guiding the nurses through a step by step process,
and the clinical reasoning cycle by Tracy Levett Jones is one abundantly used practice model.
This essay will attempt to discuss the implementation of the clinical reasoning cycle in
assessment of a patient and planning care taking the case study of a case study.
Considering patient situation:
The first stage of step of the clinical reasoning cycle is the considering patient
situation which is associated with describing the context of the patient and the facts
associated with patent when presented in the care facility (Dalton, Gee & Levett-Jones,
2015). This stage requires the nurse to discuss the very basic information of the patient and
the major concern that the patient has presented in the facility with. The focus of this
assignment is on the patient named Melody King, a 36 year old woman who presented to the
hospital with the possibility of having peritonitis after ruptured appendix.
Collecting cues or information:

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CLINICAL REASONING CYCLE ESSAY
This is the second stage of the cycle and it refers to three aspects associated patient
assessment, reviewing current information of the client from handover reports, patient
history, patient charts, results of investigations and nursing/medical assessments previously
undertaken, gathering new information on the patient from assessment and recall previous
knowledge pertaining to physiology, pathophysiology, pharmacology, epidemiology,
therapeutics, culture, and context of care to arrive at a verdict on what are the pressing care
needs of the patient (Salminen et al., 2014). In case of Melody, she presented to the
emergency department of the facility with the complaints of severe right quadrant abdominal
pain. While in the emergency department, it was discovered that she had suffered a ruptured
appendix and required an emergency laparoscopic surgery. Her previous medical history
includes asthma and depression, and her current medication regimen included Ventolin,
Seretide, Sertraline. With respect to her vital sign assessment, her BP had been 95/94 mmHg,
Temp had been 38.3 ° Celcius, respiratory rate 22 per min and oxygen saturation 95% on
room air.
Processing information, Identifying and prioritising at least three nursing problems:
Processing the information that has been gathered till now, it can be mentioned that
she had right upper quadrant pain, which is most abundantly correlated with appendicitis.
Peritonitis is the infection of the peritoneal cavity that is caused when the appendical lumen is
ruptured and the bacterial mass is spilled in the peritoneal cavity and the surrounding places
which then gets further infected (Obinwa, Casidy & Flynn, 2014). As a result, the membrane
lining the appendix and surrounding internal organs is inflamed along with the peritoneal
cavity due to the perforations in the appendix. Discussing her vital signs, her blood pressure
had been very low which can be caused due to the acute pain and infection spreading inside
her body. The higher body temperature also indicates at the innate response of the body to the

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CLINICAL REASONING CYCLE ESSAY
infection, which further confirms the probability of peritonitis, for which she had to undergo
the surgery (van Rossem et al., 2014).
Considering prioritizing the three essential care needs, first and foremost the acute
pain that she had been suffering in the abdomen post the surgery. It has to be mentioned that
post-surgical pain localized in the surgical site or around the surgical site can be indicative of
an onset of surgical site infection, which has the potential of leading to a many complications
to post-operative recovery including even sepsis. Hence, undoubtedly the first care priority or
-need will be the pain of the patient with the pain score being 7-8. The second care priority
for the patient is low blood pressure, which can be due to a variety of factors such as
hypovolemic shock, anaesthesia effect, and septic shock developed from surgical site
infection. As discussed by Alemayehu et al. (2014), low blood pressure in the post-operative
state should be addressed effectively and immediately to avoid the risk of the patient
suffering a septic shock, and as the patient had high white blood cell count which is
indicative of infection, it is a key care priority. Lastly, the high heart rate at 120 beats per
minute is also a key concern for the patient as well. Slight tachycardia after the operation is
indicative of the post-operative infection and lack of oxygen sufficiency in the body. If not
addressed adequately this can eventually lead to tissue necrosis and can slow down the
process of recovery for the patient and can even contribute to the development of septic
shock, hence this is the third priority (Argoff, 2014).
Establish goals for priority:
In this section the nursing care professional is expected to develop the goals for the
patient due to the personalized outcomes desired to achieve with the care delivery (Hunter &
Arthur, 2016). In this case, the first care goal for the patient would be to reduce the pain score
from 7-8 to 2-3 in the next 24 hours with both pharmacological and non-pharmacological

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CLINICAL REASONING CYCLE ESSAY
measures. The second care goal will be to raise the blood pressure of the patient within the
next 24 - 48 hours successfully and avoid the risk of infection or sepsis. Similarly, the third
goal or desired outcome will be to reduce the heart rate of the patient to within 100 beats per
minute from 120 beats per minute within the next 24-48 hours.
Nursing care:
This is one of the most important and vital step of the entire process and it is
associated with designing and implementing a series of care actions to address the care
priorities that have been identified by the nurse previously. The first course of action was to
take is take a thorough assessment of the pain that the patient is feeling and as an attending
registered nurse, I would be employing the PQRST pain scale for the assessment for a far
more accurate and detailed assessment of the pain that the patient had been suffering from. In
the next phase, the surgical site was also assessed thoroughly for any sign of infection such as
localized redness, oozing or bleeding. Depending on the outcome of the assessment, if the
patient has any sign of infection, a course of broad spectrum antibiotic will be administered,
in case there is no tell-tale sign yet, the site was aseptically cleaned and dressed again with an
analgesic administered to the patient. As a nurse I also ensured checking up on the pain to
check whether it is reducing and I would increase the dosage or incorporate non-
pharmacological means of pain management if required (Tan, Law & Gan, 2015).
For the second care priority, the patient was provided high saline content electrolytes
via intravenous route to raise the blood pressure effectively. Although, as this process can
have a slow impact, to accelerate the normalization of the BP, the position of the patient was
also changed by raising the feet of the patient to aid perfusion (Hargrove III et al., 2015). I
also assessed whether the medications being given to him can potentially cause the drop in

