Clinical Reasoning Cycle: Steps and Implementation in Real World Scenario

This essay explores the steps of clinical reasoning cycle to evaluate and analyze a real world care scenario taking the assistance of a perioperative case study. It explains how to implement the clinical reasoning cycle in practice while caring in a real world scenario and be able to implement safe and effective care.

Running head: CLINICAL REASONING CYCLE
Clinical reasoning cycle
Name of the student:
Name of the university:
Author note:

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Table of Contents
Introduction:....................................................................................................................................2
Considering the patient situation:....................................................................................................2
Collection of information:...............................................................................................................3
Processing the information:.............................................................................................................3
Identification of problems:..............................................................................................................4
Establishing goals:...........................................................................................................................4
Take action:.....................................................................................................................................5
Evaluation and reflection:................................................................................................................6
Conclusion:......................................................................................................................................7
References:......................................................................................................................................8

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Introduction:
The professional practice by the nurses is associated with a varied range of different skills
including clinical judgment, clinical decision making, clinical reasoning, problem solving and
critical thinking in order to provide safe and effective care to the patients. Clinical reasoning
cycle established by Tracy Levett Jones as a model framework allowing the nurses to implement
safe and effective practice along with utilizing all the above mentioned skill and at the same time
be able to learn from their practice experience (Dalton, Gee & Levett-Jones, 2015). As
mentioned by Hur and Roh, (2013), the nursing professionals with a positive critical analytical
skills and reflective skills have positive outcomes on the health and wellbeing status of the
patient. Similarly, the nursing professionals that fail to implement adequate critical analytical
skills in the professional practice are associated with diminished health and safety outcomes.
Hence, the importance of the clinical reasoning cycle is extreme to help the nursing professionals
implement practice in a manner that is inclusive of clinical reasoning and decision making skills.
This essay will attempt to explore the steps of clinical reasoning cycle to evaluate and analyze a
real world care scenario taking the assistance of a perioperative case study.
Considering the patient situation:
The selected case scenario represents a perioperative case involving the patient Candace
Evans, a year old patient who had been admitted to the health care facility to undergo elective
lower uterine caesarean section or LUCS who had been diagnosed with spinal anaesthesia. This
is the first step of the cycle which involves exploring the current situation or condition of the
patient and what information is needed to be collected in the very next step (Hur & Roh,). In this
case scenario, the patient had undergone a LUCS giving birth to a healthy baby boy and was
shifted to the PACU with intraoperative blood-loss being 150ml, which is alarming. However,

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while in the PACU, the vaginal blood loss of the patient had been extreme with her pad being
soaked with frank blood and also some clots indicating signs of extreme blood loss due to her
placenta previa (Silver, 2015).
Collection of information:
The second step of clinical reasoning cycle is the elaborative assessment of the patient
where the nurse is required to gather all information available about the patient including past
medical history, current issues, treatment plan, observational data, investigative results, handover
reports and previous medical records (Smith, Loftus & Levett-Jones, 2013). In this case the past
medical history of the patient includes gestational diabetes, anxiety and post natal depression,
which can have a significant impact on her health, hence past medical data should be adequately
collected and documented. Followed by that, the nurse should also take a thorough head to toe
assessment and document her vital signs to understand her present condition.
Processing the information:
In order to complete the patient assessment procedure successfully, the very next step of
the clinical reasoning cycle is associated with processing the gathered information and compare
and contrasting the data with best available evidences to interpret, discriminate, relate and match
the available data to predict care outcomes for the patient. In this case, the past medical history
stated that Candace had gestational diabetes, anxiety and post natal depression, which is needed
to be considered with respect to the blood loss and related complications she is facing.
Furthermore, gestational diabetes is also reported to enhance the risk of placenta previa (Kassem
& Alzahrani, 2013). The vital signs of the patient include heart rate of 88, which is lower than
normal along with a low blood pressure at 104/76, indicating signs of bradycardia which can be
caused by extreme blood loss and exhaustion from the surgery. Her body temperature is also

