Clinical Reasoning Discussion Paper

This discussion paper explores the importance of clinical reasoning in critical care nursing. It analyzes a case study where clinical errors were made due to improper communication, lack of knowledge, and overconfidence. The paper suggests that better communication, documentation, and training can improve patient outcomes.

CLINICAL REASONING
DISCUSSION PAPER
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Discussion paper on clinical reasoning
Introduction
In critical care nursing, close attention must be paid to the patient’s present status Most
errors in clinical reasoning are not due to inadequate or incompetent knowledge but to the
weakness of human thinking when there are uncertainty, complexity and pressure of time.
To minimize such perception error we need to understand its causes. Generally nurses use
clinical decision making during patient care. These decisions may affect the actions of
healthcare professionals favourably or adversely and also the health care that the patient
gets (Google Books, 2019). It’s the responsibility of the nurse to make clinical decisions
based on whatever knowledge and skills acquired so far. To make quick, instantaneous
decisions, such as steps to be taken if the condition of the patient starts deteriorating at a
rapid pace.. Nurses rely on sound decision-making skills to maintain positive outcomes
and up to date care. According to Orme & Maggs (C, 2019), decision-making is part and
parcel of clinical practice. If a number of nurses are involved and each has been given
different roles, then proper co-ordination and understanding are required for successful
treatment otherwise if there is lack of coordination between different nurses, there will be
communication gap and the patient is going to suffer. This paper will discuss why the
steps are taken did not go according to plan and discuss two critical reasoning errors.
CASE DETAILS
A patient was admitted to the emergency ward of a clinic with symptoms of severe chest
pain, sweating and other side effects. The necessary emergency measures were taken like
supplemental oxygen therapy through a nasal cannula and ECG was done to monitor the
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Discussion paper on clinical reasoning
heart condition of the patient. Sublingual nitroglycerin along with morphine was
administered to the patient to give relief of chest pain. He was given ticagrelor (an oral
antiplatelet drug used with a low dosage of aspirin generally applied to patients having
acute coronary ), to prevent any blood clotting. Instead of improving, the condition of
the patient took a serious turn with all sorts of complications like a substantial drop in
blood pressure, severe nose bleeding, breathing problem aggravated and a noticeable
drop in pulse rate was observed in ECG.
Because of the critical condition, earlier medical records of the patient and the history of
cardiac data were considered. ECG report was available and clinical handover reports of
shift nurses were available As per the reports the medications and diagnosis were in line
with earlier records The medical records showed that the patient had allergy due to
aspirin, administration of drugs like nitro-glycerin(Takx et al., 2015), morphine was in
accordance with the patient’s past medical records. The dosage of the drugs might have
some connection with the worsening condition of the patient.
Analysis and interpretation
While analysing the case a number of shortcomings on account of improper supervision,
lack of communication and also lack of knowledge to deal with such critical case were
observed.
In the emergency department, many nurses were engaged for management of diagnosis,
treatment, medicine and follow up measures. The main concern was the communication
gap between the nurses and their handover responsibilities during changeover routine at
the change of shifts. The follow-up actions of the nurses were not well documented as a
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Discussion paper on clinical reasoning
result next shift nurses were not well informed about the actions taken. For better care
and patient outcome, communication plays an important role between patient and nurse
relation (De Meester et al., 2013).
After drug administration during the two hours period when the situation worsened,
monitoring of the patient’s condition was not done efficiently. The nurses should have
involved the patient to get some information before taking a decision, as a result, the
patient had allergic side effects in the form of body rash even with a mild dosage of
aspirin. Due to dosage error the application of morphine as pain reliever in myocardial
infarction has not yielded any improvement. High dosage of morphine may have a
number side-effects when used as a pain killer. The increase of dizziness and
aggravation of breathing problem after application of morphine is possibly due to an
overdose of morphine (Parodi et al., 2015). The nurses were not well informed about the
side-effects of ticagrelor (Gaubert et al., 2014). A morphine overdose without any
compensating medicine could have been more fatal even it may lead to the death of the
patient. The naloxone can overcome the ill effects of overuse of morphine. If the
intravenous dose of naloxone was not applied in time, the patient might have succumbed
because of the respiratory problem (Kim and Nelson, 2015). In case of bleeding from the
nose, excessive bleeding could have been fatal. Necessary steps were taken to stop
bleeding through the nose. The patient had to sit upright with support, to facilitate
breathing through the mouth and nasal tampons coated with bacitracin were applied
which arrested nose bleeding and saved the patient.
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Discussion paper on clinical reasoning
From the above analysis we can come to a conclusion that coordination among all
nursing staffs working in shifts was lacking in some parts particularly important clinical
information relating to changes in patient’s conditions were not properly communicated
between nurses working in shifts (Raymond and Harrison, 2014) ,lapses on the part of
nurses in applying drugs mechanically without going in depth of the problem were the
causes for worsening of the patient’s condition.
Now I shall analyse the clinical errors mentioned using clinical reasoning. There are nine
types of errors of clinical reasoning. Some of the reasoning errors are interdependent.
The errors can be minimised if the proper communication system is used to improve
communication among nurses, more training to be given to nurses to encounter
efficiently such type of cases. From the case study, one of the error can be mapped to
overconfidence bias. Overconfidence always drives to act on incomplete information and
the patient has suffered because of the overconfidence on the part of nurses without
collecting proper information. The second error according to me is ascertainment bias
though to some extent other errors like anchoring or unpacking principle have also been
observed. Ascertaining bias comes when a nurse thinks based on prior assumptions and
preconceptions. This is very much evident in this case because of nurses administering
drugs without properly going through old case history and what dosage to be applied at
what situation and what precautionary actions to be taken.
