Utilizing Clinical Reasoning To Prioritize Nursing Care: A Case Study Analysis

Patient Assessment

Discuss about the Critically Analyze The Patient Assessment Findings.

Nursing professionals are to address complex health problems of patients by application of suitable skills and adequate knowledge. Appropriate clinical reasoning skills are required for recognizing the most important patient needs and delivering interventions accordingly. Clinical reasoning is the valuable tool with which nurses can process the patient information and set up nursing priorities for the patient. The next step is to outline interventions that can help in achieving better patient outcomes. The present paper is a nursing case study analysis report that utilizes the clinical reasoning process to prioritize patient care. The aim is to critically analyze the patient assessment findings. This takes into consideration the patient’s situation and the medical diagnosis. The data is collected and processed in terms of relevance to nursing care using DRABC (Danger, Response, Airway, Breathing and Circulation). Thereafter, three nursing priorities are identified for this person, one of which is a psychosocial need. One patient centered goal is then established for the nursing diagnosis. For each of the diagnosis, particular nursing interventions are identified including rationale and evaluation criteria.

The patient in the present case scenario is Mr. Harry Flanagan, a 24 year old individual, who suffered injury due to a road accident. The ambulance had to extract him since he was in pain and was not able to move his left leg. The patient had no significant medical history and is normally fit. Harry moved to Canberra from Alice Springs three years ago to play rugby, and has recently engaged to his partner with whom he has an 18 month old daughter. Upon arriving on the emergency department his vital signs were BP: 153/ 74 mm hg; HR: 112 beats/ minute; RR: 22 breaths / minute; Temp: 35.9 degree C and SpO2: 96% on room air. Harry complained of severe pain on the right side of his chest and there was bruising in the area. An ECG was done that indicated normal sinus rhythm. The paramedics had placed a splint on the patient’s left leg. He reported to have a pain score of 8/10 at the site in the left leg. He was given morphine on arrival to the ED that was effective in reducing the pain to 5/10. He suffered a large laceration to the left thigh that had been bleeding profusely and needed to pressure bandage to cover it up. The patient was administered normal saline IV infusion. CT scan and X-ray were performed to assess further injuries. The chest X-ray revealed that there was no rib fracture and lung fields had good air entry. There was no bone displacement or evidence fracture in the pelvis. X-ray of the limb revealed simple and closed fracture of the left femur with swelling around the left thigh. There were no other signs of injuries. It was determined that he needed surgery for stabilizing his conditions.

Identification of Nursing Priorities

the second day, Harry underwent an open reduction and internal fixation (ORIF) of his left femur. Upon discharge to the ward he was given standard post-operative care, including fluids, observations, analgesia and enoxaparin. The patient’s progress had been uneventful till the fourth day. He however had difficulty complying with the physiotherapists’ direction to do deep breathing and coughing exercises. This was due to bruising and pain in the chest. Further, harry could not comply with the instructions for leg exercises. His vital signs are BP: 133/73; HR: 92 beats/ minute; Respiratory rate: 18 breaths/ minute; Temp: 35.6 OC; SpO2: 97% on room air. Harry reports swelling in his right calf and pain.

Based on the patient information collected it would be appropriate to carry out an assessment with the help of the DRAC (Danger, Response, Airway, Breathing and Circulation) assessment tool. The tool helps in assessing the situation and identifying the nursing priorities for care (Blais, 2015). The patient has suffered large laceration to his left thigh and had been bleeding profusely when he had been attended. The patient had to undergo open reduction and internal fixation (ORIF) for minimizing further complications from the injury. An open reduction internal fixation is the surgical process undertaken for fixing a severe bone fracture. Open reduction refers to the realignment of the fractured bone into the normal position. Internal fixation refers to the use of plates, screws and steel rods for keeping the bone fracture in a stable condition for healing and preventing any chances of infection (Assal et al., 2015). While the patient was normally responsive after the surgery, he reported pain and swelling in the right calf that was found to be red. Pain is common after surgery in some patients who are at increased risk of swelling. Swelling is a part of the healing process and surgeries such as open reduction and internal fixation is involved with manifestations such as swelling and pain. The magnitude of it depends on the extent of the tissue damage that is suffered at the site. The development of pain following surgery is due to changes in the central nervous system and peripheral nervous system (Majuta et al., 2015).

