University Nursing Clinical Reasoning Cycle Case Study Report

This report presents a detailed analysis of a nursing case study involving a 17-year-old patient with diabetes mellitus and pyelonephritis. The analysis utilizes the clinical reasoning cycle to identify critical issues contributing to a critical incident, including uncontrolled blood glucose levels, inadequate communication, and ineffective handover reports. The report examines the responsibilities of the registered nurse, focusing on patient assessment, interprofessional communication, and adherence to hospital policies. The report is supported by three scholarly articles, each addressing a specific issue: the relationship between diabetes and infections, the importance of effective interprofessional communication, and the significance of comprehensive handover reports. The report highlights the need for improved patient care, adherence to hospital policies, and effective communication to prevent adverse patient outcomes. This report underscores the significance of evidence-based practice and clinical reasoning in nursing to ensure patient safety and well-being.

Running head: EVIDENCE-BASED PLAN FOR HEALTHCARE
Clinical Reasoning Cycle
Student Name
University Name
Author Note

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Part A
The clinical reasoning cycle is proposed to be undertaken to analyze the issues that
are a part of the case study (Levett-Jones et al., 2010). The clinical reasoning cycle has
various stages, which revolve around the procedure to study the case study while identifying
issues and resolving them with the best appropriate intervention (Hunter & Arthur, 2016). For
the case study that is provided, the patient is 17-year-old who suffers from diabetes mellitus
from a long time. She is presented in the emergency department with symptoms of flank pain,
dysuria and fever. It can be ascertained that type 1 diabetes mellitus and pyelonephritis are
interrelated. The cause of pyelonephritis has been observed to be majorly because of high
blood glucose levels (Sharma & Sharma, 2018). During the initial assessment of the patient
by the nursing professional, the blood glucose levels have been found to be 9.4 mmol/L. The
glucose level is a little higher than the normal value for which administration of medications
to control the glucose levels is required to cease the spreading of infection to her kidneys and
causing pyelonephritis (Bergman, Chetrit, Roth & Dankner, 2016).
As per the policy that was proposed by the hospital, staff in the High Dependency
Unite (HDU) to provide the medical wards adjacent with proper assistance whenever
required. It was the duty of Cameron, registered nurse, to contact the staff whenever a
problem arises in the ward. Two more patients have been admitted the same night, which
resulted in increased stress among the professionals. The staff had made three calls to
Cameron, which remain unanswered. There was a lack of acknowledgement observed from
Cameron’s part, which is a direct breach in the conduct of the nursing professional, by the
hospital standards. It was the duty of Cameron to continuously monitor the vital parameters
of the patient considering the critical situation that she has been brought in the hospital. The
nurse probably forgot to take the measure of blood glucose levels of the patient, which are
assumed to be the primary reason for the patient’s pyelonephritis (Torsvik et al., 2016). This

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lapse was a major breach in the conduct of the nurse in providing the patient with the best
care and putting the life of the patient under severe risk.
After this, Cameron had informed the nurse in the morning shift to avoid disturbing
the patient and consider the handover report with the assessments conducted post-midnight. It
was for this reason that the patient was not continuously assessed, which made the patients
fall under grave risk of life and death (Lang, 2019). As a registered nurse, it is their primary
duty to ensure the best care is being provided to the patients without putting their life in
danger. Because of the lapse on the duty performed by the registered nurse, the blood glucose
level of the patient has significantly increased over the duration of the night, which increased
the spreading of the infection to different parts of the body. This is a breach in the
responsibility that is bestowed upon the nursing professional. As a registered nurse, it is their
primary duty to inform the nurse in the morning shift to assess the patient repeatedly and
inform the physician to tackle any deterioration in the medical condition of the patient
(Lynch, Roberts, Keebler, Guttman & Greilich, 2017). Despite the partner informing the
nurse about the patient being not in appropriate sense, the nursing professional did not pay
enough heed and went on to carry her own work. The registered nurse has been in the
profession for five years with excellent experience on whom this kind of patient care is
unacceptable.
Part B
The three issues that are identified in the case study provided are described in brief with the
help of relevant articles to understand them better.
1. Diabetes and pyelonephritis and the necessary care to avoid spreading of the infection
Magliano et al., (2015), have conducted research, to find the prevalence of
infections in diabetes patients due to uncontrolled glucose control in blood. The patients

