CLINICAL REASONING DISCUSSION AND PROBLEM

Running head: CLINICAL REASONING DISCUSSION AND PROBLEM
CLINICAL REASONING DISCISSION AND PROBLEM
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1CLINICAL REASONING DISCUSSION AND PROBLEM
Introduction
The selected clinical encounter occur during management of the healthcare needs of the
patient Julia Walker, an 82 year old female who was admitted to the recovery unit and then the
intensive care unit (ICU) after undergoing surgical procedures for repairing of a bilateral
inguinal incisional hernia. The patient’s ICU admission was based upon presenting post-
operative problems of sinus bradycardia (SB) and dysuria respectively, possibility due to post
surgery complications of a bladder injury of the blunt or penetrating type. The possibility of a
bladder injury despite the administration of oral as well as intravenous fluids was evidenced by
Mrs. Walker’s elevated levels of blood urea nitrogen, creatinine, sodium and potassium. Bladder
injury increases the possibility of leakage of urine internally, thus increasing the risk of
hyperkalemia, hyperuricemia and hypernatremia as observed in Mrs. Walker’s blood levels
(Mirza et al. 2018). Such blood levels are not only indicative of renal failure but also the
possibility of arrhythmia and resultant SB – a condition of abnormal sinus rhythm associated
with abnormally low heart rates – as evidenced extensively in Mrs. Walker post-surgery
(Simmons and Blazar 2019). The key errors which will be focused upon during such a critical
situation are anchoring and confirmation bias with respect to administration of Hartman’s
solution, heart rate-lowering and bowel stimulating medications like Verapamil and Coloxyl
Senna.
Discussion
Clinical Reasoning Error 1
One of the first clinical reasoning errors is the administration of Hartman’s solution to
Mrs. Walker despite her condition of bladder injury. Bladder injury impairs an individual’s

2CLINICAL REASONING DISCUSSION AND PROBLEM
ability to urinate and thus, the resultant dysuria paves the way for urine retention and secretin
internally. Adverse symptoms associated with bladder injury as a result of the above symptoms
of dysuria, is hyperkalemia, hypernatremia and hyperuricemia as evidenced by Mrs. Walker’s
blood reports demonstrating high levels of sodium, creatinine and urea in her blood as well as
presented problems of high serum potassium induced peripheral edema (Jang and Lim 2016).
With this respect, it must be noted that Hartman’s solution is high in sodium and potassium and
administration of the same in a condition of hyperkalemia poses a clinical problem. If not
remedied, this problem was likely to induce fatal cardiovascular outcomes and even death in
patients like Mrs. Walker. This is because hyperkalemia is associated with irregular and
abnormally low heart rates and rhythm and thus, administration of a high potassium intravenous
solution like Hartman’s is likely to cause a standstill of cardiac functions and resultant fatal
outcomes of cardiac stoppage and possibly death in hyperkalemic patients like Mrs. Walker (Cho
and Kang 2018).
Such an error bears resemblance to the ‘Anchoring’ – a form of clinical reasoning error
characterized by merely prioritizing the initial clinical features of a patient for arriving at a
diagnosis and associated interventions, despite being provided with new information later (Scott
2009). Indeed, the decision to administer Hartmann’s solution was arrived at, merely based on
the initial perception that a patient requires the same post surgery for the purpose of maintaining
post-surgical vital sign abnormalities. There was no consideration given on further information
concerning her blood electrolyte levels, dysuria and a possibility of bladder injury as a possible
complication after surgery. Thus, to remedy this error and to ensure mitigation of possible
aggravation of hyperkalema due to this preventable clinical error, stopping the administration of
Hartman’s solution was found to be plausible and beneficial (Zhang et al. 2019). In addition to

