Clinical Reasoning and Decision-Making in Nursing

This assignment involves analyzing various case studies and research papers related to clinical reasoning in nursing practice. It includes articles on patient safety, hypoglycemia, diabetes management, and the use of clinical reasoning cycles in medical decision-making. The purpose is to understand the significance of clinical reasoning in nursing education and its application in real-world scenarios.

Hypoglycemia
Name of Student
Name of University
Author Note
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Introduction
The focus of the assignment is on the clinical care and analysis of a 67 year old
woman, Ms. S.B., who experienced a hypoglycemic condition and the care, provided using
“clinical reasoning cycle” method. It is important for a healthcare provider and nurse to have
very good clinical reasoning and decision making skills, so that in times of clinical
emergency like hypoglycemia, quick service and risk management can be arranged by
healthcare providers in the facility (Sedgwick, Grigg & Dersch, 2014). The process of clinical
decision making is a relative, progressive, and mounting process, where it is important to
gather, interpret, and evaluate the clinical data for successful selection of plan of action based
on the evidence (Groves, 2014). It involves drawing conclusion based on critical thoughts
and clinical interpretation (Robert, Tilley & Petersen, 2014). This assignment aims to talk
about an emergency case of Hypoglycemia, when I was undergoing my clinical rotation and
to practice the clinical rotation cycle. The assignment consists of the background of the
condition, reflective perspective in the assessment of Hypoglycemia using Gibb’s cycle and
followed by a recommendation that would help develop nursing professional conduct.
Background:
Individuals with diabetes face the condition of Hypoglycemia very often which has
the potential to cause life-challenging difficulties (Round et al., 2014). The condition is best
described as having an unusually lowered glucose levels in blood (Holt, 2011). It is observed
that people with type 2 diabetes have rare but harsh episodes of hypoglycemia in comparison
to people with type 1 diabetes (Lim, Munshi & Sharon, 2015). In Al Ain, UAE, a study was
conducted in 2004 which revealed that the annual diabetic treatment expense increased five
folds of 1,605$ when compared to patients with hypoglycemia than without the condition
(Al-Maskari, El-Sadig & Nagelkerke, 2010).
Clinical reasoning cycle:
The process of gathering information, processing the found data to understand the
clinical condition as well as planning and implementing intervention to evaluate efficiency
and reflective learning of the outcome of the concerned health issue is termed as clinical
reasoning cycle (Meissner, 2010). The importance of Clinical reasoning cycle is that it can
derive a positive end result of the clinical procedure based on the patient’s health condition
and way of living (Levine, 2014). It also helps a nurse in prioritizing the involvement by
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understanding the immediate plan of active to be devised and delayed action that can be used
to manage complications (Chamberland et al., 2015). Implementation of clinical reasoning
cycle is based on the skill of cognition, presence of mind and critical analysis (Rochmawati
&Wiechula, 2010). Clinical reasoning errors can arise due to biased thinking, stereotypical
notions and influence of social stigma, which needs to be avoided during clinical (Burbach,
Barnason & Thompson, 2015). Clinical reasoning cycle includes eight stages; observation,
collection, processivity, decision making, planning, action, evaluation and reflection. I have
discussed in detail about an incident that I came across during one of my clinical rotation
duties.
Clinical reasoning cycle:
1. Consider the patient situation
The initial step of clinical logic is to familiarize with the patient’s medical
history, so I got acquainted with the patient, her medical history and recognized her
main issue and tried to analyze the situation.
I checked with the nurse who was in her night shift when the patient was
admitted. I was handed over the medical account in the morning, mentioned that Ms.
S.B. was a 67-year old woman with known history diabetes, taking insulin, had
hypertension and end stage of renal disease (ESRD). The patient regularly underwent
dialysis for three times in a week. Ms. S.B. was found to have a blockage in her AV
fistula on the left arm the day she went to the dialysis unit to get her usual session and
was referred to the emergency unit. She was found to have high potassium in her
blood, 6.1 mmol/L and underwent femoral central venous access to complete her
session and avoid ventricular fibrillation (Budovich, Blum & Berger, 2014). She was
referred to my ward due to this and she was assigned to Dr. R.A. to perform
thrombectomy (removal of blockage in fistula) that day. She was prescribed complete
bowel rest for six hours before her procedure from breakfast until lunchtime at
1200p.m. The patient’s vital symptoms were as follows: tympanic temperature-
36.6ºC, heart rate- 78, blood pressure- 121/62 mmHg, respiratory rate- 16 br/min,
SpO2 levels- 99% and blood glucose levels (BGLs) at 0600 read 4.2 mmol/L.
2. Collect cues / information
2.1. Review current information
I had gathered information about the patient, thorough medical and nursing
history by noting the patient's clinical records and other accessible cues during the
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second stage of the clinical reasoning cycle. It had been more than 10 years; Ms.
S.B. was diagnosed with diabetes mellitus and hypertension. She had been taking
dialysis for three years after she was diagnosed with ESRD. Five years ago she
underwent a cholecystectomy surgery. She was prescribed a regular dose of
insulin aspart and insulin glargine for diabetes and amlodipine and Prazosin for
hypertension.
