Clinical Reasoning Web: An Evidence-based Educational Practice

 

Mrs. Fancy Paul K*

Assistant Professor, Amala College of Nursing, Thrissur, Kerala - 680555, India.

*Corresponding Author Email: fancypaulk@gmail.com

 

ABSTRACT:

Evidence-based educational practices always pave a way for better reasoning, judgment and decision making in clinical setting. Clinical Reasoning Web is a method of critical patient analysis in which relationships among nursing diagnoses supports the development of clinical reasoning skills. This method helps students to learn thinking like a nurse. Effective clinical reasoning ability promotes skills to collect data, solve problems, make decisions, provide quality care and survive in the workplace. Explaining relationships among nursing diagnoses supports the development of clinical reasoning skills. Explanations also encourage nurses and nursing students to reason forward from a problem to an outcome and also backwards from the outcome or effect to the current state of the patient. In this paper, the author has described the nursing care of a client, who was alleged with a road traffic accident and diagnosed to have right fronto-temporal-parietal contusion, brainstem contusion, acute extradural hematoma left temporal region. Cranio-cerebral trauma and traumatic brain injury are general designations to denote injury to the skull, brain, or both that is of sufficient magnitude to interfere with normal function and require treatment. The patient was unconscious, GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube). Here the author illustrates how effectively a clinical reasoning web can be formulated by identifying keystone issue and related problems.

 

KEYWORDS: Clinical Reasoning web, keystone issue, cranio-cerebral trauma.

 

 

INTRODUCTION:

A Clinical Reasoning Web is a method of critical patient analysis in which relationships among nursing diagnoses supports the development of clinical reasoning skills. This method helps students to learn thinking like a nurse. Effective clinical reasoning ability promotes skills to collect data, solve problems, make decisions, provide quality care and survive in the workplace.

 

Clinical reasoning web:

Evidence-based educational practices always pave a way for better reasoning, judgment and decision making in clinical setting. Clinical reasoning web is one of them which improves nurse’s clinical judgment, plan of interventions and evaluation of effectiveness of nursing care.

 

Clinical reasoning is defined as the reflective, creative and critical systems thinking processes nurses use to frame the meaning and facts associated with a client story, juxtapose and test the differences between a patient’s present story state and a desired specified outcome state; and make judgments about outcome achievements derived from reflection and self-regulation of thinking (Pesut and Herman, 1999).1 Patient details encourage nurses and nursing students to reason forward from a problem to an outcome, and also backwards from the outcome or effect to the current state of the patient. Reflective thinking, clinical judgement and self-regulation prompt thinking, reasoning, and explaining2. This method helps students to learn thinking like a nurse which involves knowing what information about a client is needed and how to collect that information (assessment); knowing how to organize the information collected to devise a plan of care (nursing diagnosis); identifying interventions that will help the client achieve desirable outcomes (planning and goal setting); and knowing how to evaluate the care and the client to decide how to help the client reach his or her desired level of health (evaluation)3.

 

Identification of keystone issue:

Based on the scenario, all possible nursing diagnoses will be written down. Nurse has to connect these nursing diagnoses with one-pointed arrows, reflecting the relationship of each problem with other problems. This process is called as ‘webbing’. This process leads to the identification of keystone issue of the client. Identifying the keystone issue is the first step in the clinical reasoning that arises from all the potential or actual problems identified from the client-in-context story. According to Pesut and Herman (1999), addressing the keystone issue with nursing interventions and helping the client resolve the keystone issue offers the potential to resolve other related nursing diagnoses.3

 

Patient scenario:

Cranio-cerebral trauma and traumatic brain injury are general designations to denote injury to the skull, brain, or both that is of sufficient magnitude to interfere with normal function and require treatment.4 A 24 year old man alleged road traffic accident. He got admitted in a tertiary care centre on the same day. While receiving the patient from trauma centre, he was unconscious, no motor response, pupils- right 4mm, left 5mm, both were not reacting to light. GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube). Patient was on ventilator (SIMV mode). FiO2- 100%, PEEP-5, I:E- 1:2, respiratory rate- 16 breaths per min. SpO2-100%. CT scan revealed left temporal extradural hematoma, right fronto-tempero parietal contusion and brainstem contusion, no evidence of midline shift and gross cerebral edema. Patient was on continuous bladder drainage, peripheral intravenous line and Ryle’s tube. CSF rhinorrhea, ear bleed, periorbital edema and ecchymosis were present.

 

Medical diagnosis:

Right fronto-temporal parietal contusion, Brainstem contusion, Acute extradural hematoma (EDH) left temporal region

 

Vital signs: Temperature-1000F, respiration rate- 16 breaths/min on mechanical ventilator SIMV mode, pulse- 92 beats/ min, blood pressure- 150/90mm of Hg

 

Patient was on Ryle’s tube feeding 200ml/ 2nd hourly (D- protein powder in water).

Intake/output – 4200ml/2850ml

Height - 175cm, weight - 64kg

History of allergy to dust or medication is unknown.

 

No past history of illness like tuberculosis, asthma, pneumonia. No past history of surgery.

