Need to analysis the case study NRSG366


Need to analysis the case study NRSG366. 



In the medical and nursing practice, clinical reasoning, clinical judgment, problem-solving, decision making, and critical thinking are frequently utilized conversely. The clinical reasoning can be depicted as the process, in which nurses gather signs, process data, approach towards the perception of patient’s conditions or problems, design and enforce mediations, appraise outcomes, review and also acquire a knowledge from the procedure (Shaban, 2015; Koharchik et al., 2015); it also reliant on the critical thinking which is influenced by individual’s attitude, critical thinking, theoretical understanding, and preconceptions. Critical reasoning is the basic part of the nursing proficiency (Alfaro-Lefevre, 2015). Nurses with persuasive clinical reasoning aptitude positively affect patient outcomes. During the nursing assessment, nevertheless, the complexity and tactic knowledge of nursing consolidate elements and factors that impact which data nurse practitioners focus on first and all such information are necessary to nursing prioritization, for instance, nurses should have the capability to compute amongst pertinent and less significant data for every patient they attained (Musavi, 2016). The present study will identify and discuss the two priorities of care by the implementing clinical reasoning cycle tool with respect to the case study.

Case study Analysis:

Levett-Jones et al (2009) illustrates clinical reasoning “as a process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on, and learn from the process” (Levett-Jones et al., 2010). The clinical reasoning cycle has eight crucial stages or phases; which can be distinguished into the means of look, collect, process, decide, plan, act, evaluate and reflect; however, actually, the stages consolidate and the limits between them are frequently obscured (Thompson et al., 2013). The primary phase (first and second) of clinical reasoning includes the observation and collecting information required to go to a comprehension of a patient’s health issue or circumstance. 
From the case scenario we came to the patient’s present clinical situation: Peter Mitchell, who is a 52 year old male with acute obesity and 9year history of type 2 diabetes hospitalized with complain of uncontrolled diabetes, obesity ventilation syndrome, and sleep apnoea. Second phase of the clinical cycle involve the gathering of data because nurse need to investigate the most recent information, for example, reports, handover, past and also current patient's record, consequences of examination and remedial evaluations embraced before (Nibbelink & Brewer, 2017). Peter has a history of Obesity (weight 145kgs with a BMI of 50.2m2), Type 2 diabetes (diagnosed 9 years ago), Hypertension, Depression (Diagnosed three months ago by GP), Sleep apnea, Gastro-esophageal disease reflux disease. Also, Peter has been a smoker for approximately 30 years and smokes approximately 20 cigarettes per day. During his past admission, Peter was checked by a dietician and initiated on low energy, high protein diet (LEHP) to help with weight reduction; yet, he was unwilling to do anything about it. Peter was also reviewed by the physiotherapist and was initiated on light activities which he needs to proceed at home after release. Peter states that due to his over-weight he feels fatigue and uncomfortable; also he is lonely and socially isolated. Peter is also finding it increasingly difficult to perform activities of daily living (ADLs). Then, nurses collect fresh information- after primary check-up Peter was referred by his GP after he presented with symptoms of shakiness, enhanced craving, diaphoresis, elevated BGL levels and trouble in breathing while sleeping. Next step includes retrieving theoretical knowledge (like pharmacology, therapeutics, culture, ethics, law, pathophysiology, etc.) – The weight gain issue of Peter can be a result of prolonged insulin administration. As the current medication of Peter includes Metformin 500mg, which is used to treat high blood sugar levels, caused by type 2 diabetes; so it can said that his hypertension is a result of type 2 diabetes. Both Lisinopril 10mg as well as Metoprolol 50mg are used to hypertension and prevent heart failure or stroke. Pregabalin (Lyrica) 50mg is prescribed for neuropathic pain related to diabetic peripheral neuropath and fibromyalgia. 
Third phase of the clinical reasoning cycle include the perception of changes associated with patient’s condition. During the nursing assessment, attempt and differentiate the changes by logically interpreting subjective and objective signs, which required instantaneous medical interventions, also other changes that ought to be considered for future care. Aim for even if there are any associations or approximation between the existing alterations, particularly connecting with prior experiences (Gorton, & Hayes, 2014). Anticipate a conceivable expected result. In case of the Peter, considering his condition, hypertension and type 2 diabetes are two most important priorities of care; additionally, elevated insulin dosage adding to weight gain and depression, the comparability of manifestations of depression and hyperglycemia (Amelia & Yunanda, 2018). The persistent increment in insulin administration to regulate hyperglycemia can results in weight gain from the discontinuance of glycosuria, fluid maintenance, and enhanced fat synthesis. At the point when the patient could try to lower calorie intakes, the mismatch of insulin to nutrient absorption will bring about low-level of blood glucose; additionally, indications of hypoglycemia (Tong et al., 2015).In the event that insulin dosages are not brought down in conjunction with caloric limitation, a cycle starts with hypoglycemia, indulging, encourage hyperglycemia, expanding insulin necessities, and resulting gaining of weight; also it is required to decreases the blood pressure level as hypertension can cause cardiovascular diseases, kidney disease, and sleep apnea (Holland-Carter et al., 2017). Next step incorporate findings and presumption to prepare a conclusive data of the patient’s complications. In Peter’s case, it can be concluded that he is diabetic, obese, and hypertensive. 
