Principles of Nursing: Clinical Reasoning Cycle for Patient Assessment

This article discusses the clinical reasoning cycle for patient assessment in nursing, using the case of a patient with high blood pressure, obesity, and primary open angle glaucoma. It covers the stages of observation, information collection, processing, problem identification, establishment, action, and evaluation.

Running head: PRINCIPLES OF NURSING 1
Principles of Nursing
Name of Author
Institution of Affiliation
Date of Submission

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Consider the patient
As stated by (Hunter & Arthur, 2016)., this is the first stage of the clinical reasoning
cycle, where you first observe what happens during your encounter with the patient. Now
consider the case of Mrs. Anna Maria, who has recently been diagnosed with sensorineural
hearing loss, also known as presbycusis. Anna Maria has been married to her husband Gino for
more than 50 years. She is 68 years old. At the consultation room, Anna Maria looks flushed and
holds her handbag tightly with both her hands, in front of her body as Mikaela explains to Maria
and Gino about the purpose of the meeting. Mikaela explains to the married couple that the
meeting will take place for an hour with the aims of finding ways of controlling Anna Maria’s
BP and cholesterol. After some time, Anna Maria appears to be relaxed, and she leans back in
her chair. Additionally, she is no longer holding her bag tightly and is smiling and nodding as
Mikaela talks.
Collection of information
Collection of information is the second phase of the clinical reasoning cycle. In this stage,
the nursing practitioner is required to collect all relevant information about the patient. The
information will include the history of the convalescent, medical reports, and any assessment
conducted by the nurse. Anna Maria has been receiving the services of the hospital for more than
20 years. Additionally, she also has a history of high blood pressure. Before this session, Anna
Maria has hospitalized a year ago with moderate sensorineural hearing loss (Delany & Golding,
2014). From the clinical report, Anna Maria had a prescription of Enalapril 20mg BD, which is
an angiotensin-converting enzyme inhibitor that is applied for the therapy of convalescents
experiencing hypertension. She also has a prescription of Simvastatin 20mg nocte which along
with a good diet helps in lowering the cholesterol level in the body. Besides, she also had a

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medication of 1 drop per eye of latanoprost to treat her primary open angle glaucoma. The lab
tests of Anna Maria which were taken two months ago, showed that her hemoglobin level was
146 grams per which was normal, hematocrit level was 40% indicating it was normal, mean cell
HB was also good, and mean corpuscular volume was 88% indicating it was normal. The other
tests for mean corpuscular hemoglobin concentration (310 g/L), neutrophils (5.1 109 /L),
lymphocytes (2.3 109 /L), white cell count (8.2 109 /L), monocytes (0.3 109 /L), eosinophils (0.1
109 /L), Basophils (<0.1 109 /L), and platelets (280 109 /L) all passed showing that her blood
was in good status. The other tests that had been conducted were the liver function test and the
biochemistry composition in her body. The results for the liver function test suggested that her
bilirubin level (12 umol/L), Alkaline Phosphate level (110 U/L), Aspartate aminotransferase
level (30 U/L), Gamma-glutamyltransferase level (22 U/L), and Alanine aminotransferase (38
U/L) were all in a normal range. The only difference was the protein level (55 g/L) which was
not on the normal range of 60- 80 grams per liter and albumin level (50 g/L) which was not on
the normal range of 32-48 grams per liter. The protein level and albumin level may be low and
high, respectively, due to her age.
Anna Maria’s biochemistry results showed that her sodium concentration (137 mmol/L), calcium
concentration (2.30 mmol/L), potassium concentration (4.5 mmol/L), chlorine concentration
(102 mmol/L) and magnesium concentration (0.9 mmol/L) were all in normal conditions
(Warwick et al., 2015) Furthermore, the biochemistry results also showed that her urea
concentration (5 mmol/L), cholesterol (5.0 mmol/ L), High-Density Lipoprotein cholesterol
concentration (1.0 mmol/ L), and bicarb concentration (24 mmol/L) were all in normal levels.
Moreover, her biochemistry results also suggested that her creatinine concentration (82
mmol/L) and fasting triglycerides level (1.8 mmol/L), were all in good conditions. The only

