Clinical Case Study: Clinical Reasoning in Nursing Practice

This clinical case study analyzes the case of a 56-year-old woman admitted to the hospital with pneumonia, emphasizing the application of the clinical reasoning cycle in nursing practice. The assignment begins with the collection of subjective and objective data, including the patient's medical history, vital signs, and reported symptoms like chest pain and shortness of breath. Based on this assessment, the assignment prioritizes interventions for chest pain, shortness of breath, and airway clearance, detailing pharmacological and non-pharmacological approaches. The study also explores the psychological distress experienced by the patient, considering factors such as financial status and loneliness, and suggests referrals to social welfare for support. The case study concludes by highlighting the importance of the clinical reasoning cycle for evaluating patient health and planning appropriate interventions, contributing to safe and responsive nursing care. The assignment adheres to the Registered Nurse standards of practice, demonstrating critical thinking, comprehensive assessments, and the provision of quality nursing care.

Running head: CLINICAL CASE STUDY
CLINICAL CASE STUDY
Name of the student:
Name of the university:
Author note

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CLINICAL CASE STUDY
Introduction:
Clinical reasoning is considered as a most suitable evaluating tool by which health
professionals collect cues, process the information, identify patient problem or situation, plan
and implement interventions, evaluate outcomes, and reflect on the knowledge gathered during
the process. Hence, the purpose of this paper to design interventions with the help of clinical
reasoning cycle for providing safe and responsive care to a 56 years old woman who was
admitted to the hospital due to pneumonia. This assignment will discuss the assessment of
subjective as well as observational data of patient associated with pathophysiology. Based on
the assessment of the collected data, the priorities of care of the patient would be discussed. By
in-depth reviewing of the patient it was observed that due to health condition, the patient is
subjected to psychological distress. This assignment will also discuss the impact of
psychological distress on the physical and mental wellbeing.
Collection of cues (pathophysiology):
The case study highlighted that she was in the hospital because of pneumonia. During
communication, she stated that the history of ischemic heart disease hypertension. She had a
habit of smoking 30 packs a year and after coronary artery disease, she ceased the smoking.
In this context, subjective data which was started by the patient include low mood, nausea, chest
pain, dysphonia, the ache in the upper arm and worry. The objective data was collected after the
assessment of vital signs. Since the patient was slightly diaphoretic vital signs was assessed
twice, before and after the administration of the medication.

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The first objective assessment highlighted that patient has body temperature 37.3 degree Celsius
which is normal and remain approximately the same in first and second observation, indicating
stable homeostasis of the body (Osborne et al., 2015).
While the heart rate of the patient in the first surveillance was 74 bpm, in the second
observation it was 116 beats. In the case of normal individuals, the rate is usually 60 to 100 bpm
whereas in the second observation of patient highlighted increased heart rate (116) (Cardona et
al., 2016).
The increased heart might be because of the history of coronary heart disease where arteries
become narrow because of the deposition of the plaque which further reduced blood flow and
high blood pressure (Douglas et al., 2016). Sudden rupturing increase this pulse rate of the
patient which is manifested as chest pain (angina) and because of narrowing of the blood vessels,
the heart muscles failed to pump adequate oxygenated blood (Chow & Timmis, 2019).
The lack of oxygen adequate blood in heart facilitate the development of hypoxia where
cells and tissues die as observed in patient. In the first observation oxygen saturation 98% which
dropped to 92% in the second observation and patient experience shortness of breath as well as
chest pain (Beasley et al., 2016). The low oxygen saturation is also due to pneumonia associated
mucus formation in the lungs (Kepreotes et al., 2017). As observed before, changes in the blood
pressure also induce changes in the heart and respiratory rate in patient. In the first observation,
the assessed blood pressure was 165/90, indicating high blood pressure since healthy individuals
have 120/80 mmHg blood pressure. In the second observation, the blood pressure dropped to
105/70mmHg which is common in patient of coronary artery disease (Sharman et al., 2015). The
low blood pressure drop can be because of septic shock associated with an infection which is

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observed in the patient. The patient had pneumonia for which he admitted to the hospital
(Sharman et al., 2015). The low blood pressure might be due to medications she was
administrated with.
Considering the respiratory rate, the first observation highlighted that her respiratory rate
was 14 breaths per minute which is normal for healthy patients. However, in the second
observation, the respiratory rate of the client was 26 bpm after 30 minutes (Hill et al., 2018).
The patient exhibited an increased rate of the pulse which further led to the chest pain shortness
of breath and due to shortness of breath, the respiratory rate of the patient was elevated. The
patient exhibited other risk factors such as for overweight which may cause chronic disease.
Priorities of care:
Considering the current condition of the patient and ABC assessment (airway, breathing,
and circulation), three priorities are required to address by nurses. The first priority is chest pain,
second priority is shortness of breath and third priority is clearing the airway. In each case, the
patient is required to provide appropriate intervention in order to support the faster recovery of
the patient by reducing these symptoms.
Chest pain:
After reviewing subjective as well as objective data, it can be said that one of the prime
priority of the patient is chest pain which further radiated to the upper arm. The patient was
experiencing chest pain due to the increased heart rate, pulse rate, and oxygen saturation (Cullen
et al., 2015). The chest pain can be resulted from the reduced blood flow in the heart because of
the narrowing of arteries (Klimis et al., 2016). The history of coronary artery disease was

