Analysis of Clinical Reasoning Cycle and Patient Deterioration

This report provides a detailed analysis of a case study involving an 82-year-old patient, Mary Smith, who underwent a total left knee replacement. The analysis applies the clinical reasoning cycle to assess her condition, including the consideration of facts, information collection, processing, and diagnosis. The report identifies moments of clinical deterioration, such as pain, changes in vital signs (blood pressure, pulse, oxygen saturation), and blood glucose levels, and proposes evidence-based nursing interventions. These interventions include ensuring proper infusion pump function, oxygen therapy, continuous blood glucose monitoring, and health education. The report also includes an ISBAR handover script to communicate the patient's status to a medical officer. The study emphasizes the importance of nursing interventions in managing patient's health and preventing further deterioration.

Application of clinical reasoning cycle 1
APPLICATION OF CLINICAL REASONING CYCLE
Student’s Name
Institutional Affiliation

Application of clinical reasoning cycle 2
Introduction
Osteoarthritis is a medical condition that affects joints in the body. The most common
forms of osteoarthritis affect the knees, elbows and wrists. In osteoarthritis, the cartilage that
forms the link between two bones within a joint is normally broken down and the bones in the
joint rub against one another in any movement (Fransen et al, 2015). This causes pain and
stiffness within the joints which form the classical symptoms of osteoarthritis. The consequences
of the condition are limited movement and inability to hold things. Mary is an example of a
patient suffering from osteoarthritis. The condition has affected both of her knees leading to total
knee replacement by surgical means in order to manage her condition. There is need to develop
an effective nursing care plan for the patient in order to achieve the best outcome possible as she
recuperates. The aim of this discussion is to critically analyze Mary’s case study, identify
moments of deterioration in her health care plan and provide appropriate nursing interventions
that can aid in her recovery.
Patient analysis using the clinical reasoning cycle
The clinical reasoning cycle as described by Levett-Jones enables nurses and health care
providers to clearly understand a clinical situation of a patient in depth and offer the appropriate
care plan that best suits them. The first phase of the cycle is consideration of facts from the
patient and the clinical situation at hand (Bartels et al, 2016). Mary in this case study for example
has just had a total knee replacement surgery to aid in combating her long-term osteoarthritis. In
the clinical setting the patient is still admitted for clinical monitoring after the surgery. The facts
revolving around her state include the fact that she is now fully alert and conscious after the
surgery. The wound dressing is dry without any oozing. She is experiencing pain in her knees
and feels a bit lightheaded. The fact that she feels nauseated is also an important current state

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consideration that needs to be incorporated in the nursing care plan. Mary is 82 years of age and
therefore quite old. This is an important consideration as osteoarthritis worsens with old age.
This can be explained by the fact that as the body ages, the cartilages in the joints wear out and
become less effective in their functioning leading to increased friction with minimal movement.
The second phase of this clinical cycle involves collection of information about the
patient. Mary has a past medical history of osteoarthritis of both knees. She is a known type 2
diabetic patient over the past 3 years, a history of essential hypertension and fatty liver disease.
This information is of necessity to analyze the patient’s possible risk factors related to her
condition and also in the development of a proper diagnosis and treatment plan. There is a
considerable association of osteoarthritis and diabetes. The association can best be described by
the fact that diabetes exacerbates some of the symptoms of osteoarthritis (Courties, Sellam &
Berenbaum, 2017). Pain for example in the joints due to osteoarthritis can be exacerbated by
diabetic condition. This is associated with the fact that diabetes causes poor healing of wounds.
Since Mary had just undergone through a knee surgery, the wound had not yet completely healed
and the fact that she was diabetic could lead to worsening of the wound and poor wound healing.
In order to effectively manage the patient’s current condition, there is need to include treatment
of the diabetic condition in the treatment plan. Processing of the information collected and
linking it to the pathophysiology behind the state is an important phase of the clinical reasoning
cycle that all nurses and medical professionals must engage in (Wajon et al, 2015).
Mary’s medical history is of importance in identifying the pathophysiology behind her
condition. She has a history of essential hypertension. Despite being idiopathic, this is an
increase in blood pressure associated with old age and that could be linked to various factors
including the fact that she was diabetic and poor health lifestyles. Health lifestyles and diet are

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important factors in explaining certain health conditions. Mary’s type 2 diabetes for example
could be caused by unhealthy lifestyles including poor diet and lack of exercise. The patient’s
diabetic neuropathy is a complication of diabetes and could indicate worsening of her diabetic
condition and therefore the need to manage the condition through treatment. Identification of the
root cause of the patient’s current state is an important phase of the clinical reasoning cycle
(Loeser, Collins & Diekman, 2016). Pain experienced by the patient is due to the surgical wound
that has not yet healed. There is need to monitor administration of analgesics and dress the
wound from time to time by the nurse in order to prevent bacterial infection of the wound.
In Mary’s case, the Patient Controlled (PCA) has not been accessed for the past 1 hour.
This is a threat to the patient’s well-being as the patient is bound to experience exacerbation of
the pain in the knee. The patient when asked about the severity of the pain gave a 7 out of 10
indicating a high level of pain. This could be explained by the lack of analgesic treatment. The
failure of the patient to turn on the switch and administer the analgesic could be due to
exacerbation of the patient’s diabetic state leading to numbness. It is therefore an area of concern
that requires immediate intervention of the nurse. There is need to monitor the glucose levels of
the patient in addition to monitoring their wound management (Malfait, 2016).
Another important phase of the clinical reasoning cycle is to develop and establish care
plans and goals for the patient. After analysis of the patient’s condition and coming up with an
accurate diagnosis, there is the need to incorporate a treatment plan for the patient’s well-being
(Wang et al, 2015). Mary was prescribed medication that would help manage her condition.
However these medication require nursing interventions and rationales in order for the patient to
recuperate. For example. Mary was prescribed metformin that would help suppress her diabetic
condition. There is need for the nurse to educate the patient on self-management of their