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the blood pressure and would report the doctor with the same for changing the medications if
necessary.
For the third care need, I administered medication such as beta blockers and ACE
inhibitor drugs to lower the heart rate and calm the tachycardia that the patient had been
suffering from. Similarly, the patient was administered slight dosage or antiarrhythmic drugs
as well to ensure reduced cardiac output to lower the heart rate further. Lastly, I also
maintained a continuous vigilance on her vital signs to avoid any exacerbation and achieve
homeostasis of her vitals (Kadam et al., 2015).
Evaluating nursing care strategies:
Evaluating the nursing care strategies, the analgesic provided to Melody soon reduced
the pain that she had been suffering from to a pain score of 4-5. Although, as it was not
meeting the desired goal set, I had to increase the dosage of the medication which then
reduced the pain to 3-4. The electrolytes helped in increasing the blood pressure significantly
in 24 hours however the positioning also helped tremendously. For the heartbeat, the
medication was not as effective in reducing the heart rate as expected as I had not taken the
oxygen saturation into consideration. Although, with humified oxygen provided the heart rate
slowly lowered as well.
Reflection:
The last stage of the cycle is the reflection on the care outcomes achieved by the
patient due to the care strategies planned and implemented. The initial care planning had been
successful and it helped in addressing majority of the care needs. Although, with lowering the
heart rate I encountered a few challenges, where the patient had been suffering due to my
inability to assess the cause. Although, I soon understood my mistake and amended my
nursing strategies which then successfully addressed the concern.

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Conclusion:
Nursing care involves a multidimensional approach, the patient care needs are diverse
and in order to address those care needs, the nurses often need to incorporate multifactorial
skills, knowledge, and expertise to caring for the patients. However, with the ever-changing
climate of the health care industry, the patient care needs are also diversifying regularly, and
hence, addressing each of the individualized care needs of the patients has become extremely
challenging. Clinical reasoning cycle serves as a systematic and effective model or
framework that help the nurses design and implement care effectively and in a person centred
manner. This exercise provided me with an excellent opportunity to apply clinical reasoning
cycle to care scenario and implement care in accordance to that in a real world care scenario.

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CLINICAL REASONING CYCLE ESSAY
Referencing:
Alemayehu, H., Snyder, C. L., Peter, S. D. S., & Ostlie, D. J. (2014). Incidence and outcomes
of unexpected pathology findings after appendectomy. Journal of pediatric
surgery, 49(9), 1390-1393.
Argoff, C. E. (2014). Recent management advances in acute postoperative pain. Pain
Practice, 14(5), 477-487.
Bhattacharjee, S., Ray, M., Ghose, T., Maitra, S., & Layek, A. (2014). Analgesic efficacy of
transversus abdominis plane block in providing effective perioperative analgesia in
patients undergoing total abdominal hysterectomy: a randomized controlled
trial. Journal of anaesthesiology, clinical pharmacology, 30(3), 391.
Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based
education to'flip'the Enrolled Nurse curriculum. Australian Journal of Advanced
Nursing, The, 33(2), 29.
Hargrove III, W. C., Miller, J. M., Vassallo, J. A., & Josephson, M. E. (2015). Improved
results in the operative management of ventricular tachycardia related to inferior wall
infarction. The Josephson School: A Legacy of Important Contributions to
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Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement:
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Kadam, S. V., Tailor, K. B., Kulkarni, S., Mohanty, S. R., Joshi, P. V., & Rao, S. G. (2015).
Effect of dexmeditomidine on postoperative junctional ectopic tachycardia after
complete surgical repair of tetralogy of Fallot: A prospective randomized controlled
study. Annals of cardiac anaesthesia, 18(3), 323.

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CLINICAL REASONING CYCLE ESSAY
Koivisto, J. M., Multisilta, J., Niemi, H., Katajisto, J., & Eriksson, E. (2016). Learning by
playing: A cross-sectional descriptive study of nursing students' experiences of
learning clinical reasoning. Nurse education today, 45, 22-28.
Obinwa, O., Casidy, M., & Flynn, J. (2014). The microbiology of bacterial peritonitis due to
appendicitis in children. Irish Journal of Medical Science (1971-), 183(4), 585-591.
Salminen, H., Zary, N., Björklund, K., Toth-Pal, E., & Leanderson, C. (2014). Virtual
patients in primary care: developing a reusable model that fosters reflective practice
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van Rossem, C. C., Schreinemacher, M. H., Treskes, K., van Hogezand, R. M., & van
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