Analysis of Ms. Jones' Case: Nursing Care and Clinical Reasoning

This report presents a case study analysis of Ms. Jones, a 17-year-old patient with Type 1 Diabetes Mellitus who developed pyelonephritis and sepsis. The report examines the nursing care provided, focusing on the application of the Clinical Reasoning Cycle and the factors influencing nurses' recognition of and response to patient deterioration. The analysis incorporates insights from relevant articles, including Massey, Chaboyer, & Anderson (2017), Maharmeh et al. (2016), and Lee, Lee, Bae, & Seo (2016), to highlight the importance of thorough patient assessment, clinical decision-making, and effective communication in preventing adverse outcomes. The case underscores the significance of nurses' clinical reasoning skills, experience, and the need for timely interventions in managing complex medical conditions. The report emphasizes the critical role of nurses in recognizing subtle changes in a patient's condition and responding appropriately to prevent escalation of illness, as demonstrated by the missed cues and delayed interventions in Ms. Jones' care. The report underscores the importance of experience, dialogue, and joint discussions for effective decision-making.

Running head: ASSIGNMENT
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ASSIGNMENT 1
Table of Contents
Part 1................................................................................................................................................2
Part 2................................................................................................................................................4
Article 1...........................................................................................................................................4
Article 2...........................................................................................................................................5
Article 3...........................................................................................................................................7
Reference list...................................................................................................................................9

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Part 1
The case study that has been presented describes the medical complications faced by Ms.
Jones, who is only 17 years old and suffers from Type 1 Diabetes Mellitus. She was brought to
the Emergency Unit of the local healthcare department as she had a high fever of 2/7 hx along
with dysuria and flank pain. The nurses who were responsible for the care of Ms. Jones had the
duty of making proper observations of her primary and final conditions along with a focus on the
changes she was going through (Dalton, Gee & Levett-Jones, 2015). This is done through the
Clinical Reasoning Cycle by Levett-Jones so that it can be used as a tool for the identification,
assessment, implementation, and finally, evaluation of care (Levett-Jones et al., 2010). This
model involves eight specific steps to provide care and medical assistance in a proper way. The
steps are:
1. The situation of the patient has to be considered
2. Collecting cues
3. Processing available information
4. Identification of the problem
5. Goal establishment (Levett-Jones et al., 2010)
6. Taking proper measures
7. Evaluation
8. Reflection on the whole process.
Ms. Jones was polyuric while she was in the ED, and output of urine fluid was noticed at
1.7L, which was way above average. She was admitted in the medical ward under the
observation of RN Cameron and RN Grace, who was a new graduate employee (Dalton, Gee &

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Levett-Jones, 2015). She remained under their care in the medical ward from 1800hrs to 0730hrs
the next morning after which she was quickly shifted to the Intensive Care Unit due to
deterioration in her condition. When she was initially admitted to the ED, the observations that
were taken by the nurses were described as between the flags, which mean that she was within
the safety net of appropriate care. The first reading that was taken showed Ms. Jones to have
105/60 blood pressure, her temperature was 38.3 degrees, heart rate was at 108, and the
respiratory rate was 21. The blood sugar levels were at 9.4mmol/L, and Sao2 was 97%. The
second reading that have been provided showed her a little rise in her temperature to 38.8
degrees, P 128, BP was 89/40, and RR was 29 (Liou et al., 2016). Finally, when she was shifted
to the ICU, Ms. Jones had 39.4 degrees temperature, HR was 156bpm, BSL rose to 33.4mmol/L,
RR was 32, and blood pressure dropped to 65/36, which is critical. She was already admitted for
management of pyelonephritis, and later diagnosis of sepsis was made.