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observed in patient and it may increase the chances of developing myocardial infarction (Chew
et al., 2016). It is considered as one of the prime nursing priorities. In order to reduce the
tendency of myocardial infraction and occurring chest pain, the patient is required to provide
interventions that reduce chest pain. Nitroglycerin (sublingual) is considered as the standard
treatment for preventing angina pain. The pharmacological action of this drug is that it relaxes
vascular sooth muscles and facilitate dilation of both arterial and venous beds. Consequently, the
drug increases the amount of blood as well as oxygen which can reach to the heart muscles,
tissues, and cells. Consequently, the heart can pump an adequate amount of blood and it reduces
chest pain (Boden et al., 2015). The heart rate and rhythm are required to monitor for the patient
in order to record ischemic changes (Boden et al., 2015). Moreover, the patient can be placed in
the fowler position which further reduces the congestion through expansion of the muscles and
reduces shortness of breath. The blood pressure of the patient is also required to monitor for
gathering the information of the stability of the blood pressure as it can increase chest pain.
Shortness of breath:
The second prime priority after reviewing the patient’s condition is shortness of breath.
Since the patient had pneumonia, the blocked airway is one of the major contributing factors
behind shortness of breath. The lack of oxygen is another reason behind shortness of breath
which further impacted the respiratory rate. Hence, in order reduce the shortness of breath an
intervention is required to provide to the patient which can support faster recovery in patient. The
patient can be provided with oxygen therapy which is the most suitable nursing interventions for
reducing shortness of breath. The oxygen therapy is given to the patient where the concentrations
of oxygen are greater than that in ambient air, which further treat or prevent the symptoms and
manifestations of hypoxia as observed in patient (Cabello et al., 2016). Oxygen therapy

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decreases the work of breathing by increasing alveolar oxygen tension. Hence, oxygen therapy
will increase the oxygen saturation of the patient from 92% to 98% (normal level). While no side
effects of oxygen therapy were observed in patient but skin around face mask or nasal cannula
can get irritated (Cabello et al., 2016). The inside of the nose can be dry and in severe cases, the
nose bleeding can be observed in patient.
Blocked airway:
The patient was administrated in the hospital due to the presence of lungs disease such as
pneumonia. Due to inflammation in the airway sacs in both the lungs, air sacs may be filled with
fluid or mucus which further causes coughing (Calabrese et al., 2016). Consequently, the airway
of the patient become blocked and patient experience shortness of breath. The patient is required
to provide with bronchodilator such as salbutamol in the nebulizer. Bronchodilator such as
salbutamol works in patient by dilating the bronchi and bronchioles, decreasing resistance in the
respiratory airway. Salbutamol also increases airflow to the lungs by acting on the bronchi and
bronchioles (Kopsaftis et al., 2018). Consequently, the pneumonia of the patient can be managed
and respiratory rate can be stabilized. While providing nebulizer, nurses must assess the status of
the lungs for identifying any infection in the lungs since lung infection followed by septicemia is
common in pneumonia. The side effects of the bronchodilator include nervous and shaky feeling,
upset stomach, trouble sleeping and muscles aches (Fadila et al., 2017). Hence, while providing
interventions, it is crucial to consider these side effects and continuous assessment of the health
status for these symptoms.
Psychological issues in patient:
Psychological factors are considered as the factors which have an adverse impact on the
physical and mental wellbeing of individuals. After reviewing Mrs. Kennedy it can be stated that

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she is experiencing psychological issues which not only impacted her mental wellbeing but also
have an impact on her physical health. She was experiencing constant low mood and worried
about going home.
The first contributing factor identified in the case of Mrs. Kennedy is the poor financial
status. She is retired woman where her only financial is the pension. She lives in a house alone
and her son lives away. There is a possibility that the patient might be experiencing financial
issues which impacted the physical and mental wellbeing (Paunio et al., 2015). These factors are
directly correlated with her lifestyle and may impact her dietary routine.
The second factor in the case is loneliness in the absence of her son. Since his son lives
away from her and rarely meet her, no one can take care of her which is making her depressed
day by day (Guthrie et al., 2016). In this case, nurses must refer her to the social welfare where
social workers can support her emotional wellbeing and resolve her financial issues.
Conclusion:
On a concluding note, it can be said that that clinical reasoning cycle is one of the most
suitable evaluation tools for evaluating the health of the patient as observed in this case study. By
using this clinical reasoning, it was observed that Mrs. Kennedy is experiencing chronic
diseases which required intervention. The subjective and objective data fluctuated after the
second assessment. In this case, the priorities of care of the patient according to the complexities
of the patient include chest pain, blocked airway and shortness of breathing which was
incorporated in this assignment. Mrs. Kennedy stays alone and hence has no one to take care of
her, which impacted mental condition of the patient. In this case, she would be referred to the
local social welfare for improving her mental and physical wellbeing.

