Nursing Clinical Reasoning Assignment: Mrs. Kennedy's Case Analysis

This assignment presents a detailed case study of Mrs. Carole Kennedy, a 56-year-old patient admitted for pneumonia treatment with a history of hypertension, ischemic heart disease, and early-stage peripheral vascular disease. The assignment focuses on the application of the clinical reasoning cycle to assess Mrs. Kennedy's presentation, including vital signs such as tachycardia, tachypnea, hypotension, and diaphoresis. It analyzes the patient's clinical presentation, identifies care priorities based on the ABCDE approach, and discusses the current disease stage, including angina and potential psychosocial issues such as isolation and retirement. The assignment explores interventions such as volume resuscitation, administration of vasopressors, anti-arrhythmic medications, and nitroglycerine to address the patient's acute needs. The conclusion emphasizes the importance of accurate diagnosis, implementation of medical interventions, and the development of strong clinical skills through the clinical reasoning process, particularly in managing complex clinical scenarios. The assignment also highlights the impact of psychosocial factors on the patient's overall well-being and health outcomes.

Running head: NURSING
Acute Care- Clinical Reasoning Assignment
Name of the Student
Name of the University
Author Note

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Introduction- Clinical reasoning cycle refers to the procedure that is used by nursing
professionals for collecting cues, and coming to a shared understanding about the problem
that is being faced by a patient (Levett-Jones et al., 2010). This reasoning cycle also focuses
on the implementation of interventions for addressing the priority areas, followed by outcome
evaluation and reflecting on the process. This assignment is based on a 56 year old patient
Mrs Carole Kennedy who is being observed during the second rotation. The patient had been
admitted to the hospital for pneumonia treatment. She also reports a history of hypertension,
ischemic heart disease and initial stages of peripheral vascular disease. She has been an active
smoker, however, stopped cigarette smoking seven years ago, after being diagnosed with
coronary artery disease. On finding her to be diaphoretic, the vital signs were assessed that
demonstrated some abnormalities in several physiological parameters. The following sections
will analyse the changes in clinical presentation of the patient, and will also analyse the care
priorities, followed by discussing the current disease stage and psychological issues.
Clinical presentation- Pulse refers to the tactile arterial palpitation that is manifested
by the heartbeat and pulse usually remains palpated at places where the artery becomes
compressed near the body surface. The pulse for a healthy adult at resting stage is between
60-100 beats/minute. However, Mrs. Kennedy has a pulse of 116 beats/minute, thus
indicating the manifestation of tachycardia. Also known as tachyarrhythmia, the condition
occurred due to rapid beating of the heart that decreased its efficiency to pump blood to the
different body parts, thus lowering blood supply to the heart. Research evidences elaborate on
the fact that quick beating of the heart increases the demand for oxygen in the myocardium,
or the cardiac muscles (Sapp et al., 2016). In addition, tachycardia symptoms might have
occurred owing to rapid firing in micro re-entry or an ectopic focus circuit located in the
auricles. In several patients, multiple foci are present for tachycardia that eventually result in
variations in the morphologies of P-wave on the ECG, at the time of arrhythmia.
Furthermore, tachycardia might have also been triggered due to arrhythmia. According to
Kiedrowicz, Podd and O’Neill, M. (2016) this increase in pulse can also be accredited to
onset of automaticity that occurred due to abnormal mechanism due to a reduction in
membrane potential of the fibres located in the heart, which generally demonstrate an
increased amount of membrane potential. Under normal circumstances, the breathing rate of a
healthy adult is roughly 12 to 20 breaths/minute. However, on assessing the vital signs, Mrs.
Kennedy had a breathing rate of 26 breaths/minute, a condition commonly known as
tachypnoea.