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Figure 1: Clinical reasoning cycle process
(Source: Levett-Jones et al., 2010)
However, the RN who was present failed to follow it properly and even refused the help
of the RN-in-charge from the High Dependency Unit resulting in the deterioration condition of
Ms. Jones. The RN failed to consider the fact that Ms. Jones was diabetic and polyuric from the
start. They neglected the cues when the partner of Ms. Jones complained that she was hot,
sweaty, and acting differently. As the medical ward was packed, they failed to process timely the
rise in temperature, heart and respiratory rate, and the drop in BP (Liou et al., 2016). The
increase in the BSL and the polyuric condition of the patient pointed towards her kidney and
urinary tract being infected, but they failed to identify it too. Asking for help from HDU could
have helped them to take appropriate actions on time.
Part 2
Article 1
(Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses’
recognition of and response to patient deterioration? An integrative review of the literature.
Nursing open, 4(1), 6-23.)
The article by Massey, Chaboyer, & Anderson (2017), recognizes the critical aspects that
lead to the deterioration of the health of a patient under the care of a registered nurse. The article
“What factors influence ward nurses’ recognition of and response to patient deterioration? An
integrative review of the literature." is quite straightforward to point at four key aspects that lead

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to the decline in the condition of a patient. These points comprise of the process of assessing the
person, the issue of knowing a particular patient, the education as well as the environmental
factors surrounding the patient (Gummesson, Sundén & Fex, 2018). The writers state that the
capability of a registered nurse to recognize and then respond to any sign indicating that a patient
is deteriorating is pivotal to the outcome of the patient. However, it can only be done if the
patient is assessed thoroughly at the time of his or her admission to the medical ward. The nurses
have to know the details of the patient, including all pre-diagnosed diseases, changes in the status
of their medical condition and the situation that the patient is in have to be registered too.
Various studies have confirmed that patients play a vital role in recognition of any deterioration.
The observations that were made while the patient was admitted and the vital signs that are part
of the medical history of the patient can help the nurses to identify the problem (Leoni‐Scheiber,
Mayer & Müller‐Staub, 2019). The nurse has to be thorough with the medical history of the
patient to understand all the subtle shifts in their condition. Knowing an individual patient can
lead to the nurses to develop a sixth sense if their circumstances are failing to improve even after
treatment has been administered.
The nurses in the case study that follows the deterioration of the health of Ms. Jones were
unable to accurately assess the situation that the patient was in and they also failed to know the
history of the patient carefully. Both the RNs should have taken into consideration the diagnosis
of diabetes that the patient had and the observations made by the emergency unit (Brier et al.,
2015). These data could have helped them identify the changes in the blood pressure, heart and
respiratory rate, blood sugar level, etc., that Ms. Jones went through. The timely analysis of her
situation could have prevented Ms. Jones from being admitted to the Intensive Care Unit with
sepsis. However, the issue remains that the staff was low, and the number of patients was high,

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which led to the ignorance of Ms. Jones' condition. Considering the case study as well as the
articles and research done by the peers, it can be said that the development in the educational
standards of the nurses to have an improved skill of reasoning is significant. It is for them to
respond appropriately in case of a patient under their care is deteriorating (Brier et al., 2015).
They should be able to identify the problem as well as act upon it while there is still time.h
Article 2
(Maharmeh, M., Alasad, J., Salami, I., Saleh, Z., & Darawad, M. (2016). Clinical decision-
making among critical care nurses: A qualitative study. Health, 8(15), 1807-1819.)
The case history of Ms. Jones has been able to show the necessity for a timely response
and diagnosis from the nursing team is significant for the proper course of treatment of any
patient (Laerkner, Egerod & Hansen, 2015). The registered nurses need to understand that the
patients under their condition may suffer from sudden changes in their medical condition and
failing to consider it might lead to critical complications similar to Ms. Jones' case. Therefore,
the idea that a nurse has to be a sound judge of the clinical and medicinal aspects of a patient is
something that has been the topic of discussing by various researchers. It has been identified that
the judgment made by the nurses based on the response or the situational context of a specific
patient can offer alternative clinical recommendations that are significant. According to
Maharmeh et al. (2016), the process of making decisions by the nurses after considering all the
available cues depends on the intuition as well as the experience of the nurse. The article
"Clinical decision-making among critical care nurses: A qualitative study." focuses on this very
aspect of the clinical process of decision making by nurses for the patients under their care. The

