NRSG370 Clinical Integration | Clinical Reasoning Case Study

Mrs. Connie Brownstone is a 79 year old women admitted to the Emergency Department (ED).  Connie was brought into the ED by her daughter with a one-day history of fluctuating shortness of breath/dyspnoea unrelieved by medication.

Triage Nurse Assessment:

• Vital signs: RR 35, SpO2 90% (room air), HR 125bpm, RR 35, Temp 39.4° Celsius, BP 168/70;
• Physical assessment: Dyspnoea, very anxious, audible expiratory wheeze;
• Past history: Asthma, allergies to pollen and dust mite, ICU admission 5 years ago (endotracheal intubation and ventilation for 2 days – status asthmaticus).
• Medications: (1) Ventolin, and (2) Ipratropium bromide.

Due to her respiratory distress, Connie was triaged as a category 2, as per the Australasian Triage Scale, and brought directly from the waiting room into a HDU monitored cubicle where you are the ED nurse allocated to her care (Department of Health and Aging, 2009). Oxygen of 6L/min was applied via the Hudson Mask.

Answer:

Nursing is a profession that is associated with various interrelated roles and responsibilities while assessing a patient, planning care and implementing the care interventions (Adrogué & Madias, 2014). Often these professional roles and responsibilities overlap and coincide with each other leading to the errors in the clinical judgment or decision making of the nurses. Although, there also are considerable decision making framework available for the nurses to be able to take the correct clinical decisions, and the clinical reasoning cycle is an exceptional framework (Vincent, Abraham, Kochanek, Moore & Fink, 2017). Clinical reasoning cycle has been introduced by Tracy Levett Jones, it is a systematic framework that provides the nurses with a step by step practice model that they can follow to carry out care services adequately (Levett-Jones, Reid-Searl & Bourgeois, 2018). Thus essay will attempt to explore each of the step of the clinical reasoning cycle taking the assistance of a case study.

The very first step allows the nursing professional to be able to gain an initial understanding of the condition that the patient is in and explore the previous medical data (Levett-Jones, Reid-Searl & Bourgeois, 2018). The patient in the selected case scenario is Connie Brownstone, a 79 year old patient who was admitted to the ED by her daughter due to experiencing fluctuating dyspnea which could not be remedied by her regular medication. Now a respiratory distressed can be due a variety of different causal trajectories and as she had been triaged in the ED as category 2, as per the Australasian Triage Scale, and brought directly from the waiting room into a HDU monitored cubicle, it is crucial to undertake several systematic assessments of the patient to be able to arrive at an accurate diagnosis for Connie. While in the HDU she also had been provided external oxygen therapy (6L/min) via a Hudson mask, which indicates at the alarming degree of her respiratory distress (Thomson et al., 2017).

The first and foremost investigation that is carried out is vital signs which provides key information about the stability of the patient and any immediate emergencies (Mirhaghi, 2017). The vital signs of the patient includes RR 35, SpO2 89% (6L oxygen), HR 125bpm, RR 35, Temp 39.4° Celsius, BP 172/75. The next assessment usually carried in this situations is the head to toe physical assessment which assesses the posture, consciousness, muscular stability and auscultating the adventitious breathing sounds and helps in understanding the exact cause of the respiratory distress in the patient. The information collected in this phase includes evident use of accessory muscles, bilateral expiratory wheeze, height 145cm, and peak flow as 210 L/min. in the very next phase the nurse is required to carry out a secondary assessment which is a more specialized survey and is primarily based on the acute abnormal manifestations or symptoms exhibited by the patient. As in this case, the patient Connie presented with a respiratory distress, the secondary survey will be based completely on the respiratory distress, such as FBE test, arterial blood gas assessment, Urea and electrolyte assessment, blood cultures and chest X-ray (Flori, Dahmer, Sapru & Quasney, 2015).