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Absence of sufficient amount of oxygen or an excess of carbon dioxide in the
bloodstream are common factors that might have resulted in this condition (Rauch et al.,
2016). This accumulation of carbon dioxide in the circulating bloodstream made the blood
more acidic, when compared to usual circumstances. An increase in acidity triggered the
brain, which in response sent a signal to the respiratory drive for increasing the breathing
pace. This shallow rapid breathing was initiated by the brain in an endeavour to restore the
imbalance between the respiratory gases. Hence, the primary reason for shallow breathing
symptoms was to return the blood pH to normal range, while reducing its acidity (Bunker &
Frieberg, 2017). Mrs. Kennedy was found to be diaphoretic that can be accredited to the
hyper functioning of sweat glands, in place of hypertrophy. The condition refers to excessive
sweating, devoid of any apparent reason and heart attack has often been considered a major
contributing factor. A blood pressure of 120/80 mmHg is considered normal for adults.
Owing to the fact that Mrs. Kennedy had a blood pressure of 105/70 mmHg, she reported
signs of hypotension. The renin-angiotensin-aldosterone system (RAAS) exerted a major
influence in the control of systemic vascular resistance and blood volume, which creates a
negative impact on arterial pressure and cardiac output of the patient. Renin that is
released principally from the kidneys, might have stimulated angiotensin development in the
blood and tissues. This stimulated aldosterone release from adrenal cortex. Due to a decrease
in pressure of the afferent arteriole, glomerular filtration reduced that decreased NaCl present
in distal tubule (te Riet et al., 2015). Hence, it caused renin release due to stenosis of renal
artery or systemic hypotension.
Priorities of care- With the aim of determining the care priorities in a critically ill or
deteriorating patient, it is imperative to conduct the ABCDE approach that focuses on
assessment of airway, breathing, circulation, disability, and exposure (Smith & Bowden,
2017). On conducting an analysis of the patient, no major deviations were observed in her
airways owing to the fact that she did not report any abnormalities in breathing sounds or
voice. The assessment of breathing is vital in order to diagnose and implement immediate
treatment to life-threatening health conditions. On counting the respiratory rate of the patient,
it was found to be 26 breaths/minute, thus confirming tachypnoea as a care priority. The
primary goal of this care priority is to help Mrs. Kennedy maintain an effective breathing
pattern, as confirmed by relaxed breathing that occurs at a normal rate, and no signs of
dyspnoea (Smith & Zolotorofe, 2018). The patient will be encouraged to sustain deep breath
by demonstrating slow inhalation and passive exhalation. These techniques of breathing

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without exerting any muscular effort will promote deep inspiration, which in turn will
upsurge oxygenation and prevent atelectasis, or closure of the lungs thus prevent reduction of
gaseous exchange (Vianello et al., 2018). According to Taniguchi, Hayakawa, Matsusawa
and Hayashi (2018) administration of beta-adrenergic agonist medications will help in
relaxation of the muscles present in the airways, thus widening them. These medications will
imitate the action of norepinephrine and epinephrine, and will result in activation of
secondary messenger cyclic adenosine monophosphate (cAMP), thus activating protein
kinase A (PKA), which will induce relaxation of the muscles.
On analysing the signs and symptoms presented by the patient, three more care
priorities were identified namely, hypotension, tachycardia, sweating, and cardiac discomfort.
The patient demonstrated low blood pressure, which needs to be addressed immediately
owing to the fact that it can increase susceptibility of the patient to coma, stroke occurring
due to reduction in supply of blood to the brain, and other cardiovascular complications, if
left untreated. Furthermore, hypotension needs to be treated since it can lead to dizziness or
fainting and might often make the patient suffer from shock. Volume resuscitation will be the
first strategy for addressing the signs and symptoms of hypotension (Macdonald et al., 2017).
Therefore, the administration of intravenous fluids in the patient’s blood will help in keeping
the mean arterial pressure at a level that high enough for perfusion of the essential organs,
however, lesser than the normal levels, in order to restrict bleeding. The second care strategy
that will help in increasing the blood pressure is administration of vasopressor or an
antihypotensive agent. These drugs will act in the form of vasoconstrictor and bring about an
increase in total peripheral resistance. Therefore, they will elevate the MAP and the primary
reason for using them is their deviation from the mechanism of inotropes that elevate cardiac
contractility (Chang, 2017). The goal of tachycardia treatment is to assist the patient
demonstrate sufficient cardiac output, in addition to dry and warm skin, as evidenced by
normal pulse. Mrs. Kennedy will be positioned in semi-Fowler’s position that will help in
reducing preload and ventricular filling. This positioning will also lead to chest expansion,
and help in relaxation of the muscles (Kuhajda et al., 2015). Conducting vagal manoeuvre
will form an important part of the care plan since it will create an impact on the vagus nerve,
which controls the heartbeat (Un, Dogan, Uz, Isilak & Uzun, 2016). Furthermore,
administration of anti-arrhythmic medication will also prove vital in restoring normal heart
rate, by altering the electrical current that plays an important role in beating of the heart.