2.2. Gather new information
The next step of the clinical reasoning cycle was collection fresh
information and related data for an ailing patient by setting up a questionnaire
with the patient, with their family members and other health practitioners or
nurses assigned to the patient. In the morning at 0820 am, the patient rang a bell
to which my teacher and I heeded and she complained "I feel drowsy, dizzy and
very hot", for which we examined her body temperature which read normal, 36.6
ºC. We examined her BGL after this which read, 3.2mmol/L; speculating problem,
we asked whether she had meal or not, to which she replied due to her fatigue and
sleepiness, she had skipped breakfast and remained empty stomach since last
night’s dinner. The assigned nurse from the night before failed to address that fact
and informed us that the patient had breakfast. This was troublesome as the patient
was instructed to have only 6 hours of NPO before the procedure.
2.3. Recall knowledge
It is essential to gather more knowledge apart from current record and
medical history so I had searched for further information related to the condition
by using newest facts based application and observing the patient's state in various
scenarios. I concluded that due to the fact that the patient was unfed for such a
long time, her BGL lowered vastly and she started to perspire, palpitate, starve,
confuse, nauseous, feel drowsy and could not speak (Holt, 2011). These were the
obvious reasons for Ms. S.B.’s distress.
3. Process information
3.1. Interpret
Analysis of the found data is the next step in clinical reasoning and
looking for any abnormality. It was abnormal for Ms. S.B. to have such low level
of BGL, in accordance with the National Institute for Health and Care Excellence
(NICE) the threshold BGL for people with type 2 diabetes is from 4 to 7 mmol/L
prior to meals and post meals level is 8.5mmol/L (Oldroyd, 2011). Ms. S.B. is an
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elderly woman with diagnosed renal issues and had been starving for more than 8
hours, so these factors can taken for consideration for the cause of lowered BGL
in Ms. S.B. A study in the United States studied the number of people with
medical benefits in elderly people, which suggested that age is a common factor
which elevates the risk of Hypoglycemia. About 1.2% of oral hypoglycemic
medicine users and 2.8% of insulin users above the age of 65 years suffer this
condition (Ligthelm, Kaiser, Vora & Yale, 2012).
3.2. Discriminate
The found data will be compiled by me on Ms. S.B., by stating that her
potassium level is a little elevated 6.1mmol/L, but this is not to be pondered about.
The concerning was her BGL of 3.2 mmol/L.
3.3. Relate
A step in clinical reasoning called "connecting the dots" means that at this
step I had gathered the data jointly to understand the associations and analyze
logically. Therefore, Ms. S.B's lowered BGL could originate from the starvation
or due to the renal illness. Hypoglycemia is common in people with chronic
kidney disease (CKD) (Kong et al., 2014). This happens because, inhibition of
glucose discharge and insulin expulsion by kidney, distorted drug interaction,
dialysis related issues, albuminuria and under nourishment (Alsahli & Gerich,
2014).
3.4. Infer
This step allows me to deduce results that I had followed rationally by
interpreting symptoms, considering secondary options and end results. It can be
concluded that, Ms. S.B. could have undergone cues and manifestations of
hypoglycemia.
3.5. Predict
I had needed to deduce conclusion basing on the every data that I
collected. So, if Ms. S.B. was left with her current the BGL condition, she would
have faced further complications as a result of hypoglycemia like, losing sense,
seizures, or fatal end (Feinkohl et al., 2014).
3.6. Match
This step required me to relate the condition with the previous state and
this patient’s issue with other patients. It is observed that patients with known
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history of kidney disease show lowered levels of BGL when they do not intake
proper food intake for long time.
4. Identify the problem / issue
Compilation of all the data that have been gathered to construct the diagnostic
evaluation of the patient is the fourth stage of the clinical reasoning cycle. Ms. S.B. is
elderly woman, with kidney syndrome who starved since the night before from 0600
p.m. till 0820 a.m. Consequently, Ms. S.B. experienced a hypoglycemic incident.
5. Establish goals
I had placed a precise conclusion for Ms. S.B after my intervention in the fifth
step of the clinical reasoning cycle. The short term goal I placed for Ms. S.B. to
replenish her threshold BGL 4-7mmol/L after one hour, and the long term goal I
placed for her by preventing future hypoglycemic episodes.
6. Take action
I had devised a plan that needed awareness, clinical vocation, effective patient
engagement skills and clinical reasoning aptitude as well in the sixth stage of clinical
reasoning. Consequently, we summoned the practitioner and she instructed 10%
dextrose solution and we provided it. However, SEHA hospitals says that in
accordance with the Health Authority for Abu Dhabi (HAAD) if any patient is
influenced by NPO and undergoing a vitally low BGL,10% dextrose solution is the
standard dose to control the BGL to normalize the level (Baynouna, Nagelkerke, Al
Ameri, Al Deen & Ali, 2014). Additionally, other articles hold up this intervention
and affirm that when a patient with diabetes has hypoglycemia and they are unable to
consume any fluid or if, external fluid needed, the ideal remedy is to inject venous
dextrose, because it contains water with various amounts of sugar (Pham & Borno,
2012) which dissolves in blood. Whilst, most the articles add up the administration of
dextrose for these patients the dosage is vastly variable in compliance with the
patient's condition (Coats & Marshall, 2013).
