Case Study: Applying the Clinical Reasoning Cycle to George (NNNS5807)

This case study analyzes the application of the clinical reasoning cycle in nursing, focusing on a 51-year-old patient named George diagnosed with stage 4 Chronic Kidney Disease (CKD) secondary to diabetic nephropathy, hypertension, and other comorbidities. The assignment details the eight stages of the clinical reasoning cycle, including considering the patient, collecting cues, processing information, identifying the problem, establishing goals, taking action, evaluating outcomes, and reflecting on the process. It explores George's medical history, current health status, and the nurse's actions, including medication management and patient education. The case study emphasizes the importance of clinical reasoning skills in identifying and addressing patient issues, preventing complications, and improving patient outcomes. The conclusion highlights the cycle's utility as a framework for organized, evidence-based, and holistic nursing care. This assignment demonstrates how the clinical reasoning cycle can be applied to improve patient care and enhance clinical skills.

Assessment 1

Table of Contents
Introduction......................................................................................................................................3
Consider the patient.....................................................................................................................3
Collect cues..................................................................................................................................4
Process information......................................................................................................................4
Identify the problem.....................................................................................................................5
Establish goals..............................................................................................................................5
Take action...................................................................................................................................6
Evaluate........................................................................................................................................6
Reflect on process........................................................................................................................6
Conclusion.......................................................................................................................................7
References........................................................................................................................................7

Introduction
Nurse who has efficient clinical reasoning skills are observed to have positive effect on the
health outcomes of the patient. Alternatively, nurse who has weak clinical reasoning skills
frequently lack to identify impending patient worsening which may lead to “failure-to-rescue”
(LeMone, et al., 2011). Clinical reasoning cycle signifies the clinical judgements and clinical
decision-making that are abstracted as a sequential and rational process involving eight different
and significant stages (Levett-Jones T. , 2013). As per the NSW Health Incident Management in
the NSW Public Health System 2007, chief three causes of negative patient consequences are
lack of proper diagnosis, lack of institution of suitable treatment, and unsuitable handling of
complications. It must be noticed that all these reasons are linked with weak clinical reasoning
skills. So, it is essential that importance of clinical reasoning skills must be identified and
acknowledged in nursing field. This assignment will use a case study of a 51 year old George to
establish the significance and merits of the clinical reasoning cycle.
Consider the patient- George is diagnosed with stage 4 Chronic Kidney Disease (CKD)
with macro albuminuria secondary to diabetes nephropathy during his annual health checkup.
George’s kidneys functioning have been worsening slowly. He also has hypertension, has gained
weight and has elevated levels of cholesterol. He is in prescription of perindopril and
lercanidipine, furosemide, atorvastatin, metformin, sodium bicarbonate, and vitamin D. He has
been living with his wife and their three children at their own home. George does not remember
the names of his prescribed medicines and he is also not sure about the continuity and benefit of
these medicines.

Collect cues- In the second step, nurse will gather relevant cues and data by reviewing and
thinking about George’s current observations and also gathering new information. Then the
nurse will recall the related knowledge which was taught to her in theory. George’s current blood
pressure is 153/93 which indicates that George’s blood pressure is not under control. George has
poorly controlled blood sugar level that is 9.3%. He also has microalbuminaria with urine
albumin being 30 mg/mmol. He has a history of stroke 2 years back. His family members also
have renal issues which points towards genetic disposition. It suggests that George is more prone
to development of CKD. He is overweight and has gained 10kgs in last 2 years. He also has a
history of smoking. Obesity, increased blood pressure, and diabetes are independently related to
amplified risk of developing cardiovascular and renal complications. But when these diseases are
present together, then the risk of development of these complications elevate significantly. In
addition, obesity, smoking, hypertension, raised cholesterol levels, and diabetes have been
identified as risk factors of CKD (Fox & Paul Muntner, 2008). So, it can be inferred that
George’s stage 4 CKD has been due to unregulated diabetes, obesity and hypertension
(Stenvinkel, Zoccali, & Ikizler, 2013).
Process information- In the next step of the cycle, the collected cues/information of
George will be interpreted by thorough analysis and application of nurse’s knowledge about
CKD and associated morbidities (TracyLevett-Jones, et al., 2010). Then the nurse will narrow
down the most important aspects of his care based on prioritization. Then relationships between
the cues will be identified by clustering them together. Then lastly, inferences will be made
based on the nurse’s analysis and interpretation of the cues by considering the outcomes of
nurse’s actions by forecasting potential consequences for George. Considering that he has
obesity, smoking history and diabetes, CKD has been the independent or cumulative result of