 

Currently patient is on following medications Inj. Eptoin 100mg IV, Inj. Lasix 20mg IV, Inj. Mannitol 100ml (20%), Inj. Taxim1gm IV, Inj. Metrogyl 500mg IV, Inj. Amikacin 500mg IV, Inj. Rantac 50mg IV, Inj. Fevastin IM

 

Intravenous access through peripheral line: IVF. Normal saline 500ml (2 pints) and Ringer lactate 500ml (2pints) were given in 24 hours.

 

Investigations: Routine blood investigation shows normal LFT, RFT, CBC except WBC. WBC levels and random blood sugar were 15,300/mm3 and 305mg/dl respectively.

 

ABG values were normal- PH- 7.42, PCO2- 39mmHg, HCO3- -24.6 mEq/L, PO2- 96% on FiO2-100

 

Nursing diagnoses identified based on NANDA 2018-2020 for this patient are:

1.           Decreased intracranial capacity related to cerebral edema, EDH as evidenced by dilated pupils- right 4mm, left 5mm both not reacting to light and GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube)

2.           Ineffective airway clearance related to diminished cough and gag reflex and presence of ET tube as evidenced by increased secretions

3.           Hyperthermia related to increased metabolic rate of all body cells as evidenced by temperature of 1000F

4.           Impaired bed mobility related to presence of neurological deficits as evidenced by GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube)

5.           Self care deficit, bathing related to neurological dysfunction as evidenced by inability to take bath himself and GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube)

6.           Self care deficit, dressing related to neurological dysfunction as evidenced by inability to perform dressing himself and GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube)

7.           Self care deficit, toileting related to neurological dysfunction as evidenced by inability to perform toileting himself and GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube)

8.           Self care deficit, feeding related to neurological dysfunction as evidenced by inability to have food by himself and GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube)

9.           Bowel incontinence related to impairment in neurological sensing and control as evidenced by GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube)

10.     Urinary incontinence related to impairment in neurological sensing and control as evidenced by GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube)

11.     Impaired verbal communication related to neurological deficits and presence of ET tube as evidenced by GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube)

12.     Risk for infection related to presence of ET tube, Ryles tube, urinary catheter, peripheral intravenous line, immobility

13.     Risk for unstable blood glucose level related to stress response to cerebral edema

14.     Risk for ineffective cerebral tissue perfusion related to effects of increased ICP,EDH, cerebral edema

15.     Risk for impaired gas exchange related to hyperventilation and aspiration

16.     Risk for injury related to seizures

17.     Risk for aspiration related to increased secretions, immobility, presence of ET tube

18.     Risk for imbalanced nutrition, less than body requirement related to increased metabolic demands and inadequate intake

19.     Risk for impaired skin integrity related to immobility

20.     Risk for DVT related to immobility

21.     Risk for constipation related to immobility

Nursing diagnoses identified for this patient were decreased intracranial capacity, ineffective airway clearance, hyperthermia, impaired bed mobility, self care deficit, bowel incontinence, urinary incontinence. Major underlying cause of the problems was identified as decreased intracranial capacity due to left temporal extradural hematoma, right fronto-tempero parietal contusion and brainstem contusion. Hence, the keystone issue in this scenario is ‘decreased intracranial capacity related to cerebral edema, EDH as evidenced by dilated pupils- right 4mm, left 5mm both not reacting to light and GCS- E 1VT M1 -2T/15 (verbal response cannot be assessed because of ET tube)’. If this problem is corrected all other problems in the patient will be resolved. Major domains of nursing care interventions were ICP control, maintenance of patent airway, meeting self care demands of patient and prevention of potential problems such as hospital-acquired infection, complications of immobility etc. Critical patient analysis using clinical reasoning web will improve clinical reasoning, clinical judgment, critical thinking in nursing professionals.

 

Fig. 1: Clinical reasoning web showing the relationship between the keystone issue and related problems

 

CONCLUSION:

Clinical reasoning web helps nursing students learn to think like nurses. This method facilitates nurses and nursing students to use all of the elements of the nursing process and to build on prior knowledge in an iterative fashion to further hone nursing thinking skills. Further, this method will help in improving patient care and incorporation of theory into evidence based practice.

 

REFERENCES:

1.      Pesut D J, Herman J. Clinical reasoning the art and science of critical and creative thinking. Albany, NY: Delmar Publishers; 1999.

2.      Kautz et al. Promoting clinical reasoning in undergraduate nursing students: application and evaluation of the outcome present state test (opt) model of clinical reasoning. International Journal of Nursing Education Scholarship. 2007; 2(1):1-21.

3.      Bartlett R, Rossen E, Benfield S. Evaluation of the outcome-present state test model as a way to teach clinical reasoning. Journal of Nursing Education. 2008; 47(8): 337-344.

4.      Hickey VJ. Clinical practice of neurological and neurosurgical nursing. 6th ed. Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins; 2009.

5.      Woodward S, Mestecky A. Neuroscience nursing – evidence based practice.1st ed. UK: A John Wiley and Sons, Ltd., Publication; 2011.

6.      Herdman H T, ‎Kamitsuru S. Nanda International Nursing Diagnosis-Definitions and Classification 2018-2020. 11th ed. Thieme Publication; 2017.

 

 

 

Received on 12.03.2021         Modified on 16.04.2021

Accepted on 02.05.2021      ©A&V Publications All right reserved

Asian J. Nursing Education and Research. 2021; 11(3):437-440.

DOI: 10.52711/2349-2996.2021.00106