Establishing care plan with definite patient outcomes that associate with a pragmatic time allotment is the fifth step of the CR cycle (Thompson et al., 2013). According to the case study, normalize insulin activity and blood glucose level, also reduce blood pressure level and provide emotional support are principal concern (Ismail et al., 2017). To take action after evaluating various available alternatives is the next step. On physical examination, Peter’s height is 170cms and weight is 145kgs, BP is 180/92mmHg, RR is 23 Bpm, HR is 102 Bpm, and Sp02 95% on RA. As the diagnosis of hypertension is confirmed, so simultaneous pharmacological and lifestyle modification therapy should be initiated immediately.  As per randomized clinical trials, maintaining diastolic BP close to or < 80 mmHg and systolic BP < 130 mmHg would improve CVD and microvascular outcomes, also prevent kidney diseases (Laffin & Bakris, 2018). Peter is diabetic hypertensive patient, who has normal renal function; in that case initiation of pharmacological therapy simultaneously with lifestyle modification would be recommended. In case of Peter, enhancing insulin dosage were thought to responsible for weight gain and he would require to reduce the daily insulin dosage besides proper diet to forestall hypoglycemia. Usually, a diabetic diet endeavors to deliver nutrition and calories all through the 24-hour time frame.  Day by day calories comprises roughly 50% carbohydrate, 30% fat, with the rest of the calories comprising of protein. The weight reduction can be achieved through regular exercise and physical activity as it enhances the cellular sensitivity to insulin, enhances resistance to glucose, also enhances the feeling of prosperity concerning his well-being (Inzucchi et al., 2015). Assessment of cognitive and sensory impairment is an essential part for diabetic patients as it hamper with the capability to precisely execute insulin. Monitoring and maintaining skin temperature and integrity, deep tendon reflexes, sensation; preventing soft tissue damage and dryness are essential factors to be concerned. As persistent diabetes can raise or worsen the manifestations of depression, so providing mental health support is needed for Peter (Mohammad & Ahmad, 2016). For the documentation purpose, blood and urine test result for glucose level monitoring, Physical health observation includes visual impairments, skin diseases or wounds, alteration in sensation or circulation; apart from that, educating Peter in regards to appropriate insulin preparation and administration, to avoid alcohol and refined sugars consumption, encouraging him stop smoking, and checking their understanding, response of insulin administration must be done to achieve patient care goal (Waddell, 2017). Evaluation of effectiveness of care plan followed by contemplation of learning from patient outcome is the last two steps of the clinical reasoning cycle. In the next consecutive visits, the BP should be achieved target measurement (<130/80 mmHg) (Grossman & Grossman, 2017). Once Peter is convinced to reducing his daily insulin dosage would avert hypoglycemia, which would empower him to diminish calories and reduce weight, he must be substantially more disciple to his treatment regimen. The utilization of metformin may have helped diminish her appetite and insulin prerequisites and in this manner aided his weight loss. For this situation, Peter’s symptoms of depression and fatigue should be improved with the better blood glucose regulation, which in turn brought about elevated energy level. He must be capable to engage himself in daily exercise and follow diet regimen; additionally, reducing his insulin prerequisites and prompting favorable weight loss (Wilding, 2015)

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Clinical reasoning is the enlightened clinical decision-making procedure based on theoretical knowledge and contemporary learning, which is being progressively identified as the essential part of nursing professionals, who have been working within the intricate healthcare setting and taking care of the patients with growingly varied health needs. The nursing evaluation was observed to be a part of effective and prescient judgment whose aim was to give a precise scenario of the patient's present condition, and this was likewise observed to be assessed often inducing the dynamic idea of such evaluation. Normally, making a clinical decision is a purposeful, objective effort upheld systematically to come down on a choice among different alternatives; adiitioanly, this thinks about the necessity to exhibit the both critical patient-based thinking and additionally activity. The prioritization and decision-making are interrelated factor; preference is given considering the patient needs that nurse view as essential, and that will impact prioritization of patient requirement for care. Utilization of formal decision-making method like ‘Clinical-reasoning cycle’ supports subsequent problem-solving and clinical decision-making process, also acknowledge nursing professionals of all competencies and experience levels to improve assessment, develop and execute appropriate medical interventions for their patients. 


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