3CLINICAL REASONING DISCUSSION AND PROBLEM
the same, the possible outcomes of this clinical problem was also mitigated by stopping the oral
administration of Coloxyl Senna – a medication known for stimulating bowel activity and as a
results, increased urine urgency and internal secretion due to bladder injury induced dysuria (Hay
et al. 2019). Additionally, it has been evidenced that as a replacement of Hartman’s solution, the
intravenous administration of calcium solutions coupled with insulin, glucose and sodium
bicarbonate, is useful to alleviate cardiac toxicity, stimulate cellular potassium uptake and
mitigate metabolic acidosis as a result of bladder injury induced hyperkalemia and hyperuricemia
(Yu et al. 2017). These clinical interventions were considered for mitigation of this clinical
problem in Mrs. Walker’s case management. However, such an error of anchoring could have
been prevented had further emphasis been given to the Clinical Reasoning Cycle (CRC) step of
cue collection so as to seek for further information which could be used to critique, evaluate and
rectify the possible outcomes of the initial decision to administer Hartmann’s solution.
Additionally, discussing the viability of this initial decision with other professionals of the
multidisciplinary team could have also prevented the same (Scott 2009).
Clinical Reasoning Error 2
Another key clinical encounter problem which was identified in case of Mrs. Walker is
the administration of medications like Verapamil, despite her presenting problems of SB. SB is a
condition in which an individual’s sinus rhythm demonstrates clinical abnormalities which is
observed in symptoms like the lowering of heart rate below 60 beats per minute or even less. In
the case of Mrs. Walker, the condition is particularly severe and symptomatic since her heart rate
has been observed to drop alarmingly below 50 beats per minute (Arasalingam et al. 2018).
Despite the clear presentation of such symptoms – it can be observed that Mrs. Walker has been
given oral medication of Verapamil. Verapamil is a known to induce blockages to the calcium

4CLINICAL REASONING DISCUSSION AND PROBLEM
ion channels of the body and as a result assists in the relaxation of cardiac muscles and lowering
of heart rates for mitigation of a hypertensive situation in a patient.
Thus, this clinical error can be assumed to be caused as a result of confirmation bias –
which is characterized by a tendency to look for clinical information compliant to initial
diagnosis rather than seeking further information to refute and critique the same (Levett-Jones
2018). Indeed, the need to administer Verapamil was considered only on the basis of Mrs.
Walker’s hypertensive vital signs rather than considering the need to holistically view all vital
signs assessment results such as her abnormally low heart rate. Administration of such a
medication in patients like Mrs. Walker, whose heart rate is already lowered as a result of SB, is
likely to induce adverse clinical outcomes such as: severe hypotension, aggravation of edema,
progression towards congestive heart failure, lack of adequate blood circulation and resultant
hypoxia and possible death of the patient (Saedder et al. 2019). It has been evidenced that
ceasing the intake of such medications in the patients with SB will assist in reducing the adverse
complications of SB. With this respect, in order to mitigate the possibility of this clinical
problem and missed opportunity for clinical correction in Mrs. Walker, the administration of
Verapamil was ceased in Mrs. Walker. Additionally, there is a need to continuously monitor the
heart rate of patients with SB as well as consider the intravenous administration of atropine – a
medication known to enhance slowed heart rate (Bell et al. 2019). With this respect, the above
interventions were considered with the healthcare multidisciplinary team in order to mitigate this
clinical problem in Mrs. Walker. However, such an error could have been prevented if the
decision to administer Verapamil could have been re-confirmed by monitoring other vital signs
such as heart rather than focusing only on Mrs. Walker’s hypertension (Levett-Jones 2018).

5CLINICAL REASONING DISCUSSION AND PROBLEM
Conclusion
A key aspect of learning from this clinical encounter is the importance of critical thinking
in improving nursing competency as well as preventing the risk of medical errors and resultant
hindrance of patient safety (Levett-Jones, Courtney-Pratt and Govind 2019). Indeed, the lack of
critical thinking and reasoning can be evidenced by the administration of Hartmann’s solution as
well as medications like Verapamil and Coloxyl Senna in Mrs. Walker despite her presentation
of hyperkalemia, SB and bladder injury as per blood reports which could have resulted in
adverse outcomes like aggravation of hyperkalemia, hyperuricema and cardiac stoppage. Thus, a
key nursing which I will do differently to prevent diagnostic errors like anchoring and
confirmation bias when met with similar patient scenarios in the future is adherence to Standard
1.6 of the Professional Standards of Practice postulated by the Nursing and Midwifery Board of
Australia (NMBA 2016). As per this standard, registered nurses must not only engage in accurate
and comprehensive patient assessments and documentation but must also engage in critically
evaluating the obtained results followed by implementing clinical decision-making and care plan
interventions customized to the identified assessment results of the patient. Thus, religiously
following this key standard will assist me to develop care plans and interventions only after
critically assessing the documented results of a patient. To conclude, not only must registered
nurses collect relevant patient healthcare cues but must also use critically view to same to
critique, refute and validate the veracity of initial diagnosis for prevention of adverse patient
health outcomes (Levett-Jones, Courtney-Pratt and Govind 2019).

