CNA155 Clinical Reasoning Report: Analysis of John Wells' Case Study

This report presents a clinical reasoning analysis of the case of John Wells, an 82-year-old dairy farmer admitted to the emergency department after a fall. The report follows the clinical reasoning cycle, starting with considering the patient's profile, including age, health history, and the circumstances of the fall. It then details the collection of cues and information, including the patient's symptoms (confusion, nausea, headache, dizziness), vital signs, and the nurse's assessment. The information processing stage involves interpreting the data, differentiating relevant from irrelevant information, and relating the information to potential diagnoses, such as a concussion. The report discusses the patient's high blood pressure and its potential link to the fall and concussion, and predicts potential complications if the concussion is not properly managed. The report also refers to the patient's history of not wearing a helmet and the potential impact of the fall on his cognitive function and overall health. The report concludes by highlighting the importance of immediate intervention and proper medication to prevent further health issues, such as dementia.

CLINICAL REASONING 1
Clinical Reasoning

CLINICAL REASONING 2
Clinical Reasoning
Consider the patient
In the clinical reasoning cycle, considering the convalescent is the first phase. In the
stage, the nurse is supposed to confront the convalescent and immediately identify the instant
impression of the patient (Alsalaheen et al., 2016). The impression might be recognized by the
nurse either from just observing the patient’s behavior or from the handout report. As a result,
while analyzing the initial impression of John Wells, it is very crucial to consider the fact that
previous suppositions may have affected some of the data in this stage.
In regards to the information above, now put into consideration the case of John Wells,
who has the age of 82 years. John Wells works as a dairy farmer. He has a spouse and a son. The
name of his wife is Mavis while that of his son is Sam. John Wells was brought to the hospital by
his son Sam and was admitted to the emergency department. This was after Mavis called Sam
after feeling worried about his husband’s health status. Mavis had observed that John had not
taken his dinner that night. She also noticed that John looked quieter than always. John Wells
had told his wife that he had fallen from a stationary bike after he became unbalanced
(YAZDANI, HOSSEINZADEH, and HOSSEINI, 2017). Additionally, before falling, John had
just come from the dairy while riding the same bike and stopped when he reached home.
Because of the fall, John Wells hit his head on the hard summer ground. It is good to note that
John rarely wears a helmet, and even during that day of the incidence, he was not wearing any.
Additionally, John Wells rarely wears any protective gadget while working and even on that day,
also he was not wearing. Moreover, due to the fall, John Wells incurred a slight skin tear to his
left arm. Furthermore, Mr. John also experienced a minor scratch to his elbow. In relation to this,

CLINICAL REASONING 3
Mr. John also told his wife that he was not suffering from any other injuries or pain. Moreover,
John Wells also stated that he was not experiencing any decreased range of motion or stiffness to
his neck, chest, and limbs.
Collection of cues and information
Collection of cues and information is the second phase of the clinical reasoning cycle. In
this phase, the nursing practitioner supposed to gather any information in regards to John wells.
Additionally, the stage also requires the nursing practitioner to analyze the patient’s data that is
available from his history handover report, nursing notes, and clinical documentation. Now, for
the case of John wells, there are no previous medical records indicating that John Wells had
previously suffered from a head injury or concussion (Stubbs, Brefka, and Denkinger, 2015).
During the nurse assessment, the nursing practitioner reported that John suffered from
mild confusion, nausea and headache. The three symptoms combined can either signal a
migraine or a concussion. Moreover, John wells also experiences mild hypertension, but he has
not yet been given any antihypertensive therapy. Besides, from the nurse notes, John indicated
that he was currently experiencing a feeling of confusion. John also added that he was feeling
headache pain on the scale of 4 out of 10. The confusion could be as a result of John Wells’ age
or the fall. Furthermore, the headache could be a sign of a concussion or migraine (Stevens,
Mahoney, and Ehrenreich, 2014).
Furthermore, John Wells indicated that before feeling hazy, he was experiencing
dizziness. The dizziness feeling could be a sign of a concussion.
According to the assessment regarding John Wells’ vital signs, his body temperature was
recorded at 36.7 degrees Celsius. Furthermore, his blood pressure was at 148/84mmHg, his pulse
rate at 81 beats per minute, and his respiratory rate was recorded at 17 breaths per minute.

CLINICAL REASONING 4
Moreover, John Wells’ oxygen saturation level was recorded at 97% (Richardson, Bennett, and
Kenny, 2014).
Information Processing
As stated by (Alfaro-LeFevre, 2015), information processing is the most important stage
of the clinical reasoning cycle. In this stage, the nursing practitioner should examine and analyze
all the information gathered from the other prior phases. Furthermore, He or she is supposed to
differentiate all the data form the relevant to irrelevant information. Information processing is
divided into six steps:
1. Interpretation.
In this step, the nursing practitioner is required to carefully analyze the information and come
to an understanding of the signs and symptoms. Now, put into consideration the case of John
Wells. The normal body temperature should be between 36.1 degrees Celsius to 37 degrees
Celsius. Therefore, there is no concern on John Wells’ body temperature (36.7 degrees Celsius).
Additionally, the normal respiratory rate of a person should be between 12 to 18 breaths per
minute (Koivisto et al., 2016). Therefore, John Wells had a normal respiratory rate (17 breaths
per minute). Moreover, the normal oxygen saturation level of an individual should be between 96
percent to 100 percent, which indicates that John Wells’ saturation rate of 97% was normal.
Furthermore, the normal pulse rate of a person should be in the range of 60 to 100 beats per
minute; therefore, John Well’s pulse rate of 81 beats was normal and therefore no concern
(Alfaro-LeFevre, 2015). John Wells’ blood pressure was measured at 148/84 mmHg. The normal
blood pressure of a person should be around 120/80 mmHg, but due to his age, the blood
pressure should be around 140/90 mmHg. Therefore, even though John is old, still his blood
pressure was way above normal to persons of his age. The blood pressure may have arisen