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slightly elevated at 36.9° Celsius, hence, he patient is also slightly febrile. However, the major
concerns regarding the patient is the blood loss and frank haematuria due to her placenta previa.
The presence of rose coloured urine is validating the presence of postpartum haemorrhage
(Räisänen, Kancherla, Kramer, Gissler & Heinonen, 2014).
Identification of problems:
After the nurse is finished with complete patient assessment and processing of the
information collected, the clinical reasoning cycle encourages the nurses to engage in
discovering the acre cues or nursing problems presented by the patient so that adequate care can
be provided to the patient. In this case, the nursing problems faced by Candace includes:
 Postpartum haemorrhage with clots and fresh blood loss leading several
complications due to placenta previa
 Low heart rate due to blood loss and exhaustion (Räisänen, Kancherla, Kramer,
Gissler & Heinonen, 2014)
 Hypotension or low blood pressure due to the consistent blood loss
 Risk of infection due to consistent heavy vaginal bleeding with clots
 Complete lack of pain which can be due to high block of anaesthesia
 Discomfort, anxiety and grief due to the complications and post natal depression
(Woolhouse, Gartland, Perlen, Donath & Brown, 2014).
Establishing goals:
In this step of the cycle the nurse is required to discover and analyze the care problems
identified with detail and with the help of patient assessment, available best practice evidence
and personal critical analytical thinking and decision making skills recognize care priorities that

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need immediate clinical attention to protect health and safety of the patient under consideration
(Hur & Roh, 2013). In this case the primary concern for the patient is the extreme vaginal blood
loss due to her placenta previa. Now, as per the assessment data the greatest concern that the
patient had been facing is the extreme vaginal blood loss to the placental anomaly. And as this
anomaly has no direct cure, the nursing goal for the patient would be to minimizing the blood
loss and cure the post-partum haemorrhage.
Take action:
First and foremost, the nurse must begin with the five ‘R’s of Clinical reasoning cycle
and also take informed consent from the patient before progressing with the care interventions
(Levett-Jones et al., 2010). For the blood loss, the nurse will need to help the patient with a fresh
vaginal pad with adequate cleaning and hygiene maintenance to ensure infection control. Along
with that, the nurse will require to provide complete and comfortable resting position for the
patient and preferably encouraging her to keep one leg elevated to help with the blood clotting,
along with administration of Gonadotropin-releasing hormone agonists (Abdel-Aleem,
d'Arcangues, Vogelsong, Gaffield & Gülmezoglu, 2013). The post-partum haemorrhage is a
grave concern for the patient and the nurse must take into consideration uterine fundus massage
which will help in uterine contraction and will also help in reducing the bleeding, preventing and
eliminating the post-partum haemorrhage (Matsubara et al., 2013). The nurse with the
collaboration of the midwife will also need to instruct Candace to breast feed her baby boy which
will also facilitate uterine contraction and reduce bleeding.
The next care priority for Candace is the complete lack of pain which can be facilitated
by high spinal block anaesthesia as evidenced by the dermatome level T3 in the patient. The
nursing intervention in this case should be to check the sensory levels with ice or blunt needle