6CLINICAL REASONING DISCUSSION AND PROBLEM
References
Arasalingam, S., Peer, M.S., Rama, S. and Jeyapalan, P., 2018. Amisulpride and fluvoxamine
combination resulted in sinus bradycardia: a case report. ASEAN Journal of Psychiatry, 19(1).
Bell, K., Elmograbi, A., Smith, A. and Kaur, J., 2019, April. Paradoxical bradycardia and
hemorrhagic shock. In Baylor University Medical Center Proceedings (Vol. 32, No. 2, pp. 240-
241). Taylor & Francis.
Cho, M.H. and Kang, H.G., 2018. Acute kidney injury and continuous renal replacement therapy
in children; what pediatricians need to know. Korean journal of pediatrics, 61(11), p.339.
Hay, T., Deane, A.M., Rechnitzer, T., Fetterplace, K., Reilly, R., Ankravs, M., Bailey, M., Fazio,
T., Anstey, J., D’Costa, R. and Presneill, J.J., 2019. The hospital-based evaluation of laxative
prophylaxis in ICU (HELP-ICU): A pilot cluster-crossover randomized clinical trial. Journal of
critical care, 52, pp.86-91.
Jang, J. and Lim, K.H., 2016. Pseudo-renal Failure Caused by Urinary Bladder Rupture in
Multiple Trauma Patient. Journal of Trauma and Injury, 29(4), pp.191-194.
Levett-Jones, T. ed., 2018. Clinical reasoning: Learning to think like a nurse. Pearson Australia.
Levett-Jones, T., Courtney-Pratt, H. and Govind, N., 2019. Implementation and Evaluation of the
Post-Practicum Oral Clinical Reasoning Exam. In Augmenting Health and Social Care Students’
Clinical Learning Experiences (pp. 57-72). Springer, Cham.
Mirza, R.D., Wong, E.K., Yang, R. and Clase, C., 2018. Abdominal Pain, Hyperkalemia, and
Elevated Creatinine after Blunt Trauma: Bladder Rupture and Pseudo–Acute-Kidney-
Injury. Canadian Journal of General Internal Medicine, 13(2).

7CLINICAL REASONING DISCUSSION AND PROBLEM
NMBA, 2016. Nursing and Midwifery Board of Australia - Professional standards. [online]
Nursingmidwiferyboard.gov.au. Available at:
https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-
standards.aspx [Accessed 23 Jan. 2020].
Saedder, E.A., Thomsen, A.H., Hasselstrøm, J.B. and Jornil, J.R., 2019. Heart insufficiency after
combination of verapamil and metoprolol: A fatal case report and literature review. Clinical
Case Reports, 7(11), pp.2042-2048.
Scott, I.A., 2009. Errors in clinical reasoning: causes and remedial strategies. BMj, 338, p.b1860.
Simmons, T. and Blazar, E., 2019. Synergistic Bradycardia from Beta Blockers, Hyperkalemia,
and Renal Failure. The Journal of emergency medicine, 57(2), pp.e41-e44.
Yu, M.Y., Yeo, J.H., Park, J.S., Lee, C.H. and Kim, G.H., 2017. Long-term efficacy of oral
calcium polystyrene sulfonate for hyperkalemia in CKD patients. PloS one, 12(3).
Zhang, Y., Sha, H.H., Shao, P.F., Wang, Y. and Gui, B., 2019. Intraoperative hyperkalemia
during laparoscopic pelvic surgery and prostatectomy. Chinese medical journal, 132(15), p.1872.