CLINICAL REASONING 5
because he may be suffering from high blood pressure. Consequently, John’s blood pressure may
also have risen as a result of a concussion. Now considering that John was experiencing nausea,
headache, and mild confusion, with the fact that John’s blood pressure also rose, it is clear that
John is suffering from a concussion (Alsalaheen et al., 2016).
2. Discrimination
In the discrimination step, the nursing practitioner is required to separate the relevant
information from the irrelevant (Khan et al., 2016). Now, in regards to John Well’s health status,
his blood pressure is high, but considering the fact that it might have risen due to the concussion,
there is not much concern there. The nurse should, therefore, perform a cognitive test and
detailed exam on John Wells. Some of the tests to be performed on John Wells should include
Memory test, balance and coordination, hearing, vision, attention span, and reflexes.
Additionally, the nurse should perform a scan on John wells to ensure he is not suffering from
any internal injuries.
3. Relating the information
In this stage, the nursing practitioner is required to find new patterns and the relationship. In
most cases, many elderly persons suffer from a concussion. Moreover, because of John Wells’
age, while riding the bike from the dairy without a helmet, John experienced the confusion that
led to the imbalance and therefore making him fall which led to the concussion (Hunter and
Arthur, 2016).
4. Inference
In this step, the nurse should make opinions that are logically viewed from the cues and the
data analyzed (Fann et al., 2018). The blood pressure of John may have arisen due to the
concussion that he experienced after the fall.

CLINICAL REASONING 6
5. Matching
In this step, the nurse is required to discover the relationship between the current case and
previous cases (Delany and Golding, 2014). According to the World Health Organization,
elderly individuals have a high possibility of experiencing concussions. Therefore, some of the
issues that Mr. John is experiencing are related. Furthermore, as people get old, their muscles
become weak, which in turn exposes them to the risk of falling. Additionally, due to his old age,
it is highly likely that Mr. John may have forgotten what really occurred that day.
6. Prediction
If the nurse does not attend to the concussion immediately and administer proper medication
to John Wells, the health status of John Wells may deteriorate and lead to further problems like
dementia (Caprani et al., 2016).

CLINICAL REASONING 7
References
Alfaro-LeFevre, R., 2015. Critical Thinking, Clinical Reasoning, and Clinical Judgment E-
Book: A Practical Approach. Elsevier Health Sciences.
Alsalaheen, B.A., Whitney, S.L., Marchetti, G.F., Furman, J.M., Kontos, A.P., Collins, M.W.
and Sparto, P.J., 2016. Relationship between cognitive assessment and balance measures in
adolescents referred for vestibular physical therapy after concussion. Clinical journal of sport
medicine: official journal of the Canadian Academy of Sport Medicine, 26(1), p.46.
Caprani, N., Doyle, J., Komaba, Y. and Inomata, A., 2015, July. Exploring healthcare
professionals' preferences for visualising sensor data. In Proceedings of the 2015 British HCI
Conference (pp. 26-34). ACM.
Delany, C. and Golding, C., 2014. Teaching clinical reasoning by making thinking visible: an
action research project with allied health clinical educators. BMC medical education, 14(1), p.20.
Fann, J.R., Ribe, A.R., Pedersen, H.S., Fenger-Grøn, M., Christensen, J., Benros, M.E. and
Vestergaard, M., 2018. Long-term risk of dementia among people with traumatic brain injury in
Denmark: a population-based observational cohort study. The Lancet Psychiatry, 5(5), pp.424-
431.
Hunter, S. and Arthur, C., 2016. Clinical reasoning of nursing students on clinical placement:
Clinical educators' perceptions. Nurse education in practice, 18, pp.73-79.
Khan, A., Prince, M., Brayne, C. and Prina, A.M., 2015. Lifetime prevalence and factors
associated with head injury among older people in low and middle income countries: a 10/66
study. PLOS one, 10(7), p.e0132229.

CLINICAL REASONING 8
Koivisto, J.M., Multisilta, J., Niemi, H., Katajisto, J. and Eriksson, E., 2016. Learning by
playing: A cross-sectional descriptive study of nursing students' experiences of learning clinical
reasoning. Nurse education today, 45, pp.22-28.
Richardson, K., Bennett, K. and Kenny, R.A., 2014. Polypharmacy including falls risk-
increasing medications and subsequent falls in community-dwelling middle-aged and older
adults. Age and ageing, 44(1), pp.90-96.
Stevens, J.A., Mahoney, J.E. and Ehrenreich, H., 2014. Circumstances and outcomes of falls
among high risk community-dwelling older adults. Injury epidemiology, 1(1), p.5.
Stubbs, B., Brefka, S. and Denkinger, M.D., 2015. What works to prevent falls in community-
dwelling older adults? Umbrella review of meta-analyses of randomized controlled
trials. Physical therapy, 95(8), pp.1095-1110.
YAZDANI, S., HOSSEINZADEH, M. and HOSSEINI, F., 2017. Models of clinical reasoning
with a focus on general practice: a critical review. Journal of Advances in Medical Education &
Professionalism, 5(4), p.177.