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via pin prick sensation test. If the levels are higher than expected, the nurse will need to position
the patient sitting straight up which will stabilize the blood volume and will help in washing out
the anaesthesia from the blood. The aid of goal directed fluid therapy might also help in
regaining heamodynamic stability of the patient (Xiao et al., 2015).
The third care priority for the patient is her discomfort, anxiety and depression. The nurse
should be providing a warm and comfortable stay in the facility and encourage fluid intake to
help her regain strength and help her feel better (Wetta et al., 2013). The patient will also need
antidepressants and antianxiety pills such as Selective serotonin reuptake inhibitors to help with
her anxiety and depression. For a new mother, being able to hold her new born child and interact
with the loved ones help extremely in accelerating the recovery (O'hara & McCabe, 2013). The
nurse, in collaboration with the midwife, will need to let Candace’s baby boy and husband
interact with her to help uplift her mood and help her recover.
Evaluation and reflection:
In the last step of the clinical reasoning cycle, the nurse is expected to evaluate the
outcome of the care interventions or actions implemented and reflect on the entire experience
(Dalton, Gee & Levett-Jones, 2015). In this case, the periodic vaginal cleaning and infection
control helped the patient overcome her discomfort. The hormone therapy had also been helpful
in reducing the excessive heavy bleeding along with elevating the legs. However, wearing the
support hose had been very difficult for the patient and she soon complained of extreme
discomfort and became very anxious. In this case, taking informed consent while clearly
explaining to her about the hose could have been more beneficial and could have enhanced
comfort for Candace (Hur & Roh, 2013). Although, letting her hold her baby boy and talk to her
husband had distinct positive impact on her mood and with the antidepressant pills in effect, her

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anxiety and depression was adequately managed. Within next 24 hours the bleeding reduced with
no visible clots along with her bradycardia; her blood pressure also improved and she looked
visibly better.
Reflecting on the practice, I would like to mention the fact that thus had been an excellent
opportunity for me to care for Candace and help her with the post-partum complications that she
had been suffering with. Along with that, it gave me opportunity to connect with her and engage
with therapeutic communication which not only helped ease her anxiety and distress but also
helped her verbalize her issues and wishes better with me. I would like to state that this has been
an excellent opportunity to learn how to care for patients with postpartum complications and how
to provide safe and effective care.
Conclusion:
On a concluding note, caring for a postpartum woman with various interrelated post-
operative complications are associated with many risks. In order to be able to provide adequate
care and be able to address each and every issues of the patient requires the assistance of a
systematic framework. Clinical reasoning cycle serves as a key model framework providing the
nurses with the opportunity to follow all the clinical practice guideline and implement critical
thinking and judgment skills with respect to evidence based practice in a simple step by step
manner. This assignment has given me an excellent opportunity to implement the clinical
reasoning cycle in practice while caring in a real world scenario and be able to implement safe
and effective care. This has helped me learn my strengths and flaws and it can be hoped that it
will be an excellent help for my gradual professional growth in the future.

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References:
Abdel-Aleem, H., d'Arcangues, C., Vogelsong, K. M., Gaffield, M. L., & Gülmezoglu, A. M.
(2013). Treatment of vaginal bleeding irregularities induced by progestin only
contraceptives. Doi: 10.1002/14651858.CD003449
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. Retrieved from
https://search.informit.com.au/documentSummary;dn=018184224173600;res=IELHEA
Hur, H. K., & Roh, Y. S. (2013). Effects of a simulation based clinical reasoning practice
program on clinical competence in nursing students. Korean Journal of Adult
Nursing, 25(5), 574-584. Doi: 10.7475/kjan.2013.25.5.574
Kassem, G. A., & Alzahrani, A. K. (2013). Maternal and neonatal outcomes of placenta previa
and placenta accreta: three years of experience with a two-consultant
approach. International journal of women's health, 5, 803. Doi: 10.2147/IJWH.S53865
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
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Matsubara, S., Yano, H., Ohkuchi, A., Kuwata, T., Usui, R., & Suzuki, M. (2013). Uterine
compression sutures for postpartum hemorrhage: an overview. Acta obstetricia et
gynecologica Scandinavica, 92(4), 378-385. Doi: 10.1111/aogs.12077

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O'hara, M. W., & McCabe, J. E. (2013). Postpartum depression current status and future
directions. Annual review of clinical psychology, 9, 379-407. Doi: 10.1146/annurev-
clinpsy-050212-185612
Räisänen, S., Kancherla, V., Kramer, M. R., Gissler, M., & Heinonen, S. (2014). Placenta previa
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Wetta, L. A., Szychowski, J. M., Seals, S., Mancuso, M. S., Biggio, J. R., & Tita, A. T. (2013).
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