PRINCIPLES OF NURSING 4
discrepancies were the Low-density lipoprotein level (3.5 mmol/L) which was out of the normal
range of 2.0- 3.4 mmol/L, estimated glomerular filtration rate level (64 ml/min/1.73 m2) out of
the normal range of >90 ml/min/1.73m2, and fasting blood glucose level (5.6 mmol/L) out of the
normal range of 3.0 -5.4 mmol/L. The estimated glomerular filtration may be low due to a
kidney disease or because of Anna Maria’s age. Additionally, the fasting glucose level was out
of normal range, indicating that Anna Maria could be suffering from prediabetes, and there is a
high possibility of developing type 2 diabetes. Moreover, the low-density lipoprotein level was
higher than normal, either because of Anna Maria’s age or the fact that Anna Maria is
overweight (Bolton, 2015).
I performed a check on Anna Maria’s vital signs. The results showed that her blood
pressure level was 175/ 93 which was consistent with hypertension, heart rate of 96 beats per
minute which is normal with regular peripheral pulses but there were no signs of arterial disease
(Warwick et al., 2015). Anna Maria’s respiration rate was 20 breaths per minute, the tympanic
temperature was recorded at 37®C, which was normal, and her oxygen saturation level was at
98%. Her height was 160 cm, and her weight was recorded at 80 kgs, therefore according to the
height and weight, I concluded that Anna Maria’s body mass index was 31.2. The urinalysis test
showed a specific gravity of 1.010 with a pH of 6, which was normal.
Processing gathered information
In this stage, every detail from the previous phases is examined (Dalton, Gee, & Levett-
Jones., 2015). Any differences or discrepancies found are identified and highlighted.
Furthermore, patient past information is compared to the recent information from the clinical
records. This will assist me in identifying the possible outcomes and in regards to the available

PRINCIPLES OF NURSING 5
treatment options. The processing of the collected information comes in six steps, namely
interpretation, discrimination, relation, inference, matching, and finally predicting the outcome
(Delany, & Golding, 2014).
1. Interpretation
The standard blood pressure should be 120/80mmHg (Dalton et al., 2015). Therefore, in this
case, considering that Anna Maria’s blood pressure was way above normal (175/93), it is clear
that Anna Maria is suffering from high blood pressure. Additionally, after calculating the body
mass index of Anna Maria from her height and mass, the body mass index showed that Anna
Maria had a body mass index of 31.2 whereas the normal body mass index should be in the range
of 18.5 to 24.9. (Chowdhury et al., 2015). The results from the body mass index in addition to
the fact Anna Maria’s low-density lipoprotein level was higher than normal, it is clear that Anna
Maria is suffering from obesity. Moreover, from the fact that the fasting glucose level was out of
range shows that Anna Maria is suffering from prediabetes and there is a high chance that Anna
Maria may develop type 2 diabetes (Rajpura, & Nayak, 2014).
2. Discrimination
Even though Anna Maria’s estimated glomerular filtration level was low, due to her age, it is
not a major concern (Delany, & Golding, 2014). Moreover, Anna Maria’s protein level is lower
than normal but do not pose a great concern. Furthermore, the albumin concentration level in her
body is not a serious issue at it is mostly related to aging. The more emphasis is on the blood
pressure, obesity, and the prediabetes.

