Clinical Reasoning Case Study NiCS: Critical Care 2021 Clinical Reasoning Case Study NiCS: Critical Care Semester 2 2021 Clinical Reasoning Case Study Assignment Please note that this assignment shares the same patient as another one of your courses (3011OL Cancer and Palliative Care) and under no circumstances is content for either assignment to be reused in the other. Each assignment is very clearly looking at different aspects of Sharon’s care. If content is reused, your assignment will be returned to you, unmarked, for you to re-work and resubmit. Patient information: Sharon is a 57-year-old woman who was diagnosed with Amyotrophic Lateral Sclerosis (ALS) type 18 months ago. She is married to George and they have 2 children: Tom (17 years) and Sophie (23 years). George runs a small business from home and has been able to provide some support for Sharon in the past 12 months. Tom is preparing for year 12 next year and Sophie is recently married and has just announced that she is pregnant. Sharon was working as a primary school teacher but has been forced to take leave due to the progression of her disease. Sharon identified as Buddhist on admission. Sharon’s condition has rapidly deteriorated over the last 18 months. She is unable to speak clearly, slurring her words, she is also unable to walk and uses a wheelchair at all times. She is unable to complete her own ADL’s and both George, and some community services, assist with this. History of admission: Sharon developed cold and flu like symptoms (COVID-19 negative) over the last 3 days. She has had a fluctuating temperature and has had some breathing difficulties. George called an ambulance after contacting Sharon’s usual GP and Sharon was taken to the Royal Adelaide Hospital (RAH) Emergency Department three days ago. Sharon was assessed and admitted with a diagnosis of aspiration pneumonia. She has also tested positive for Respiratory Syncytical Virus (RSV). She has been placed on the Intensive Care Unit for non-invasive ventilation and management. You are a final year Nursing student in the RAH ICU. You and your RN have been allocated to care for Sharon today on your early shift. You receive the below ISBAR handover from the RN on the previous shift. NiCS: Critical Care 2021 Clinical Reasoning Case Study Identify: Sharon Rachel Griggs DOB: 26/03/1964 URN: 321654 Situation: Sharon has been admitted for aspiration pneumonia. She is also positive for RSV. Background: Sharon was diagnosed with Motor Neuron Disease (ALS Subtype) (subtype) 18 months ago. Since then, she has had a rapid decline. She is unable to speak clearly, mobilise or care for herself. Her husband has become her full-time carer in the last 6 months (he also runs in his own business) and is supported by some community services. 3 days ago, Sharon had a fever and over the course of the following 48 hours she developed some breathing difficulties. George called an ambulance and Sharon was transported to the Royal Adelaide Hospital ED where she was assessed and admitted to the ICU. This is now day 2 in ICU where Sharon’s condition is being managed. She continues on Non-Invasive Ventilation (BiPAP) which was commenced 36 hours ago. Assessment: • Airway/breathing: o Sharon continues BiPAP-IPAP 10, EPAP 5 FiO2 55% o Respiratory rate: 20-26 breaths per minute o SpO2: 92-95% o Tidal volume: 380-450 mL o Sharon finds the mask uncomfortable and pressure areas are noted on the bridge of her nose and both ears • Haemodynamics: o Arterial line inserted into left wrist-NV intact o 5-lead ECG monitoring in place o Blood pressure: 105/65 mmHg with a MAP 70 mmHg o HR: 90-105bpm o CRT: 2-3 seconds o Temperature: 37.8C • Neurological: o GCS: 10 (E4, V2, M4) and this is normal for Sharon o Communicates via a communication board supplied by the Speech Pathologist o Husband also helpful with communication • Input/Output: o Intravenous Therapy: Isotonic solution running at 40mls/hr o Dietician has ordered a pureed diet and thickened fluids o IDC insitu-draining straw coloured urine, drained 102mls in the last hour o Pad insitu-BO yesterday-soft. NiCS: Critical Care 2021 Clinical Reasoning Case Study o Strict FBC monitoring • Social: o George was here until 2300 last night and will return around lunchtime today. o Tom and Sophie called and spoke to Sharon yesterday, will try and come in this evening. • Allied health: o Physiotherapist has been providing some passive limb exercises to help with painful cramps that Sharon gets in her thighs Most recent blood results: Please plan your nursing care for this early shift only, in alignment with the clinical reasoning cycle and the associated assignment instructions for this assignment. The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients Nurse Education Today 30 (2010) 515–520 Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier .com/nedt The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients Tracy Levett-Jones a,*, Kerry Hoffman a,1, Jennifer Dempsey b,2, Sarah Yeun-Sim Jeong b,3, Danielle Noble a,4, Carol Anne Norton b,5, Janiece Roche a,6, Noelene Hickey b,7 a School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW 2308, Australia b School of Nursing and Midwifery, The University of Newcastle, P.O. Box 127 Ourimbah, NSW 2258, Australia a r t i c l e i n f o Article history: Accepted 30 October 2009 Keywords: Clinical reasoning Nursing student Novice nurse Failure to rescue At risk patients 0260-6917/$ - see front matter � 2009 Elsevier Ltd. A doi:10.1016/j.nedt.2009.10.020 * Corresponding author. Tel.: +61 02 49216559; fax E-mail addresses:
