INTRODUCTION:

In nursing, mainly students have to undergo clinical placements and they have to do case study, especially post graduate students have to do case study based on some or the other theories. Thus, this paper will present the implementation of Tracy Levette Jones (2010) theory of Clinical Reasoning Cycle (CRC).

Patients with complicated chronic illnesses suffering from at least two or three chronic disorders require appropriate planning of health which use various medical facilities⁷. When a client with different long term disorder is brought to a medical institution with a severe condition, clinical practices of the nurse such as complex thinking processes are required to investigate and combine a massive amount of data that are both subjective and objective¹².

Nurses striving to be critical thinkers must be rational, reasonable, transparent, thorough, truthful, and fair; and all those qualities must be expressed while behaving, communicating, or writing¹⁰.

Clinical reasoning is the mechanism by which practitioners gather, analyse and interpret the condition or issue of a patient so that treatments can be prepared and applied and findings evaluated¹⁰.

Adapted from Tracy Levett-Jones, et al. (2010):

The Clinical Reasoning Cycle (CRC) is a tool that helps in making decision that enable nurses to select best care options using a process systematically which takes into consideration many factors. This paper presents a case study in medical-surgical nursing through a discussion of patient-centred, and evidence-based care provisions through a theoretical examination using the CRC. The plan for person-centred care is for Gordon Deltori (Pseudo name), a sixty-eight years old individual with complain of moderate chest pain.

In the present case of Mr. Deltori, the CRC has been used to demonstrate how the tool can be implemented in practice. This tool has eight steps which form a continuum that may at times move back and forth until the most accurate assessment is obtained. These steps are discussed in details in the sections below as they relate to the current case.

1. Consider the patient situation:

A well-groomed male patient, Gordon Deltori, a taxi driver by occupation, is 68 years old, has been brought to the Emergency Department with the complain of pain in chest which is dull, achy, radiating to neck and progressively increasing in nature since midnight. Apart from this, Mr. Deltori has a history of hypertension for 10 years, atrial fibrillation, osteoarthritis, type 2 diabetes for 5 years, and he is currently using drugs that include perindopril, epixban, anginine, metformin, and vitamin D.

2. Collect cues/information:

Mr. Deltori is obese and appears to be alert but anxious and diaphoretic with +2 pitting edema on both the lower extremities. His observations showed that his Blood Pressure is 169/90 mm Hg, Heart Rate is 120 beats per minutes and palpable pulse of +2 characteristic, RR is 24 per minutes without shortness of breath and body temperature 37.1°C. He is smoking since he is 14 years of age. He is having sedentary lifestyle and eats lots of junk food. His jugular veins appear distended. He had taken anginine thrice in last 5 months following chest pain. Anginine is a nitrate drug which is used for relieving angina (chest pain) by increasing blood supply and oxygen to the heart muscles. It is absorbed through the lining of the mouth, metabolism takes place in liver and excretion occurs in kidney⁶. Moreover, he had previous history of hypertension for 10 years for which he is taking perindopril a hypertensive drug. Perindopril is an antihypertensive medication which is rapidly absorbed and its peak plasma concentration occurs 3-4 hours after oral administration. It leads to the formation of very low quantities of metabolites in liver and is eliminated after 17 hours through urine². Furthermore, he had history of atrial fibrillation for which he is on epixban which is a blood thinner. He has osteoarthritis for which he is taking vitamin D and he had type 2 diabetes for 5 years for which he is taking metformin.

3. Process Information:

Mr. Deltori arrived with complain of increasing chest pain. 46% cases of patient aged > 60 years do have dull achy pain in the chest which worsens in the span of time in the event of heart failure⁴. A reading of under 120/80 mmHg is an ideal Blood pressure reading. BP above 140/90mmHg is typically considered high¹. Hence, considering Mr. Deltori’s BP of 169/90 mmHg, he is having hypertension. His pulses were all palpable and heart rate of 120 regular bpm which indicates sinus tachycardia³. This indicate that ventricle has less time to fill as the Stroke Volume has decreased which may produce residual blood in the atria¹¹. His respiratory rate is 24 breaths per minute which is above normal that is 14-22 breathes per minute¹⁴. His jugular veins are distended that suggest increased right arterial pressure pointing towards congestive heart failure mostly right sided⁹.

