Clinical reasoning scenario
Mr Richards is a 79 year old man, undergoing surgical repair of a fractured hip. He has no known living relatives. He was living at home independently when he slipped and fell in the bathroom, fracturing his right neck of femur. He was on the floor for an indeterminate amount of time prior to being found by a neighbour, who came to check in on him. The ambulance was called. Paramedics found the patient on the bathroom floor in a confused state. He was unable to accurately note the date or time, and he had no recollection of how he ended up on the floor. During the head-to-toe assessment, it was noted that Mr Richards had sustained a small scalp laceration over his right temporal region, which was clotted by the time the ambulance personnel arrived. His leg was in a displaced position, and a fractured hip was suspected. He was also noted to have a healed scar on his sternum, indicative of a previous open-heart procedure. The paramedics also noted Mr Richards Webster pack has not been opened this morning.
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Upon arrival in the emergency department, the patient is evaluated by orthopaedic, cardiology, and neurology specialists. His history was reviewed and revealed a previous open-heart procedure 8 years ago, a long history of smoking prior to the cardiac procedure, and a history of lifelong obesity. The patient’s skin condition is poor. He has multiple folds of fatty skin, and between these folds, the skin is quite dirty and malodourous, indicating poor personal hygiene. He has a list of medications in his wallet, which identifies the following
drugs: Digoxin, Simvastatin, Frusemide, Potassium Chloride, Metoprolol and Timolol eye drops.
Mr Richards greatest immediate need is stabilization of the fractured femur. The neurologist deems that it is appropriate to perform the surgery under general anaesthesia and that postoperative neurologic assessment should be initiated. The cardiologist agrees that the patient is stable from a cardiac standpoint and that he will most likely be able to tolerate the effects of anaesthesia. The orthopaedic surgeon performs the fractured hip repair.
Mr Richards is transferred back to the ward. His hip is positioned for optimum healing. His vital signs are: blood pressure 182/105 mm Hg, pulse 102 beats per minute, respiratory rate 26 breaths per minute, oxygen saturation 89% on 4 litres nasal prongs, and core temperature 34.5°C. GCS 13/15 (E 3, V4, M6). No urine is noted in the Foley catheter. He has a right peripheral cannula, a belovac drain in situ which has drained 20mls of blood stained fluid.
Task:
You are the registered nurse caring for Mr Richards following his surgery. Apply the clinical reasoning cycle to this case study to establish a plan of care for Mr Richards. Use the headings of the clinical reasoning cycle to guide your thinking. Not all phases of the cycle need to be responded to.
1700 words.
You do not need to include an introduction or conclusion.
You must use the headings provided below.
Your responses must be written in full sentences and adhering to academic convention (no use of personal pronouns).
Approved nursing abbreviations and acronyms are allowed.
Your responses need to be supported by a minimum of 10 current (less than 7 years) in total. Peer reviewed, and scholarly sources are to be used.
Rationale: The phases of the clinical reasoning cycle will facilitate problem-solving and decision making, allowing you to provide the best care for Mr Richards.
The phases of the clinical reasoning cycle: Phase 1. Consideration of facts from the patient or situation (this phase does not require a response) This is the phase where you are first presented with a clinical case. Here you receive the presenting information and current medical status of the patient. Phase 2. Collection of information (approx. 300 words) In this phase, you collect primary and secondary survey data. You need to use a systematic approach. For example, A2K, head to toe or primary/secondary survey. You then analyse the findings using your established knowledge of physiology, pharmacology, pathology, culture, and ethics to establish cues and draw information. Phase 3. Processing gathered information (approx. 300 words) This is a critical stage and the core of clinical reasoning. Here, you process the data on the patient’s current health status in relation to pathophysiological and pharmacological patterns, know what details are relevant, and determine potential outcomes for possible decisions you make. Phase 4. Identify the problem (approx. 300 words)
With a solid information processing phase, you will be able to determine the reason behind the patient’s current state. Phase 5. Establish goals (approx. 300 words) Here, you determine the treatment goals for the patient’s situation. Treatment plans should not be open-ended or without a time-oriented goal. Consider a SMART approach. Phase 6. Take action (this phase does not require a response) Now, you implement the actions steps needed to meet the patient’s treatment goals. This will, of course, involve other members of the healthcare team, so everyone should be updated about the treatment goals for the particular patient. Phase 7. Evaluation (this phase does not require a response) At this phase, you evaluate the effectiveness of the course of action you have taken. This will allow you to determine whether to readjust or continue the line of action. Phase 8. Reflection (approximately 500 words) At this phase, you reflect on significant events within the scenario, analyse these events in relation to your learning.