However, the errors were eventually remedied by taking rearguard action by supporting
evidence-based literature like the patient’s case history reports , the fact that the patient
is having allergy to aspirin was known after the case history reports was scrutiny,
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Discussion paper on clinical reasoning
intravenous administration of naloxone was given to offset overdose of morphine. To
stop bleeding through the nose, the patient sat in an upright position with support so that
he can breathe through the open mouth. Nasal tampons coated with bacitracin was
applied as well as 2% oxymetazoline (Morgan and Kellerman, 2014) was administered.
The patient gained stability in condition and his consciousness was restored.
Conclusion
I can arrive at the following conclusion that when a patient is admitted to an emergency
ward instead of following the traditional approach of the health care process. a well
structured and organized diagnostic plan is to be followed and follow up method with
proper documentation would improve the patient care. (Guerrasio and Aagaard,
2014).For improving communication and incomplete verbal exchange of information
between nurses. clinical handoff tool (SBAR) during clinical transfer of responsibilities
provide improved communication between shift nurses and physicians (De Meester et al.,
2013). SBAR communication tool (Randmaa et al., 2014) provides a framework for good
structure communication between physicians and nurses. To improve patient safety and
efficient care, more and more nurses should be trained in standardized documentation
formats so that they can keep records of the past and present details of the patient
(Munroe et al. 2013). Clinical documentation gives more accuracy and efficiency in
providing better method of health care services and intervention to patients (Kern et al.,
2013). This measure will definitely reduce the risk of faulty treatment and applying faulty
medication. One of the learning points from this case study is that a lack of expertise and
information can have serious consequences in dealing with this type of critical cases.
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Discussion paper on clinical reasoning
Unless the knowledge level is improved with the latest technology to deal with difficult
cases becomes a challenge. The nurses also should get specialized training and exposure
in dealing different departments of medical science like heart, kidney, infectious diseases,
cancer etc. so that they can be an expert in a particular department instead of dealing all
departments without any value addition.
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Discussion paper on clinical reasoning
References
Google Books. (2019). Decision Making in Nursing. [online] Available at:
https://books.google.com/books/about/Decision_Making_in_Nursing.html?
id=FXkk2kNrWtAC [Accessed 21 Jan. 2019].
C, O. (2019). Decision-making in clinical practice: how do expert nurses, midwives and
health visitors make decisions? - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available
at: https://www.ncbi.nlm.nih.gov/pubmed/8413127 [Accessed 21 Jan. 2019].
De Meester, K., Verspuy, M., Monsieurs, K. and Van Bogaert, P. (2013). SBAR
improves nurse-physician communication and reduces unexpected death: A pre and post-
intervention study. Resuscitation, 84(9), pp.1192-1196.
Gaubert, M., Laine, M., Richard, T., Fournier, N., Gramond, C., Bessereau, J., Mokrani,
Z., Bultez, B., Chelini, V., Barnay, P., Maillard, L., Paganelli, F. and Bonello, L. (2014).
Effect of ticagrelor-related dyspnea on compliance with therapy in acute coronary
syndrome patients. International Journal of Cardiology, 173(1), pp.120-121.
Guerrasio, J. and Aagaard, E. (2014). Methods and Outcomes for the Remediation of
Clinical Reasoning. Journal of General Internal Medicine, 29(12), pp.1607-1614.
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Discussion paper on clinical reasoning
Kern, L., Malhotra, S., Barrón, Y., Quaresimo, J., Dhopeshwarkar, R., Pichardo, M.,
Edwards, A. and Kaushal, R. (2013). Accuracy of Electronically Reported “Meaningful
Use” Clinical Quality Measures. Annals of Internal Medicine, 158(2), p.77.
Kim, H. and Nelson, L. (2015). Reducing the harm of opioid overdose with the safe use
of naloxone: a pharmacologic review. Expert Opinion on Drug Safety, 14(7), pp.1137-
1146.
Morgan, D. and Kellerman, R. (2014). Epistaxis. Primary Care: Clinics in Office
Practice, 41(1), pp.63-73.
Parodi, G., Bellandi, B., Xanthopoulou, I., Capranzano, P., Capodanno, D., Valenti, R.,
Stavrou, K., Migliorini, A., Antoniucci, D., Tamburino, C. and Alexopoulos, D. (2015).
Morphine Is Associated With a Delayed Activity of Oral Antiplatelet Agents in Patients
With ST-Elevation Acute Myocardial Infarction Undergoing Primary Percutaneous
Coronary Intervention. Circulation: Cardiovascular Interventions, 8(1).
Randmaa, M., Mårtensson, G., Leo Swenne, C. and Engström, M. (2014). SBAR
improves communication and safety climate and decreases incident reports due to
communication errors in an anaesthetic clinic: a prospective intervention study. BMJ
Open, 4(1), p.e004268.
Raymond, M. and Harrison, M. (2014). The structured communication tool SBAR
(Situation, Background, Assessment and Recommendation) improves communication in
neonatology. South African Medical Journal, 104(12), p.850.
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Discussion paper on clinical reasoning
Takx, R., Suchá, D., Park, J., Leiner, T. and Hoffmann, U. (2015). Sublingual
Nitroglycerin Administration in Coronary Computed Tomography Angiography: a
Systematic Review. European Radiology, 25(12), pp.3536-3542.
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