[email protected] [email protected] (K. Hoffman), Jennife (J. Dempsey),
[email protected] (S.Yeun newcastle.edu.au (D. Noble), Carol.Norton@newcast
[email protected] (J. Roche), Noelene.Hickey@ 1 Tel.: +61 02 43494533; fax: +61 02 49216301. 2 Tel.: +61 02 4349 4532; fax: +61 02 4349 4538. 3 Tel.: +61 02 4349 4535; fax: +61 02 4349 4538. 4 Tel.: +61 02 4349 4534; fax: +61 02 4349 4538. 5 Tel.: +61 02 43484017; fax: +61 02 4349 4538. 6 Tel.: +61 02 2 4921 6230; fax: +61 02 4921 6301. 7 Tel.: +61 02 43484078; fax: +61 02 4349 4538. s u m m a r y Acute care settings are characterised by patients with complex health problems who are more likely to be or become seriously ill during their hospital stay. Although warning signs often precede serious adverse events there is consistent evidence that ‘at risk’ patients are not always identified or managed appropri- ately. ‘Failure to rescue’, with rescue being the ability to recognise deteriorating patients and to intervene appropriately, is related to poor clinical reasoning skills. These factors provided the impetus for the devel- opment of an educational model that has the potential to enhance nursing students’ clinical reasoning skills and consequently their ability to manage ‘at risk’ patients. Clinical reasoning is the process by which nurses collect cues, process the information, come to an understanding of a patient problem or sit- uation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process. Effective clinical reasoning depends upon the nurse’s ability to collect the right cues and to take the right action for the right patient at the right time and for the right reason. This paper provides an overview of a clinical reasoning model and the literature underpinning the ‘five rights’ of clinical reasoning. � 2009 Elsevier Ltd. All rights reserved. Introduction Contemporary practice environments are dynamic, unpredict- able and reactive. Increasing numbers of adverse patient out- comes are evident in Australia and internationally. Hospitals have a growing proportion of patients with complex health problems who are more likely to be or become seriously ill dur- ing their admission (Bright et al., 2004). Although warning signs often precede serious adverse events such as cardiac arrest, un- planned admission to intensive care and unexpected death (Buist et al., 2004), there is evidence that ‘at risk’ patients are not al- ways identified; and even when warning signs are identified ll rights reserved. : +61 02 4921 6301. u.au (T. Levett-Jones), kerry.
[email protected] -Sim Jeong), Danielle.Noble@ le.edu.au (C.A. Norton), Jan. newcastle.edu.au (N. Hickey). they are not always acted on in a timely manner (Thompson et al., 2008). Nurses with poor clinical reasoning (CR) skills often fail to de- tect impending patient deterioration resulting in a ‘failure to res- cue’ (Aiken et al., 2003). CR is an essential component of competence (Banning, 2008). However, contemporary teaching and learning approaches do not always facilitate the develop- ment of a requisite level of CR skills. A recent Australian report described critical patient incidents that often involved poor CR by graduate nurses (NSW Health, 2006). This report parallels the results of the Performance Based Development System, a tool employed to assess nurses’ CR, which showed that 70% of grad- uate nurses in the United States scored at an ‘unsafe’ level (del Bueno, 2005). The reasons for this are multidimensional but include the difficulties novice nurses encounter when differenti- ating between a clinical problem that needs immediate attention and one that is less acute; and a tendency to make errors in time sensitive situations where there is a large amount of com- plex data to process (O’Neill, 1994). These factors provided the impetus for the development of an educational model that has the potential to enhance graduates’ CR skills and consequently their ability to identify and appropriately manage ‘at risk’ patients. This paper begins by providing an overview of the CR model. It then profiles the literature that underpins the model’s development, structured as the ‘five rights’ of CR. http://dx.doi.org/10.1016/j.nedt.2009.10.020 mailto:
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