Clinical Reasoning Cycle Application in Nursing: George's Case Study

This report provides a comprehensive analysis of a nursing case study, focusing on the application of the Levett-Jones Clinical Reasoning Cycle to a patient named George, a 51-year-old Aboriginal and Torres Strait Islander man with stage 4 chronic kidney disease. The report systematically applies the cycle's stages, including collecting cues (vital signs, medical history, and lab results like GFR, HbA1c, and serum creatinine), processing information to identify key health problems (hypertension, low GFR, and high cholesterol), establishing care priorities (treating hypertension and low GFR), and taking action (pharmacological interventions like ACE inhibitors and ARBs, as well as nursing interventions like sodium restriction). The report justifies care priorities with evidence-based research, emphasizing the importance of blood pressure control and GFR management to prevent further kidney damage. It also addresses medication management and the need for evaluation and reflection to improve future care. The report highlights the importance of clinical judgment and evidence-based practice in nursing care.

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Application of clinical reasoning cycle in the case scenario
Introduction
Clinical reasoning is an important competency required by nurses to engage in
safe and effective care. In daily practice, clinical reasoning involves following step-wise process
of collecting cues, processing the information, analysing key problems, selecting appropriate
interventions and evaluating outcomes for patient. In nursing practice, nursing staff engage in
multiple clinical reasoning episodes to provide appropriate care to patient (Carvalho et al., 2017).
The essay will demonstrate the application of critical thinking and reasoning in the case scenario
of George using the Levitt-Jones Clinical Reasoning Cycle. This will be done by using the stages
of the clinical reasoning cycle to collects cue from the case study, identify key health problems
for the patient and identify important care priorities from the scenario. The essay will provide
justification for the care priorities using evidence based research literature.
<Collecting cues>
This essay focuses on the case study of George, a 51 year old Aboriginal and Torres
Strait Islander (ATSI) man suffering from stage 4 chronic kidney disease with macro
albuminuria secondary to diabetes nephropathy. To identify care priorities for George,
identifying key health issues for patient is important. This can be done by collecting data related
to current vital signs, medical history and key investigation results done for George (Dalton, Gee
& Levett-Jones, 2015). Current symptoms found in patient include high blood pressure and some
weight gain. His blood pressure at last visit was 153/93 compared to the target BP of 130/80. His
current weight is 104 kg. The review of his laboratory test results shows GFR value of 27

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mL/min/1.73 m2, HbA1c level of 78 mmol/mmol and serum creatinine value of 237 micromol/L.
The laboratory results are all above normal limits as normal GFR value is 90 to 120 mL/min/1.73
m2, HbA1 c value is less than 53 mmol/mol and normal serum creatinine level is 60-110
micromol/L. He has a history of diabetes too. The above data of George should be analyzed to
come to a conclusion on major health problem for patient.
Processing the information and identify problem and issues
The second stage of clinical reasoning cycle is processing the information which
involves linking patient’s current health status to pathophysiological patterns of patients. It
involves inferring subjective and objective data of patient to identify problem or issues (Hunter
& Arthur, 2016). George is a patient with chronic kidney disease evidenced by deteriorating
kidney function and albuminaria. Chronic kidney disease is a progressive disease condition
associated with renal insufficiency which may proceed to renal failure (Webster et al., 2017).
George is suffering from stage 4 CKD indicating advanced kidney damage with significant
decrease in GFR (Glomerlar filtration rate). For this reason, George’s GFR rate was abnormally
low. The pathophysiological process leading to low GFR include diminished renal reserve or
renal tissue function. This renal function interferes with kidney’s ability to maintain fluid and
electrolyte homeostasis (Levey, Becker & Inker, 2015). Hence, such pathophysiological change
lead to low concentration of urine followed by decrease in ability to excrete phosphate and
potassium thus resulting in decreased GFR. George’s GFR value suggests that his kidney has lost
the ability to effectively dilute urine.
Such patients are most likely to develop complications like high blood pressure. Similar
symptom was found for George too. According to Sinha and Agarwal (2014), hypertension is a
common complication for patients with CKD which occurs because of sodium loading. In

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patients with progression of CKD, the GFR value decline resulting in less filtering of sodium.
This leads to sodium retention and expansion of the extracellular fluid volume. This leads to
hypertension in patient. Improper activation of renin-angiotensin-aldosterone system (RAAS)
also provokes renal ischemia and blood pressure in patient (Sinha & Agarwal, 2014). As
George’s kidney disease is secondary to diabetic nephropathy, this is also the contributory
factor behind his high blood pressure (Sulaiman, 2019).
Another clinical issue related to CKD is the issue of high cholesterol. High
cholesterol is a complication linked to CKD as kidney impairment leads to increased plasma
triglycerides and very low density lipoprotein (Bulbul et al., 2018). Other patient related
issues include George’s confusion regarding the medications given to him. This problem
needs to be addressed to promote better adherence to treatment. By processing current
symptoms and laboratory findings of George, it can be interpreted that hypertension, low GFR
rate and increase cholestrole level are major clinical problem for George. The above inference
has been made by linking his symptom to the pathophysiology of chronic kidney disease. To
ensure recovery of patient, the next step will be to establish care priorities for patient and
establish appropriate care option to support recovery for George.
Care priorities or establish goals
From the processing of information related to George’s current symptoms and laboratory
findings, it can be said that two important care priority to treat hypertension and low GFR value.
In addition, other list of priorities necessary for treatment and recovery of George includes
decreasing his cholesterol level, treating macroalbuminaria and lowering HbA1c value as he is a
patient with diabetic nephropathy. Decreasing cholesterol level is important to prevent
complication because high cholesterol level leads to decline in kidney function and accelerate