PRINCIPLES OF NURSING 6
3. Relating the information
High blood pressure, obesity, and diabetes, and are all related to the high chances of the
development of renal and cardiovascular problems. Therefore, when combined together, they
pose a major risk of suffering from stroke, heart attack, and chest pains (Chowdhury et al.,
2015).
4. Inference
The blood pressure of Anna Maria may have become higher than normal because of the
presbycusis and primary open angle glaucoma that Anna Maria is suffering from (Yaxley &
Thambar, 2015).
5. Matching
According to a research, almost 35% of adults who were 65 years and above and are
currently located in the united states of America are obese. The research was conducted between
2007-2010. In estimation, the 35% represented almost 8 million people aged between 64-74 year
and approximately 5 million individuals aged 75 and above (Kim & Kim, 2015). Therefore, there
is a high prevalence of obesity in individuals aged 65-74 years compared to other people.
Additionally, almost 30,000 Australians experience glaucoma. Furthermore, in every 100
Australians, two will suffer from glaucoma in their lifespan. Moreover, 1 in every 8 individuals
located in Australia aged over 80 years will experience glaucoma (Forneris et al.,2015).
Therefore, Anna Maria’s obesity issue and the primary open angle glaucoma affect mostly
people aged from 65 and above.
6. Prediction
If Anna Maria’s high blood pressure and obesity are not treated immediately, they may lead
to the development of cardiovascular illnesses.

PRINCIPLES OF NURSING 7
Identification of the problem
I have identified that Anna Maria is suffering from obesity, the primary open angle
glaucoma and high blood pressure (Gabb et al., 2016). Therefore, I am going to assist her in
reducing the problem with high blood pressure.
Establishment
Within an hour, I will write a list of ways that Anna Maria would use to help her will help
her reduce the high blood pressure without the use of further medications (Moonen et al., 2015).
Take Action
For the purpose of reducing the risk of the health status of Anna Maris from deteriorating
without further prescriptions of medicines, Anna Maria should:
 Take regular walk and exercise- participating in exercises will help in boosting the heart
condition and efficient pumping of blood which will, in turn, lower the pressure in her
arteries.
 Lower down the amount of caffeine she takes- caffeine increases the blood pressure and
therefore, lowering the intake of caffeine will ultimately lower the blood pressure level.
 Use non-alkalized cocoa powder- It has no added sugar and flavonoids. It also contains
plant compounds that assist blood vessels, therefore, reducing the blood pressure.
 Add berries in her diet- Berries have a lot of polyphenols. The polyphenols aid in
reducing the blood pressure and overall risk of experiencing heart diseases.

PRINCIPLES OF NURSING 8
 Try deep breathing or meditation- By doing meditation and taking deep breaths, the acts
activate the parasympathetic nervous system, which will help in slowing the heart rate
and reduce the blood pressure.
 Take natural supplements- Natural supplements such as whey protein, berberine, aged
garlic extract, hibiscus, and fish oil have ingredients that help lower the blood pressure
(Benetos et al., 2016).
Evaluation
As stated by (Forsberg et al., 2014), this stage is essential for the nursing practitioner. It
allows him/her to re-evaluate the patient’s information and the current health status of the
convalescent so as to get the most effective nursing care and whether the patient’s health status
has improved. Therefore, after a few days of engaging in the propositions I made, Anna Maria’s
health status has started improving. Additionally, her blood pressure level has started reducing.
Moreover, there was no need to increase the medications that Anna Maria had been prescribed.
Therefore, the approach that I take has, in fact, better the quality of life of Mrs. Anna Maria
(Hunter, & Arthur, 2016).
Reflect on Process and New Learning
This stage provides nurses with the chance to review how he/ she has conducted the case.
Moreover, this phase provides nurses the chance to better or change the interventions methods,
or improve the process. In this case, I would have helped Anna Maria by explaining why she
should consider the use of a home blood pressure monitor. Additionally, I would have
encouraged her to keep coming with her husband (Ironside, McNelis, & Ebright, 2014). Her
husband being there is important because Anna Maria will have moral support and see that she is
not fighting the problems. This act will help Anna in her overall health status improvement.

PRINCIPLES OF NURSING 9
Moreover, I would have encouraged Anna Maria to participate in activities that will help her
reduce weight which will, in fact, help her mitigate the problem of hypertension. Additionally, if
I had the skills of a personal trainer, I would have assisted Anna Maria in regarding the exercises
that she can take to reduce her weight and also her blood pressure (Forneris et al.,2015).

PRINCIPLES OF NURSING 10
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