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Cardiac discomfort reported by the patient can be cited as angina or chest pain that
might have occurred when oxygen-rich blood did not reach the cardiac muscles. This resulted
in a squeezing pressure in the chest that radiated to the arm and shoulder. Hence, treatment of
angina is vital to prevent the onset of stroke. The patient will be administered sublingual
nitroglycerine that has been identified as the mainstay treatment for the prevention of angina
pain. Nitroglycerine will activate guanylyl cyclase (GC) via heme-dependent mechanism, and
help in formation of cyclic guanosine monophosphate (cGMP) (MacIsaac, Jarvis & Busche,
2019). The latter will activate the myosin light chain phosphatase, thus promoting smooth
muscle relaxation in the blood vessels. In addition, sustained-release tablets will also prevent
relapse by lowering coronary vasospasms and subsequently reducing cardiac
workload. Administration of morphine sulphate (MS) will also prove effective since it will
result in peripheral vasodilation and decrease the myocardial workload, thus creating a
sedative effect and bringing about relaxation (McCarthy, Mullins, Sidhu, Schulman &
McEvoy, 2016). The final care priority is diaphoresis that is manifested by abnormal and
excessive sweating in Mrs. Kennedy, in relation to the surrounding environment. It requires
instant care since it is a marker of underlying health abnormality and can be life-threatening
as well. Administration of pain medications such as, celecoxib or naproxen might prove
beneficial in reducing the amount of sweating (Peter & Joshua, 2016). Nonetheless, if the
symptoms persist, the procedure of iontophoresis might also be implemented. This process
will use a small electrical shock and help in preventing excessive sweating from the hands
and feet (Ricchetti-Masterson et al., 2018).
Psychosocial issues- On analysing the patient scenario, major issues identified are
namely, isolated housing, retirement, inadequate support from family, and poor
socioeconomic status. According to Ahmed, Hershberger, Lemkau, Rakel and Rakel (2016)
the elderly are at specific threat both for aloneness and the health concerns of isolation. The
fact that she resides alone has increased her susceptibility to cardiovascular illness than social
separation itself. Furthermore, this loneliness has significantly increased her risks of suffering
from functional decline. Time and again it has been found that spending time with
individuals who demonstrate healthy habits might strengthen healthy behaviour, improved
nutrition, advance entree to health-related evidence, transport to health care providers, added
physical activity, and even upsurge monetary resources (Ong, Uchino & Wethington, 2016).
Furthermore, perceived isolation and solitude are allied with augmented activity of the
sympathetic nervous system, greater than before inflammation, and reduced sleep, all of

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which can hasten cardiovascular aging. Thus, owing to the fact that she did not have any
other family member or friend to look after her, and rarely interacted with others, both
physical and mental health were affected (Xia & Li, 2018). Following her retirement, she was
only able to utilise the superannuation pension as her income source. This reduced her access
to healthcare services, necessary medicines, and healthy food choices, thus deteriorating her
health. Hence, the aforementioned factors deteriorated the health status of the patient.
Conclusion- To conclude, the patient Mrs. Kennedy suffered from several health
abnormalities namely, chest discomfort, diaphoresis, tachypnoea, and hypotension. The
clinical reasoning cycle helped in collecting signs of the patient that allowed to understand
the present health problem, followed by implementation of medical interventions. Conducting
a clinical reasoning was important since it helped in considering different aspects of patient
care that eventually helped in development of strong clinical skills. The process is essential
since it provides assistance in handling and management of complicated clinical scenarios
that require a comprehensive and thorough understanding of the underlying health condition.
It could be deduced from the reasoning that the patient was reporting signs of angina, or pain
in the chest, which if not treated immediately could even be fatal. Therefore, it is imperative
to correctly diagnose the health condition, followed by implementation of necessary medical
treatment, to manage medical complication.

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