Application of clinical reasoning cycle 5
condition by advising on the routes of administration required for any drug (Palmieri-Smith et al,
2017).
Close monitoring of the patient is an important nursing intervention. This ensures that the
patient complies with the prescribed medication and does not skip a single dose (Qin et al, 2017).
It also helps in providing assistance to the patient whenever needed in activities such as drug
administration of propping up the patient into a comfortable position. The patient’s diabetic
condition requires the input of both the nurse and the patient to achieve good outcomes. The
patient should be advised on how to measure their blood glucose levels using continuous glucose
monitoring devices. This helps in establishing the effectiveness of the medication prescribed and
to monitor progress in the healing process (Singh et al, 2015).
Clinical deterioration of the patient
There were several moments of clinical deterioration in Mary’s case that needed nursing
care attention. The patient for example was experiencing a lot of pain in her left knee that had
undergone the surgery. The patient had not be able to access the Patient Controlled Analgesia for
the past 1 hour and therefore the pain stimuli was not suppressed. Her vitals also showed
deterioration in some aspects of her well-being. Her blood pressure levels exponentially dropped
within 60 minutes from 123/70 to 105/56. Her radial pulse on the other hand increased
significantly. According to Mathiessen & Conaghan (2017), these changes in a patient could be
as a result of a significant loss of fluids post-surgery. She was under isotonic fluid infusion in
order to compensate for the lost fluid during surgery and the dehydration that followed post-
surgery.

Application of clinical reasoning cycle 6
The drop in the blood pressure signifies low blood volume in the patient. This could be
due to the fact that she had lost a lot of blood during surgery. In addition to this the implication
of the drop in blood pressure levels could have resulted from the depletion of the isotonic saline
solution that was infused to her or inaccessibility of the infusion pump. There was a significant
increase in the capillary refill duration from 2 to 3 seconds and a resultant pale cool digits
indicating a significant clinical deterioration. This increase in capillary refill indicates poor
perfusion of peripheral tissues. The reason behind this could be attributed to a decrease in the
patient’s blood volume leading to inadequate tissue perfusion (Robinson et al, 2016). Lack of
adequate fluid infusion could be a significant cause in this happening within the 60 minute
duration. The decreased cardiac output due to a decrease in the blood volume led to a significant
increase in the heart rate to compensate for the low volume hence a rise in the radial pulse rate.
The patient’s deterioration was also indicated by a decrease in the oxygen saturation
levels. The reduced oxygen levels made the body respond physiologically to changes by
increasing the respiratory rate in order to compensate for the low oxygen levels. This changes
could be easily attributable to low perfusion and oxygenation of tissues as a result of decreased
blood volume. Mary’s blood glucose levels were 11.5 mmol/l indicating a rise above the normal
levels and need for management. Nursing interventions form an important part of the patient’s
care delivery and well-being (Greene & Loeser, 2015). There are several nursing interventions
that can be applied to reverse the deterioration of Mary’s condition. The first one is ensuring
that the nurse should always ensure that the infusion pump is working properly and
replacing depleted isotonic saline fluid bags until the patient’s blood volume is stabilized to
normal. This can be done by monitoring the patient’s blood pressure and other necessary vitals
from time to time.

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Another important nursing intervention is placing the patient under an oxygen
saturation therapy in order to increase oxygen perfusion within tissues and increase SPO2
to levels above 95%. Failure to maintain oxygen saturation to normal levels could have severe
consequences. Low oxygen levels in blood and tissues could lead to central and peripheral
cyanosis (Jüni et al, 2015). Central cyanosis is linked to fatal outcomes as a result of stroke and
other complications. Another nursing intervention necessary for the patient’s well-being is
ensuring continuous blood glucose monitoring by the patient. The patient should be educated
by the nurse on how to measure their glucose levels and self-administer insulin (Varela-Eirin et
al, 2018). This helps prevent diabetic complications and suppress blood glucose to normal levels.
Health education and health promotion is an important nursing intervention that
should be included in the patient’s care plan. There is need to advise the patient on taking a
healthy diet in order to prevent exacerbation of their condition and promote wellness (Lepetsos
& Papavassiliou, 2016). The patient should for example be advised on low sodium intake, low
cholesterol intake and avoidance of sugary foodstuff. The patient should also be advised on
performing exercises once in a while to improve mobility of the joints and also burn calories
associated with heart diseases. A healthy lifestyle should therefore be incorporated in the
patient’s care plan.
Patient hand over using ISBAR
The ISBAR approach is an important aspect when handling patients over in nursing. It
involves introduction, situation, background, assessment and recommendation. In Mary’s clinical
case, I would hand over the patient to a medical officer as follows. Hi, am Justus. I am a
registered nurse at Auburn hospital. This is Mary, a patient who just underwent through a total
left knee replacement surgery. She was admitted to the hospital three days ago following

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exacerbation of her osteoarthritis condition. The background is that she is an 82 year old female
with a medical history of osteoarthritis of both knees. She has type 2 diabetes that was diagnosed
3 years ago, essential hypertension and a fatty liver disease with slight enlargement. On
assessment she complains of severe pain in her left knee and her vitals indicate a BP of 105/56,
RR of 20bpm, SPO2 of 93% and a radial pulse of 66. My recommendation is that you further
manage the patient and offer a treatment plan that best suits the patient’s pain management.

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