While processing the information, the data collected will be interpreted, discriminated, related, referred and matched to be able to predict the care needs presented by the patient (Levett-Jones, Reid-Searl & Bourgeois, 2018). In case for Connie, the vital signs indicated respiratory rate of which is much higher than the normal levels; along with that the oxygen saturation of the patient is also at 89% indicating low levels of oxygen saturation, which indicates at severe shortness of breath as a key care problem for the patient. The next most important investigation for Connie given her signs and symptoms is the arterial blood gas test, which indicates Connie having pH of 7.48, PaCO2 at 30 and HCO3 at 24. Undoubtedly the results generated deviate considerably from the normal levels and as per the data, it can be clearly deduced that Connie is suffering from acute respiratory alkalosis. The chest X-ray results indicate at the patient having hyper-expanded lungs which is the most likely cause for the acute respiratory alkalosis that Connie is suffering from (Kiang et al., 2015).

The key health problems that Connie is experiencing includes:

• Shortness of breath due to acute respiratory alkalosis
• Wheezing due to blocked hyperventilated airways
• Acute respiratory alkalosis caused by hyperventilated airways and alveoli by aggravated long term asthma (Kiang et al., 2015)
• Discomfort caused due to the hyper-expanded lungs
• Heart palpitation, dizziness and lightheaded-ness due to respiratory distress, weakness, and decrease in the cerebral blood flow due to lack of sufficient oxygen intake (Özbek, Divriko?lu, Y?lmaz, Ayta? & Çelik, 2018)

In this case, the most pressing care need of the patient is the shortness of breath which is alleviating the respiratory rate of the patient to as high as 35/min. hence the first care priority selected for the patient that needs immediate attention is the shortness of breath. Another immediate care is the acute respiratory alkalosis that Connie is suffering which is leading to many other complications for her and can lead to hypocholeremia and hypokapnia further exacerbating her already distressful condition if adequate care is not taken (Mahler & O'Donnell, 2014). Lastly, tachycardia and heart palpitations is associated with cerebral blood flow reduction which in turn can lead to cerebrovascular accident. Hence, third most pressing issue for Connie is the tachycardia and heart palpitation which will require immediate attention.

With respect to nursing interventions, the first care priority for Connie is Dyspnea for which she is already provided external oxygen in 6L/min rate, however, in order to accelerate oxygen saturation the patient can also be provided humidified oxygen. Along with that, the interventions will also include administration of bronchodilators (Mudd & Sloand, 2015). The next care need for the patient includes management of respiratory alkalosis so that the patient regains homeostasis. The interventions that need to implemented includes ausculating breathing sounds for any signs of complication, the patient also be encouraged for CO2 aspiration breathing when slightly stable using a brown paper bag so that the blood pH returns to homeostasis. Electrolyte balance of Connie is needed to be assessed as well to avoid chances or hypocholeremia or hypokalemia. The tachycardia and palpitation is mainly due to the lack of adequate cerebral blood flow and related tissue necrosis however it can lead to convulsions, seizures and even stroke. Although the oxygen therapy will help in enhancing the cerebral blood flow and improve the palpitation, mild antianxiety medication or sedation medication will relax the patient and will help her recover (Agerstrand, Burkart, Abrams, Bacchetta & Brodie, 2015).

In this case, the three nursing care priorities selected for the assignment includes shortness of breath, respiratory alkalosis, and tachycardia along with palpitations. The most effective interventions which showed marked progress in her condition have been the external humidified oxygen and bronchodilators. The use of the bronchodilators smoothed the constricted airways due to the asthma, attack or bronchospasm that she had while the aid of external oxygen via Hudson mask eased her respiratory distress. The use of CO2 aspiration slowly was successful in reverting her blood pH back to homeostasis and the aid of sedation and antianxiety pills helped her calm down which addressed her tachycardia as well (Yeh et al., 2016). Although, I believe the patient had been complaining of chest tightness in her sleep while mumbling although it was very unclear and the nursing supervisor ignored it. I believe if I could have mustered the courage to cross her and highlight the issue the care could have been more patient centred and effective for Connie.

On a concluding note, the clinical reasoning cycle serves as a key guidance framework for nurses engaged in professional practice providing the nurses with the opportunity to learn from each and every experience of care. In this case, the patient had been suffering from respiratory alkalosis which stemmed from the exacerbation event of the asthma. This exercise helped me to understand how to assess the patients that arrive with acute respiratory emergency and along with that this assignment has also helped me to understand how to implement the steps of clinical reasoning to the real world care scenario for the patient and implement intervention successfully.