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who are suffering from type 1 diabetes have been long suffering from a risk of sustaining
infections in the form of hospital-acquired infections or urinary tract infections. It has
been studied that long term of uncontrolled blood glucose levels can decrease the ability
of the immune system to fight off the microorganisms, which can cause infections in the
body. The research conducted by them included patients suffering from type 1 and type 2
diabetes who sustained pneumonia, septicemia and osteomyelitis (Magliano et al., 2015).
Females who had persistent septicemia have died in comparison to pneumonia and
osteomyelitis. In the case study, Ms Jones is likely to contract infection in the form of
sepsis, which may turn fatal for her medical condition due to her uncontrolled diabetes for
a long time. The research article tests the mortality of the individuals who are suffering
from infections with the presence of high diabetes. Despite the presence of age-related,
factors associated with the occurrence of diabetes in individuals, the mortality ratio is 10
and 2 for type 1 and type 2 form of diabetes. Pyelonephritis is a bacterial infection, which
causes inflammation in the kidneys, which starts from the bladder and later spreads to the
kidneys (Quaia, Gennari & Cova, 2018). Majority of the kidney diseases, which are
prevalent in individuals, have been observed to be caused by uncontrollable diabetes. The
renal function of the individual is hampered when there is high amount of glucose present
in the human body (Yang et al., 2017). The usual symptoms that an individual
experiences is vomiting, flank pain and nausea among others. The most prevalent
symptoms in these kind of patients is fever. In the case study, Ms Jones have been
experiencing high fever for a long time which was not paid enough attention by the
nursing staff which resulted in the spreading of infection to different body parts. The
nurse who is deployed to take care for the patient should repeatedly assess the patient and
inform the concerned physician in case of a major fluctuation in the vital parameters
(Lewis et al., 2016).

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2. Registered nurse did not pick up the phone of the nurse in the high dependency unit
despite of presence of a hospital policy
In the healthcare system, there are presence of inter professionals who are part of the
team to provide the patient with the best care possible for a positive health outcome.
When the patient is admitted in the hospital, they encounter a number of staff members
whose primary responsibility is to ensure the best care to the patient to relieve them of the
problems that they have been brought in. for an effective clinical practice, the inter
professionals must conduct themselves as per the code of conduct to communicate with
the patient. Accurate communication among the inter professionals can lead to better
outcome for the patient. In case of an inefficient communication, the medical condition of
the patient is at risk, which may have detrimental effects on the health. Collaboration in
healthcare has been supported by a number of organizations to work cooperatively by
displaying appropriate problem-solving skills and making the best decision for the
patient. In the case study, it has been observed that hospital had policy regarding the
nurse deployed in the high dependency unit to communicate with Cameron regularly in
case of an emergency. Despite repeated calls, there was no answer from Cameron’s side.
This could have been because there was some personal issues between the two nurses,
which resulted in Cameron not picking up the phone (Kalliokoski, Kyngäs, Ala-Kokko &
Meriläinen, 2019). It was hard for the nurse to realize that this can lead to breach of the
policy that has been stipulated by the hospital organization. Effective strategies like
regular interactions of the inter professionals with each other will help in building a sense
of friendship and better communication. It is probable that the nurse in the high
dependency unit was calling to enquire about the condition of the patient, which may
have resulted in continuous checking of the parameters of the patient. This could have
decreased the chances of the blood glucose levels to be minimum and avoid the spreading

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of the infection to different parts of the body. The nursing professionals must ensure the
best care for the patient with regular monitoring of the vital parameters and informing the
physician to decrease the risk associated with the medical condition. In the research study
conducted, the nurse should be viable to answer the authority of the hospital while
conducting a major lapse in the professional area in the hospital.
3. Nurse informed morning shift nurse to not disturb the patient for a handover report, which
further deteriorated the condition of the patient.
According to the paper published by Piper, Lea, Woods and Parker, (2018), patient
handover reports are a critical form of report that are observed in Australia to improve the
patient outcome for critical illnesses. It is crucial for ensuring patient safety by the nurses
who work in shifts in hospital organizations. Inability to communicate with the nurses for
the clinical handover report can cause detrimental effects on the outcome of the patients.
Previous researchers have observed the connection between ineffective handover and
patient safety in the country (Hay, Wilton, Barker, Mortley & Cumerlato, 2019).
Disastrous effect on the health of the patient is reported in individuals who are deprived
of an effective handover report from the nursing professionals. There is presence of
substantial evidence, which reports that clinical error in collecting the necessary
information of the patient in the form of vital parameters and relevant assessment has
been causing harm to the wellbeing of the patient (Runciman, Merry & Walton, 2017).
There is a dire need of nursing professionals to communicate with other nurses effectively
to make them understand the medical condition of the patient. Due to the inefficiency in
delivering, the optimum care to the patient can lead to injurious health conditions in the
patient. In the case study, the nurse deployed in the night shift instructs the morning shift
nurse to not disturb the patient for a handover report and work on the report that has been
assessed post-midnight. It is the primary duty of the nursing professionals to conduct