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rate of inflammation (Bulbul et al., 2018). The rational for identifying blood pressure regulation
as the first important care priority for George is that unless blood pressure is controlled, the
health condition of George will further deteriorate. This is said because uncontrolled blood
pressure can lead to narrowing of the arteries around the kidneys and limited delivery of blood to
the kidney tissue. Hence, the untreated blood pressure can lead to kidney failure for George. For
this reason, addressing hypertension is a high clinical priority area (patient (Carvalho et al.,
2017). In addition, reducing the value of GFR has been identified as the second important care
priority for George because if the value GFR value becomes less than 15 micromol/L, it can lead
to respiratory failure. Hence, unless GFR value is controlled, the patient is at risk of kidney
failure.
Take action
To address hypertension, it is necessary to consider different options of care and select
the best action for patient patient (Carvalho et al., 2017). Hypertension treatment in CKD patient
is done by various treatments like salt restriction, invasive endovascular procedures and
pharmacological therapy (Sinha & Agarwal, 2014). Considering that George is a patient with
advanced CKD, pharmacological therapy is best for hip to achieve rapid symptom control.
Current research evidence emphasize use of angiotensin converting enzyme (ACE) inhibitors
and angiotensin receptor blocking medications to treat hypertension in CKD patient. These two
drugs are the main treatment options for hypertension in kidney. ACE plays a role in blocking
conversion of angiotensin I to angiotensin II and ARBs plays a role in competitively blocking the
angiotension II receptor. The therapeutic effect occurring through such interaction is that it can
lead to reduce aldosterone secretion and peripheral vascular resistance thus contributing to
reduction in systemic blood pressure (Sinha & Agarwal, 2019). This can be complemented with

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nursing intervention like sodium restriction to treat George. Restricting sodium is important
because volume overload is the main pathological cause behind hypertension in CKD.
To improve the GFR value of George, there is a need to consider best treatment options
for him. Pharmacological treatment option should be prioritized first as George’s GFR value is
very low than the normal GFR value. According to Breyer and Susztak (2016), if GFR rate is
less than 60mL/min, then drugs liks metformin, enoxaprin and methotrexate should never be
provided. It is necessary to provide medications that do not have any effect of kidney functions.
Such alternative drug preparations include metoprolol and carabmazepine. The nursing
consideration that will be important while implementing this treatment option to George is to
review the current medication of patient and consider the possibility of dose adjustment. Dose
adjustment is critical to achieve maximum therapeutic effect of the drugs.
Evaluation and reflection
As part of effective and safe nursing practice, evaluation of interventions given to patient
is critical to identify the impact of intervention on patient outcome. To evaluate the efficacy of
pharmacological treatment given to George, it will be necessary to identify improvement in
blood pressure and GFR value of patient. In addition, improvement in kidney function needs to
be reviewed using GFR testing because this will be a sign of improvement in clinical symptoms
of patient. Feedback from patient can also be taken to evaluate the outcome of actions taken.
Reflection on practice should be done to identify improvement in care provided when giving the
same intervention in the future.

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Conclusion
The essay highlighted the use of critical reasoning cycle process to identify two care
priorities for George. From the analysis of the case study of George, it was found that George
was suffering from significant kidney decline because of advanced CKD. Abnormal sign and
symptoms identified for CKD included high blood pressure, low GFR value, abnormal HbA1c
level and high cholesterol. By processing of the data and the impact on overall patient safety,
treating hypertension and low GFR rate was prioritized as two important care priorities for
George. The essay discussed about two best treatment options to support recovery of George.
The essay demonstrated effectiveness of nursing care using clinical judgment guided by the use
of the stages of the clinical reasoning cycle.

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References
Breyer, M. D., & Susztak, K. (2016). Developing Treatments for Chronic Kidney Disease in the 21st
Century. Seminars in nephrology, 36(6), 436–447. doi:10.1016/j.semnephrol.2016.08.001
Bulbul, M. C., Dagel, T., Afsar, B., Ulusu, N. N., Kuwabara, M., Covic, A., & Kanbay, M. (2018).
Disorders of lipid metabolism in chronic kidney disease. Blood purification, 46(2), 144-152.
Carvalho, E. C. D., Oliveira-Kumakura, A. R. D. S., & Morais, S. C. R. V. (2017). Clinical reasoning in
nursing: teaching strategies and assessment tools. Revista brasileira de enfermagem, 70(3), 662-
668.
Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based education
to'flip'the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, The, 33(2), 29.
Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement: Clinical
educators' perceptions. Nurse education in practice, 18, 73-79.
Levey, A. S., Becker, C., & Inker, L. A. (2015). Glomerular filtration rate and albuminuria for detection
and staging of acute and chronic kidney disease in adults: a systematic review. Jama, 313(8),
837-846.
Sinha, A. D., & Agarwal, R. (2014). Hypertension Treatment for Patients with Advanced Chronic
Kidney Disease. Current cardiovascular risk reports, 8(10), 400. doi:10.1007/s12170-014-0400-
y
Sinha, A. D., & Agarwal, R. (2019). Clinical Pharmacology of Antihypertensive Therapy for the
Treatment of Hypertension in CKD. Clinical Journal of the American Society of
Nephrology, 14(5), 757-764.

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Sulaiman M. K. (2019). Diabetic nephropathy: recent advances in pathophysiology and challenges in
dietary management. Diabetology & metabolic syndrome, 11, 7. doi:10.1186/s13098-019-0403-4
Webster, A. C., Nagler, E. V., Morton, R. L., & Masson, P. (2017). Chronic kidney disease. The
lancet, 389(10075), 1238-1252.