Though Harry’s progress had been uneventful after the surgery, he had difficulty in complying with the instructions on deep breathing and coughing exercises, and leg exercises. As opined by Tripathi and Sharma (2017) deep breathing and coughing exercises help in increased mobility after a patient has undergone surgery. The exercises help in the breathing pattern and augment clearing of lungs, thereby reducing the risks of infection. In the present case Harry was unable to carry out the exercises due to pain and bruising. The difficulty in carrying out breathing exercises denotes airway obstructions. Airway obstruction leads to paradoxical chest movements and the use of accessory muscles of respiration. At the time of assessment of breathing it is crucial to diagnose any abnormalities in the respiratory rate ad oxygen concentrations. The patient’s respiratory rate was 18 breaths/ min while his oxygen saturation was 97% on room air. The normal respiratory rate for adults is 12-20 breaths per minute while the normal oxygen saturation level is 94-99% (Jain, 2017). In all surgical emergencies, it is crucial to assess risks of cardiac complications. This is to be done by assessing pulse rate of the patient and blood pressure. In the present case, Harry’s heart rate was 92 beats/minute while his blood pressure was 133/73 mmHg which was previously BP153/ 74. A normal resting heart rate for adult is between 60 to 100 beats per minute (Portnoy & Farrington, 2015). The systolic reading of 133 is in the prehypertension range as outlined by the American Heart Association’s guidelines for blood pressure. The diastolic reading of 73 is in the normal range. The patient is thus subjected to prehypertension.

Interventions for Pain Management

Based on the DRABC assessment carried out on the patient, the three nursing priorities that have been identified for the patient are pain management, blood pressure management, and stress management. For pain management, the patient-centered goal would be to enable the patient describe satisfactory pain control at a level less than 4 on a scale of 1-10. In relation to blood pressure management, the goal would be to maintain the patient’s blood pressure within the acceptable range. In relation to stress management, the goal would be to enable the patient gain mobility and resume normal life (Butcher et al., 2018). 

Nurses are responsible for addressing the concerns of the patient in relation to pain suffered. The first intervention would be foreseeing the need for pain relief. Early intervention reduces the total amount of analgesic required. Report of pain is to be acknowledged immediately for preventing further aggravation. Demonstration of the concern for the comfort and welfare of the patient helps in development of a comforting and trusting relationship (DeVore et al., 2017). Additional stressors that might lead to further discomfort are to be removed from the environment. The rationale is that patients often experience pain exaggeration if there are intrapersonal, environmental or intrapsychic factors present causing stress. Providing rest periods is important for promotion of sleep, relief and relaxation. This is because pain is aggravated due to exhaustion (Andersson et al., 2017). The patient might be given non-opioid pharmacological drug for effectively managing pain through blockage of prostaglandin synthesis. The effectiveness of the interventions would be evaluated by assessing the patient’s level of pain and the individual’s improvement in coping (Lehne& Rosenthal, 2014).

For addressing pre-hypertension stage, it is crucial to note presence and quality of peripheral and central pulses. Pulses in the legs might be diminished, reflecting the impact of venous congestion and vasoconstriction systemic vascular resistance (Hering et al., 2016). The patient’s capillary refill time, and skin color, moisture and temperature are to be recorded. Such assessment reflects decreased cardiac output. The patient is to be provided with restful, calm surrounding for minimizing environmental activity. This helps in promotion of relaxation. It is also crucial to schedule periods of uninterrupted rests and provide assistance for self-care activities. The rationale is that such measures reduce the physical stress and lessens the tension that otherwise leads to blood pressure (Butcher et al., 2018). Monitoring response to medication is crucial for controlling blood pressure. Response to drug delivery is dependent on a number of factors. Medications such as thiazide or beta-blockers can be administered as an anti-hypertensive drug (Lehne& Rosenthal, 2014). The outcome of the intervention would be evaluated by monitoring the blood pressure of the patient on a regular basis.