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References:
Beasley, R., Chien, J., Douglas, J., Eastlake, L., Farah, C., King, G., ... & Walters, H. (2017).
Target oxygen saturation range: 92–96% Versus 94–98%. Respirology, 22(1), 200-202.
Boden, W. E., Padala, S. K., Cabral, K. P., Buschmann, I. R., & Sidhu, M. S. (2015). Role of
short-acting nitroglycerin in the management of ischemic heart disease. Drug design,
development and therapy, 9, 4793.
Cabello, J. B., Burls, A., Emparanza, J. I., Bayliss, S. E., & Quinn, T. (2016). Oxygen therapy
for acute myocardial infarction. Cochrane Database of Systematic Reviews, (12).
Calabrese, C., Corcione, N., Rea, G., Stefanelli, F., Meoli, I. and Vatrella, A., 2016. Impact of
long-term treatment with inhaled corticosteroids and bronchodilators on lung function in
a patient with post-infectious bronchiolitis obliterans. Jornal Brasileiro de
Pneumologia, 42(3), pp.228-231.
Cardona-Morrell, M., Prgomet, M., Lake, R., Nicholson, M., Harrison, R., Long, J., ... &
Hillman, K. (2016). Vital signs monitoring and nurse–patient interaction: A qualitative
observational study of hospital practice. International journal of nursing studies, 56, 9-
16.
Chew, D. P., Scott, I. A., Cullen, L., French, J. K., Briffa, T. G., Tideman, P. A., ... & Aylward,
P. E. (2016). National Heart Foundation of Australia and Cardiac Society of Australia
and New Zealand: Australian clinical guidelines for the management of acute coronary
syndromes 2016. Medical Journal of Australia, 205(3), 128-133.

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Chow, C. K., & Timmis, A. (2019). Rapid access clinics for patients with chest pain: will they
work in Australia?. The Medical journal of Australia, 210(7), 307-308.
Cullen, L., Greenslade, J., Merollini, K., Graves, N., Hammett, C. J. K., Hawkins, T., ... &
Dalton, E. (2015). Cost and outcomes of assessing patients with chest pain in an
Australian emergency department. Medical Journal of Australia, 202(8), 427-432.
Douglas, C., Booker, C., Fox, R., Windsor, C., Osborne, S. & Gardner, G., (2016). Nursing
physical assessment for patient safety in general wards: reaching consensus on core
skills. Journal of clinical nursing, 25(13-14), pp.1890-1900.
Fadila, M., Keeney, E., Dias, S., & Oba, Y. (2017). Fixed‐dose combination inhalers compared
to long‐acting bronchodilators for COPD: a network meta‐analysis. The Cochrane
database of systematic reviews, 2017(3).
Guthrie, E. A., Dickens, C., Blakemore, A., Watson, J., Chew-Graham, C., Lovell, K., ... &
Tomenson, B. (2016). Depression predicts future emergency hospital admissions in
primary care patients with chronic physical illness. Journal of psychosomatic
research, 82, 54-61.
Hill, A., Kelly, E., Horswill, M. S., & Watson, M. O. (2018). The effects of awareness and count
duration on adult respiratory rate measurements: an experimental study. Journal of
clinical nursing, 27(3-4), 546-554.
Kepreotes, E., Whitehead, B., Attia, J., Oldmeadow, C., Collison, A., Searles, A., ... & Mattes, J.
(2017). High-flow warm humidified oxygen versus standard low-flow nasal cannula
oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised
controlled trial. The Lancet, 389(10072), 930-939.

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Klimis, H., Thiagalingam, A., Altman, M., Atkins, E., Figtree, G., Lowe, H., ... & Chow, C. K.
(2017). Rapid‐access cardiology services: can these reduce the burden of acute chest pain
on Australian and New Zealand health services?. Internal medicine journal, 47(9), 986-
991.
Kopsaftis, Z. A., Sulaiman, N. S., Mountain, O. D., Carson-Chahhoud, K. V., Phillips, P. A., &
Smith, B. J. (2018). Short-acting bronchodilators for the management of acute
exacerbations of chronic obstructive pulmonary disease in the hospital setting: systematic
review. Systematic reviews, 7(1), 213.
Osborne, S., Douglas, C., Reid, C., Jones, L., & Gardner, G. (2015). The primacy of vital signs–
acute care nurses’ and midwives’ use of physical assessment skills: a cross sectional
study. International Journal of Nursing Studies, 52(5), 951-962.
Paunio, T., Korhonen, T., Hublin, C., Partinen, M., Koskenvuo, K., Koskenvuo, M., & Kaprio,
J. (2015). Poor sleep predicts symptoms of depression and disability retirement due to
depression. Journal of affective disorders, 172, 381-389.
Sharman, J. E., Howes, F. S., Head, G. A., McGrath, B. P., Stowasser, M., Schlaich, M., ... &
Nelson, M. R. (2015). Home blood pressure monitoring: Australian expert consensus
statement. Journal of hypertension, 33(9), 1721.