7. Evaluate
I had evaluated the efficacy of the planning in this stage. We calculated a
capillary BGL at the beginning of signs to affirm the hypoglycemic condition and
then we constantly checked at 10–15 minutes interval of the dextrose administration
(Lim, Munshi & Sharon, 2015). At 0930 the dextrose administration was completed
10 minutes before, so we examined the BGL and it stabilized at 5.2mmo/L. hence her
BGL was in stable threshold currently, but we were required to check frequently.
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8. Reflect
Reflection is closing step of the clinical reasoning cycle and it consists of two
segments, the first one being retrospection, meaning what learning experience you got
from this course of action and flash forward which is devising what could have been
done another way. Utilizing the Gibbs reflective cycle I employed it, to figure up the
clinical reasoning cycle in this step (Lewis, 2015).
Gibbs reflective cycle is a documented scaffold of reflective thinking that
contains six segments to concur one cycle and these segments are descriptive,
emotion, evaluate, analyze, conclude and act management (Ritchie, 2012). I had
discussed the condition first for starting the cycle. Throughout the service of Ms. S.B.
rang the bell at 0820 am and she said "I feeling drowsy, dizzy and very hot" so we
examined her vitals and she was fine, then we examined the BGL and it read
3.2mmol/L. However, she had undergone NPO and we were not supposed to give her
anything orally, so the practitioner instructed dextrose for her and following one hour
the patient's BGL stabilized at 5.2mmol/L. Also I remembered sitting beside the
patient trying to calm her during her distress.
I described my feelings in the second segment where I was thinking
throughout the condition. I was concerned regarding the patient due to the fact that
she was lonely and frightened.
In the evaluation segment, I felt sad when my teacher just observed me while I
was injecting the dextrose and just stepped out from the ward. I helped the patient
calm down because she did not have her family to comfort her.
In the analytical segment, we did the correct intervention for Ms. S.B., my
teacher and I examined the BGL and let the assigned practitioner know. The doctor
instructed the amount of fluid that needed by the patient. After that my teacher and I
injected it and evaluated the efficacy of the intervention. I provided emotional
support for Ms. S.B when my teacher was engaged with other patients. We faced
inaccurate clinical reasoning when the assigned nurse for the previous night shift did
not make sure whether the patient had her breakfast and we were not sure until she
met with the episode. We faced a mismanagement of clinical reasoning which
occurred due to the fact that there was inefficiency while gathering all the important
data in making a discrepancy examination that resulted in noteworthy end result being
overlooked (Chamberland et al., 2015).
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In the conclusive step, the constructive outcome from this incident was that I
learned how to provide proper emotional support to a suffering patient. The negative
outcome was that my senior just observed me whilst I'm injecting the IV solution then
she stepped out when the previous assigned nurse gave us wrong information and my
senior did not question her. Besides, I educated myself from this incident that when I
will become a registered nursing staff, I will endow with time management and good
patient engagement skills with the patients and I will pay heed to their requirements.
Additionally, I also learned that I should crosscheck the patient data with the patient
and their family to avoid complication and miscommunication.
The final step of the Gibbs reflective cycle is having a plan of action. I will be
prepared for the next time I encounter similar case, I will he a ready plan of action to
avoid any complication and quick care service can be provided to the patient.
Another clinical trick I learned was that not just plain sugar but a 10% solution of
dextrose can help lowering the BGL of the patient and not just by oral administration.
I learned to provide care of the patients in an all rounded approach to provide the best
care service. Lastly, I learned to be more aware of the policies that my working
healthcare facility has and also the state laws regarding patient safety.
Recommendation
Wellness service providers and especially nurses must have enhanced indispensable
application skills such as medical interpretation, analytical thinking and decision making, via
studying, discussion and proof related application to include world class service (Groves,
2014). I would recommend future nursing students to carry out complete evaluation of the
patients, gather adequate data and question patients and not to hold back information from the
next assigned nurse to avoid unpacking principle error (Groves, 2014). Furthermore, I would
recommend the current nursing staff to make patient involvement a proper practice, elucidate
the care plan to them and inform them. In special cases where the patient has critical
condition and is undergoing NPO instructions like in this incident by following the infirmary
policies (Rochmawati & Wiechula, 2010).
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Conclusion
The process of Clinical reasoning cycle is a well-versed judgment making technique
that is gaining a wide influence in the health care service sector that requires effective staff
communication to provide best service for the ailing patients and meeting their demands
(Meissner, 2010). All the same, being a patient activist nurse having to support and maintain
patients in care plan is important (Groves, 2014). Ensuring wellbeing and healthy life is
important and can be maintained by engaging the patient the care plan and letting them
known about their current condition and how it can be handled, like in this case, educating
the woman might help her check her disease condition. (Holt, 2011).
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