Interventions for Blood Pressure Management

Stress management for the patient would be crucial to promote better mobility and enhance his quality of life. The first intervention would be to assist the patient to identify feelings of depression and stress. The strategy would be to establish a therapeutic relationship for two-way communication. The patient is to be assisted to develop self-awareness of pain (Black, 2016).  The patient is to be further assisted to identify methods of coping. It is important to review feelings and thoughts related to surgery and pain. This would guide in coping and help the patient lead a normal life. Since the patient is a rugby player and lives alone, it is crucial that he demonstrates suitable coping mechanism (Moorhead et al., 2014). The patient is to be further encouraged to be independent in movement and positive reinforcement would be crucial for such behaviors. Positive reinforcement is essential for enhancing self-esteem. Enhanced self-esteem is crucial for leading a better quality of life. The evaluation of the interventions would be done by assessing the patient’s level of coping (Khan et al., 2016).

Below is a detailed structure of the nursing care plan explained under a tabular format.

In conclusion, the present case study analysis offered an opportunity to apply clinical reasoning cycle in nursing practice. The processing of collected information was helpful in understanding the key issues faced by the patient. On the basis of such as an assessment with the DRABC framework nursing priorities of care could be identified. These are related to pain management, high blood pressure management and stress management. Suitable nursing interventions would enable faster recovery of the patient.

References  

Andersson, V., Bergman, S., Henoch, I., Ene, K. W., Otterström-Rydberg, E., Simonsson, H., &Ahlberg, K. (2017). Pain and pain management in hospitalized patients before and after an intervention. Scandinavian journal of pain, 15, 22-29. DOI:https://doi.org/10.1016/j.sjpain.2016.11.006

Assal, M., Ray, A., & Stern, R. (2015).Strategies for surgical approaches in open reduction internal fixation of pilon fractures. Journal of orthopaedic trauma, 29(2), 69-79. DOI: 10.1097/BOT.0000000000000218

Black, B. (2016). Professional Nursing-E-Book: Concepts & Challenges. Elsevier Health Sciences. Retrieved from:https://books.google.co.in/books?hl=en&lr=&id=ndcEDAAAQBAJ&oi=fnd&pg=PP1&dq=nursing+book&ots=Ly3ZjLRuYv&sig=KU78JW742ESNKwmC-JJwXD57be4#v=onepage&q=nursing%20book&f=false

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DeVore, J., Clontz, A., Ren, D., Cairns, L., & Beach, M. (2017).Improving patient satisfaction with better pain management in hospitalized patients. The Journal for Nurse Practitioners, 13(1), e23-e27. DOI: https://doi.org/10.1016/j.nurpra.2016.07.020

Hering, D., Kara, T., Kucharska, W., Somers, V. K., &Narkiewicz, K. (2016).Longitudinal tracking of muscle sympathetic nerve activity and its relationship with blood pressure in subjects with prehypertension. Blood pressure, 25(3), 184-192. DOI: https://doi.org/10.3109/08037051.2015.1121708

Jain, K. K. (2017). Physical, physiological, and biochemical aspects of hyperbaric oxygenation. In Textbook of hyperbaric medicine (pp. 11-22). Springer, Cham.    

Khan, J. S., Devereaux, P. J., LeManach, Y., &Busse, J. W. (2016). Patient coping and expectations about recovery predict the development of chronic post-surgical pain after traumatic tibial fracture repair. British journal of anaesthesia, 117(3), 365-370. DOI: https://doi.org/10.1093/bja/aew225

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Portnoy, J., & Farrington, D. P. (2015). Resting heart rate and antisocial behavior: An updated systematic review and meta-analysis. Aggression and violent behavior, 22, 33-45.

Tripathi, S., & Sharma, R. (2017). Deep Breathing Exercise and Its Outcome among Patient with Abdominal Surgery: A Pilot Study. International Journal of Nursing Science, 7(5), 103-106. DOI: 10.5923/j.nursing.20170705.01

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