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repeated assessments of the patient to check any sign of fluctuations in the vital
parameters and any sign of improvement in the patient. The registered nurse, Cameron,
did not take the parameters for blood glucose levels during the night, which resulted in no
medication being administered for the proper control of the blood glucose levels. It is a
common incidence of discrepancies in the handover report while transferring it to a
different shift nurse. Patients admitted in the acute care setting are required with nurses
who effectively communicate with clinicians. There are many factors, which decrease the
efficiency of the nursing professionals in performing in line with the conduct that have
been released by the hospital organization. External noise and extraneous talking are
some of the most common factors that have been associated with reducing the
enhancement of the handover reports of the patients (Fealy et al., 2018). In the research
study, different physicians and nursing professionals have participated across the country
to understand the key problem areas to help in addressing the issue. It was found that
relevant training to the nursing professionals by making them understand the policy
associated would be easier for execution of the procedure. The nursing professional must
never let go of the critical complications that can arise in the patient due to their extensive
medical history. In the case study, it was evident that the patient had been suffering from
type 1 diabetes mellitus for which proper care should have been taken. It was the duty of
the registered nurse to conduct regular assessment of the blood glucose levels and report
to the doctor in case of any rapid fluctuation.

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References
Bergman, M., Chetrit, A., Roth, J., & Dankner, R. (2016). One‐hour post‐load plasma
glucose level during the OGTT predicts mortality: observations from the Israel Study
of Glucose Intolerance, Obesity and Hypertension. Diabetic Medicine, 33(8), 1060-
1066.
Fealy, G., Donnelly, S., Doyle, G., Brenner, M., Hughes, M., Mylotte, E., … Zaki, M.
(2018). Clinical handover practices among healthcare practitioners in acute care
services: A qualitative study. Journal of Clinical Nursing.doi:10.1111/jocn.14643
Hay, P., Wilton, K., Barker, J., Mortley, J., & Cumerlato, M. (2019). The importance of
clinical documentation improvement for Australian hospitals. Health Information
Management Journal, 1833358319854185.
Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement:
Clinical educators' perceptions. Nurse education in practice, 18, 73-79.
Kalliokoski, J., Kyngäs, H., Ala-Kokko, T., & Meriläinen, M. (2019). Insight into hospital
ward nurses’ concerns about patient health and the corresponding Medical Emergency
Team nurse response. Intensive and Critical Care Nursing.
Lang, P. (2019). Record-keeping and the patient healthcare record. Applied Paramedic Law,
Ethics and Professionalism EBook: Australia and New Zealand, 258.
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 risk” patients.
Nurse Education Today, 30(6), 515–520. doi:10.1016/j.nedt.2009.10.020

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Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D.
(2016). Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical
Problems, Single Volume. Elsevier Health Sciences.
Lynch, I. P., Roberts, P. E., Keebler, J. R., Guttman, O., & Greilich, P. E. (2017). Error
Detection and Reporting in the Intensive Care Unit: Progress, Barriers, and Future
Direction. Current Anesthesiology Reports, 7(3), 310-319.
Magliano, D. J., Harding, J. L., Cohen, K., Huxley, R. R., Davis, W. A., & Shaw, J. E.
(2015). Excess Risk of Dying From Infectious Causes in Those With Type 1 and Type
2 Diabetes. Diabetes Care, 38(7), 1274–1280. doi: 10.2337/dc14-2820
Piper, D., Lea, J., Woods, C., & Parker, V. (2018). The impact of patient safety culture on
handover in rural health facilities. BMC health services research, 18(1), 889.
Runciman, B., Merry, A., & Walton, M. (2017). Safety and ethics in healthcare: a guide to
getting it right. CRC Press.
Quaia, E., Gennari, A. G., & Cova, M. A. (2018). Ultrasound of Upper Urinary Tract
Infections. In Imaging and Intervention in Urinary Tract Infections and
Urosepsis (pp. 57-71). Springer, Cham.
Sharma, A. K., & Sharma, A. R. (2018). Fungal Infections and Intervention in Diabetic
Complication. In Fungi and their Role in Sustainable Development: Current
Perspectives (pp. 483-503). Springer, Singapore.
Torsvik, M., Gustad, L. T., Mehl, A., Bangstad, I. L., Vinje, L. J., Damås, J. K., & Solligård,
E. (2016). Early identification of sepsis in hospital inpatients by ward nurses increases
30-day survival. Critical care, 20(1), 244.

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Yang, G., Cheng, Q. L., Li, C. L., Jia, Y. L., Yue, W., Pei, X. T., ... & Ao, Q. G. (2017). High
glucose reduced the repair function of kidney stem cells conditional medium to the
hypoxia-injured renal tubular epithelium cells. Beijing da xue xue bao. Yi xue ban=
Journal of Peking University. Health sciences, 49(1), 125-130.