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. Google images 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.
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