Marking rubric
Marking criteria and standards
Criterion
Clinical reasoning includes:
HD
DI
CR
PS
FL
Weighting
50%
Collecting information and cues
A wide variety of objective and subjective data was drawn from the scenario to uncover useful information. A systematic approach identified and evidenced
8.5-10
Subjective and objective data was used, most useful information is identified; may have missed some subtle signs. A systematic approach was evident
7.5-8
Subjective and objective data was used. Focussed on the most obvious data. Missing some cues. A systematic approach was referred to.
6.5-7
Did not differentiate between the subjective and objective data. Focussed on the basic data. Missing some important cues. Unsure if a systematic approach was applied
5-6
Did not draw from both objective and subjective data Missed major cues.
No evidence of a systematic approach being used.
0-4.5
/10
Processing the gathered information and recognising deviations from expected patterns
Recognizes subtle patterns and deviations from expected patterns in data. Differentiates relevant and non-relevant data
17-20
Recognizes most obvious patterns and deviations in data. Differentiates between relevant and irrelevant data, but has included some details that are not relevant
15-16.5
Identifies obvious patterns and deviations, missing some important information
13-14.5
Focuses on one thing at a time and misses patterns and deviations from expectations
10-12.5
Unable to demonstrate processing of the information. Patterns and deviations from expectations are not identified.
Irrelevant information was used
0-9.5
/20
Identifying problems and making sense of the data
Is able to identify the reason behind the patients current state and has made sense of patterns in the patient’s data and compare these with what is known from the nursing knowledge base and research
17-20
Is able to interpret the patient’s data patterns and compare these with what is known from the nursing knowledge base and research
15-16.5
Is able to compare the patient’s data with patterns from the nursing knowledge base and research
13-14.5
Has difficulty interpreting the patients data but has drawn some accurate conclusions; has trouble distinguishing among competing explanations from the nursing knowledge base
10-12.5
Has not been able to demonstrate an understanding of the patient’s problem.
Has not drawn from the nursing knowledge base to make sense of the data
0-9.5
/20
Prioritising data and establishing goals
Is able to prioritise the patient’s data and develops a treatment plan following the SMART goals process
17-20
Is able to focus on the most important data and develops a treatment plan using the SMART goals process
15-16.5
Is able to demonstrate some prioritisation of patient data but also focusses on some less relevant data. Explains intervention plans with an accompanying rationale for the patients goals
13-14.5
Makes an effort to prioritise data and attempts to provide a rationale for patient goals which are relevant to the patients’ needs
10-12.5
Has not been able to demonstrate prioritisation of patient data. Attempts to attend to all available data
Patient treatment plan is incomplete or is not supported by a rationale
0-9.5
/20
Reflection on learning
Student clearly identifies and critically analyses significant learning events and reflects critically on them in a deep and significant way by relating the reflections to their learning experiences.
17-20
Student identifies and analyses significant learning events and reflects on them in a significant way by relating the reflections to their learning experiences.
15-16.5
Some analysis is employed to examine the learning experience but is mostly left at the descriptive level.
13-14.5
Student describes significant learning events but makes no attempt to provide reasons for their learning experience.
10-12.5
Student makes little attempt to personally relate events during the learning experiences and makes few attempts to critically analyse these situations. Few attempts are made to examine the reasons why the learning experience did not work out well or explore alternatives to find ways as to how they could have been improved
0-9.5
/20
Demonstrate structure, grammar and referencing appropriate for the health sciences.
An extensive range of relevant literature from scholarly sources has been analysed substantially supporting the arguments.
APA (6th) referencing conventions in both in-text referencing and reference list have been accurately and consistently.
Formal academic language and precise and correct discipline and professional terminology have been used to clearly communicate meaning.
There is consistent adherence to grammatical conventions.
8.5-10
An extensive range of relevant literature from scholarly sources has been applied in supporting the arguments.
APA (6th) referencing conventions in both in-text referencing and the reference list have been used almost always accurately and consistently.
Formal academic language and precise and correct discipline and professional terminology have been used to clearly communicate meaning.
There is consistent adherence to grammatical conventions.
7.5-8
Literature from scholarly sources has been understood and incorporated, supporting key points.
APA (6th) referencing conventions in both in- text referencing and the reference list are in evidence but there are inconsistencies.
Formal academic language has been used to clearly communicate meaning.
There is mostly consistent adherence to grammatical conventions, although minor errors remain.
6.5-7
Literature from a range of sources, some of which are not credible or relevant, have been recognised.
Attempt made to adhere to APA (6th) referencing conventions in both in- text referencing and the reference list, but with some errors and inconsistencies.
Formal academic language has been used to communicate meaning.
Grammatical conventions have been adhered to in some areas although there are minor errors.
5-6
Literature from sources, most of which are not credible or relevant, and are tenuously related to the topic.
Adhered to APA (6th) referencing conventions in both in-text referencing and the reference list is minimal or non- existent.
Formal and informal language has been used to communicate meaning and in many areas meaning is unclear.
The work includes multiple grammatical errors.
0-4.5
/10
Adapted from the Laster Clinical Judgement Rubric (2007)