References: 

Adrogué, H. J., & Madias, N. E. (2014). Respiratory acidosis, respiratory alkalosis, and mixed disorders. Comprehensive Clinical Nephrology E-Book, 169. Retrieved from https://books.google.co.in/books?hl=en&lr=&id=xesLBAAAQBAJ&oi=fnd&pg=PA169&dq=acute+respiratory+alkalosis&ots=PLAX00aEM1&sig=tuy_HTIIAJvQGyQs9aj9U9aaECo#v=onepage&q=acute%20respiratory%20alkalosis&f=false

Agerstrand, C. L., Burkart, K. M., Abrams, D. C., Bacchetta, M. D., & Brodie, D. (2015). Blood conservation in extracorporeal membrane oxygenation for acute respiratory distress syndrome. The Annals of thoracic surgery, 99(2), 590-595. doi: 10.1016/j.athoracsur.2014.08.039

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. Retrieved from https://search.informit.com.au/documentSummary;dn=018184224173600;res=IELHEA

Flori, H., Dahmer, M. K., Sapru, A., & Quasney, M. W. (2015). Comorbidities and assessment of severity of pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Critical Care Medicine, 16(5_suppl), S41-S50. doi: 10.1097/PCC.0000000000000430

Kiang, T. C., Anthony, Y., Adrian, C. K. W., Sophie, L. T., & Siyue, K. M. (2015). Anxiety, depression and hyperventilation symptoms in treatment-resistant severe asthma. Clinical and translational allergy, 5(2), P7. Doi: 10.1186/2045-7022-5-S2-P7

Levett-Jones, T., Reid-Searl, K., & Bourgeois, S. (2018). The clinical placement: An essential guide for nursing students. Elsevier Health Sciences. Retrieved from https://books.google.co.in/books?hl=en&lr=&id=vw9aDwAAQBAJ&oi=fnd&pg=PT6&dq=tracy+levett+jones+clinical+reasoning+cycle&ots=sEW7-2gNC6&sig=sr_Eo8Tsnk2mXc95UuDRSYmmHjQ#v=onepage&q=tracy%20levett%20jones%20clinical%20reasoning%20cycle&f=false

Mahler, D. A., & O'Donnell, D. (2014). Dyspnea: mechanisms, measurement, and management. CRC press. Retrieved from https://books.google.co.in/books?hl=en&lr=&id=3YDSBQAAQBAJ&oi=fnd&pg=PP1&ots=lKbmpmceaM&sig=WG1bL6qEbE74IEkz1mg0AQc737g#v=onepage&q&f=false

Mirhaghi, A. (2017). Vital Sign Assessment Directives Have Not Associated With Diagnostic Validity. Acta Medica Iranica, 55(6), 414-414. Retrieved from https://acta.tums.ac.ir/index.php/acta/article/viewFile/5721/4956

Mudd, S. S., & Sloand, E. D. (2015). Lower Respiratory Disorders. Pediatric Nurse Practitioner Certification Review Guide, 137. retrieved from https://books.google.co.in/books?hl=en&lr=&id=6_CeCgAAQBAJ&oi=fnd&pg=PA137&dq=bronchodilators+and+respiratory+distress&ots=SEk7E-pO1l&sig=4KWvAq52FtGqn5UotbTaQWkXQXQ#v=onepage&q=bronchodilators%20and%20respiratory%20distress&f=false

Özbek, A. E., Divriko?lu, Y. S., Y?lmaz, S., Ayta?, N. Ü., & Çelik, E. (2018). Nonsteroidal anti-inflammatory drug-induced acute respiratory distress syndrome. The American journal of emergency medicine. doi: 10.1016/j.ajem.2018.07.004

Vincent, J. L., Abraham, E., Kochanek, P., Moore, F. A., & Fink, M. (2017). Textbook of Critical Care (7th ed.). St. Louis, Missouri: Elsevier

Yeh, T. C., Kao, L. C., Tzeng, N. S., Kuo, T. B., Huang, S. Y., Chang, C. C., & Chang, H. A. (2016). Heart rate variability in major depressive disorder and after antidepressant treatment with agomelatine and paroxetine: findings from the Taiwan Study of Depression and Anxiety (TAISDA). Progress in Neuro-Psychopharmacology and Biological Psychiatry, 64, 60-67.doi: 10.1016/j.pnpbp.2015.07.007