He is 173 cm tall and weighs 91 kgs, which suggest that his BMI is 30.4 which is obese. A senior individual with high BP and obesity is prone to develop diabetes, atrial fibrillation, visual and hearing problems. Hence, this clearly points out the reason for some of his past comorbidities¹⁶. Moreover, he is having bilateral +2 pitting edema in lower extremities which clearly point towards the congestive heart failure especially right side¹⁵. Mr. Deltori is smoking for 54 years that is one of the risk factors for the cardiac disease. Additionally, according to his wife, he is having an inactive life style and eats fast foods which are the other risk factors of heart failure⁸. As Mr. Deltori does not have any complain of shortness of breath or other symptoms of pulmonary edema this clearly points that he is having right sided heart failure and not the left sided one¹³. A hypothetical pattern of his disease condition can be explained as per the chart below

4. Identify problems/needs:

In this case, the major problem of Mr. Deltori is ineffective myocardial tissue perfusion which can be evidenced by chest pain, visible pulsation, chest heaving and diaphoresis which can be due to imbalanced oxygen exchange. The next problem that needs to be addressed in this case is of excess fluid volume as the patient has bilateral pitting edema in the lower extremities, distended jugular vein, increased heart rate and also increased BP.

5. Establish goals:

The goals can be to treat chest pain, increase activity tolerance, maintain balance between oxygen supply and demand in the body and to assist him in maintaining a satisfactory quality of life and to manage adequate fluid volume of Mr. Deltori and to reduce edema and distention of the jugular vein.

6. Take action:

Mr. Deltori is adviced to stop all activities and sit or rest in bed. He is been provided with a semi-Fowler position as in this position there is better expansion of lungs and gas exchange and there by decrease in workload of heart by decreasing the preload¹¹.

Assessed the pain, vital signs and the ECGS specifically increased heart rate, irregular rhythm, difficulty in breathing, sweating and paleness because this will help in detecting the abnormal findings and can identify immediate increase in HR and demand of oxygen¹¹.

Administered oxygen therapy to Mr. Deltori as his respiratory rate is increased at 2L/min via nasal prongs. Administered Anginine via sublingually, and assessed his response for any reduction in angina; and administered epixban in order to prevent thrombus formation and blocking of the artery¹¹.

Monitored Mr. Deltori’s fluid status closely— by lungs auscultation, checking his weights daily, and helping him to stick to diet which is low in sodium by reading food labels and avoiding high-sodium foods such as canned, processed, and convenience foods⁵.

Recorded accurately his intake and output chart; calculate 24-hr fluid balance noting plus-minus so that adjustments can be made in the following 24-hr intake if needed. Elevate the lower extremities which are edematous and frequently change position to reduce tissue pressure and risk of skin breakdown⁵.

7. Evaluate outcomes:

Mr. Deltori shows relief of chest pain, also no signs of respiratory distress were seen, and vital signs were within the targeted range with adequate tissue perfusion.

Maintains ﬂuid balance by exhibiting decreased peripheral and sacral edema, demonstrating methods for preventing edema.

8. Reflect on process and new learning:

Mr. Deltori, according to scenario can be seen a person who does not take his condition seriously so maybe he is knowledge deficit regarding his disease condition. His knowledge deficiency about eating habits, smoking habits, inactive life style should have been focussed more in detail as they are the modifiable risk factors of major cardiovascular disease which needed to be addressed with Mr. Deltori and his wife¹⁸.

Moreover, the paper did not discuss regarding the importance of taking his prescribed medications regularly without any of the dose missing as medication adherence play a vital role in the treatment of long-term therapies like diabetes and hypertension¹⁷.

CONCLUSION:

Clinical reasoning and critical thinking guarantee that nurses will develop some positive attitudes that maintains patient’s safety via holistic care approach within their scope of practice.

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Received on 28.10.2020 Modified on 12.05.2021

Asian J. Nursing Education and Research. 2022; 12(1):82-85.

DOI: 10.52711/2349-2996.2022.00017