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article provides information about how decision making is considered to be an essential element
and a necessary quality for a nurse who offers critical care (Dang & Dearholt, 2017).
The study states that the nurses are always forced to make decisions on their own that are
informed, without help from any other medical practitioner. These decisions can be ethical ones
or just routine decisions based on the patient. The critics confirm that the experience of a nurse is
critical to understand which cues are to be given importance and at what time they are to be
considered. Furthermore, intuitive or joint decision making can also be useful while caring for a
patient (Hunter & Arthur, 2016). However, intuition depends on the interpretation of the cues or
information that is available, which is apparent for all nurses providing clinical care. In the case
of Ms. Jones, RN Cameron has years' experience only, and RN Grace is entirely new. This leads
to the issue that their intuition did not involve expertise. Nonetheless, the nurses could have just
followed the registered path to check and deliberate the changes. Following that, they could have
focused on taking a joint decision along with the help of the HDU. Registering the verbal as well
as the non-verbal cues that the patient and her partner provided was the proper step, which could
have ensured that the patient does not deteriorate. The research on the capability of the nurses to
deduce the course of treatment from the cues that have been collected proves that experience is
vital for the deduction to be appropriate (Blondon et al., 2017). In case the nurses lack
experience, they should consider the dialogue and joint discussions, which will lead them to
effective decision making.
Article 3
(Lee, J., Lee, Y. J., Bae, J., & Seo, M. (2016). Registered nurses' clinical reasoning skills and
reasoning process: a think-aloud study. Nurse education today, 46, 75-80.)

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The article by Lee, Lee, Bae, & Seo (2016), states that the skills of reasoning are
quintessential for all the registered nurses so that they can provide valuable care to their patients.
There are several aspects that the reasoning process of any registered nurse comprises of so that
they can find out the problems that the patient is facing. The article "Registered nurses' clinical
reasoning skills and reasoning process: a think-aloud study." provides information on the
necessity of the nurses to have the quality of reasoning while assessing the complexities that are
visible in a patient. A proper assessment will lead to the development of appropriate diagnosis of
the health problem that an individual patient under their care is facing (Lee, Lee, Lee & Bae,
2016). The determination of the appropriate interventions in an accurate, as well as timely
fashion, is the competency expected of all registered nurses. The most prominent skills of
reasoning that are being used by the clinical nurses are that of reliability and accuracy. The
nurses check the patient's status and then suggest data that can help them determine if the
objective as well as the subjective information that is available is reliable or not. Processing the
information in such a manner gives them better credibility to find the underlying problem. There
are five steps that are part of this process, namely, assessing, analyzing, diagnosing,
implementing or planning, and evaluating (Austin, Saylor & Finley, 2017). Data assessment
helps in the clustering of comprehensive data as well as the identification of the missing data.
The analysis step helps in making a connecting between the available data so that a proper
diagnosis for the health-related issue that is most likely to affect the patient can be considered.
The plans for improvement are implemented, focusing on the priority of the patient, and the
evaluation step helps in the analysis of any abnormal data.
While considering the case study of Ms. Jones, it can be said that the nurses failed to
assess and re-analyze the information that was available to them (Guillaumie, Boiral &

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Champagne, 2017). Their focus should have been on the issue of the patient being polyuric
throughout the night even after she was being treated for pyelonephritis. The RN failed to assess
this data on time, along with the failure to link the earlier diagnosis of the patient as diabetic as
well of her flank pain lead to sepsis. Therefore, it can be said that the nurses should have
considered the observations that were made in the Emergency Department already while
admitting the patient to the medical ward. The use of proper reasoning skills and the application
of all the five steps are significant for the nurses to process the data and identify the problem.
The 16-bed ward was being observed by two staff, which led to the elongation of the diagnosis
resulting in the patient not getting a timely treatment (Guillaumie, Boiral & Champagne, 2017).
However, the dependency of the test results and the delay in the time for assessment due to the
nurse lacking intuitiveness has to be checked immediately if the reasoning skills of the nurses are
to be strengthened.

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Reference list
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effects of mindfulness on nurses. Journal of advanced nursing, 73(5), 1017-1034.

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