these factors singly or independently. He is also confused regarding the names, usage and
importance of drugs prescribed for him. George has obesity-associated and diabetes-associated
renal disease which are linked to physiological, structural and pathological changes in the
kidney. CKD associated with these factors has sequential stages starting from the elevation in
GFR and PGc, glomerular hypertrophy and microalbuminuria (Maric-Bilkan, 2013). In addition
George also has hypertension and raised systolic blood pressure further aggravates the
advancement of the disease to proteinuria, nodular glomerulosclerosis and tubulointerstitial
injury and a decrease in GFR resulting in ESRD. So, if not managed properly and timely George
may develop ESRD which has a high fatality rate.
Identify the problem-In this stage, nurse will bring together all of the facts that she has
gathered and inferences she has made to make a conclusive nursing diagnosis of George’s chief
issues. So, George has been impacted with obesity and diabetes, along with other components of
the metabolic syndrome like hypertension (Hall, et al., 2014). These are much correlated and
lead to the development and advancement of renal disease. George has already reached stage 4 of
CKD and it is essential to inhibit the progression of his disease further in order to improve his
prognosis. So, the main issue in George’s case is to reverse, if possible or at least prevent further
progression of CKD which otherwise may prove fatal for him.
Establish goals- After identifying the chief issue of George, nurse will clearly specify the
goals of the nursing care prior to taking any action (Levett-Jones, Hoffman, Bourgeois, Kenny,
& Dempsey, 2009). Reducing body weight through caloric limitation and enhancing George’s
physical activity are some of the important measures for managing obesity, increased blood
pressure, and CKD. Nurse will also specify target range for blood pressure, weight and blood
pressure. For George, target blood pressure to achieve is <130/80mmHg and target HbA1c is

<7%. Even though early intervention and management of obesity, blood sugar and blood
pressure are vital, this strategy may not be effective in producing long-term weight loss or in
preventing cardiorenal and metabolic consequences in many obese patients. Therefore,
pharmaceutical interventions are required in George’s case to lower the morbidity and mortality
related to CKD secondary to diabetic nephropathy (Alicic, Rooney, & Tuttle, 2017). If George is
morbidly obese patients, nurse can consider the option of surgical interventions to attain
sustained weight loss.
Take action- This step is nursing action, which is the behavior after the decision. This stage
involves practical abilities, intellectual actions and communication competency. Nurse also must
make a decision regarding the priority of certain parts of care plan over other. Other aspects to be
considered at this stage is identifying which included procedures and policies, and person and
time of notification. Medical therapy will be commenced as per Doctor’s instructions. Since
hypertension is more difficult to regulate in obese people, particularly when there is substantial
renal injury, George will require combination drug therapy to attain the target blood pressure
level. Nurse will also educate George regarding the importance of taking these medicines on
time and continuously. She will teach him the names of the medicine and make him aware
regarding the complications which may occur if he fails to take his medicine.
Evaluate- At this stage nurse will evaluate the outcomes of the actions taken in previous stage.
After administering and continuing the prescribed medicine, it is likely that George’s
hypertension, renal injury, cholesterol level and blood sugar level will improve. Nurse will check
if she was able to instruct George regarding the medicine adherence properly or not by checking
if he has followed the medicinal regimen.

Reflect on process- Reflection is the last stage of the cycle in which nurse will look back
with careful deliberation of the experience and a critical evaluation of practice with a view to
improve (Rossiter, 2013). I have learnt that CKD is a significant outcome of obesity, and
diabetes. Moreover, hypertension and diabetes have been established as two chief causes of
CKD. George’s case exemplifies that it is essential to deeply consider the accompanying
morbidities of a patient as they can prove to be the underlying cause or contributing factor of the
chief issue. In future, I will thrive to take thorough history of the patient and aim for a treatment
which not only includes the presenting complain but all the concomitant impairments.
Conclusion
Levitt-Jones clinical reasoning cycle is a methodical framework which can help the nurses at
every step of nursing care. Like in the given case study, the clinical reasoning cycle not only
helped the nurse in making a decision regarding George’s diagnosis but also care planning,
specifying care goals, prioritizing the care goals, taking action, reviewing the consequences of
action and ultimately reflecting on the whole case. By using the cycle, nurse will not miss any of
the stage, which will make the nursing care more organized, evidence-based and wholesome.
References
Alicic, R. Z., Rooney, M. T., & Tuttle, K. R. (2017). Diabetic Kidney Disease. CJASN, 12(12),
2032-2045.
Fox, C. S., & Paul Muntner. (2008). Trends in Diabetes, High Cholesterol, and Hypertension in
Chronic Kidney Disease Among U.S. Adults: 1988–1994 to 1999–2004. Diabetes Care,
31(7), 1337–1342.

Hall, M. E., Carmo, J. M., Silva, A. A., Juncos, L. A., Wang, Z., & Hall, J. E. (2014). Obesity,
hypertension, and chronic kidney disease. Int J Nephrol Renovasc Dis., 7, 75-88.
LeMone, P., B., Dwyer, K., T., L.-J., T., M., L., R.-S., . . . K., H. (2011). Medical-surgical
nursing: Critical thinking in client care. NSW: Pearson.
Levett-Jones, T. (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.
Levett-Jones, T., Hoffman, K., Bourgeois, S., Kenny, R., & Dempsey, J. (2009). Clinical
Reasoning. School of Nursing and Midwifery.
Maric-Bilkan, C. (2013). Obesity and Diabetic Kidney Disease. Med Clin North Am, 97(1), 59-
74.
Rossiter, R. (2013). The Clinical Reasoning Cycle: A Tool for Building Excellence in Nursing
Practice. 2nd Al Gharbia International Nursing Conference. Abu Dhabi.
Stenvinkel, P., Zoccali, C., & Ikizler, T. A. (2013). Obesity in CKD—What Should
Nephrologists Know? JASn, 24(11), 1727-1736.
TracyLevett-Jones, KerryHoffmana, JenniferDempsey, Yeun-SimJeong, S., DanielleNoble,
AnneNorton, C., . . . NoeleneHickey. (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.