NUR4153CBE Rasmussen Clinical Reasoning Appropriate for the Situation HW Scenario You recently finished new graduate orientation in the emergency room (ER

NUR4153CBE Rasmussen Clinical Reasoning Appropriate for the Situation HW Scenario

You recently finished new graduate orientation in the emergency room (ER) of a rural, 60-bed hospital, and tonight is the first shift you have worked independently. The Intensive Care Unit of the hospital has only four beds and usually sends the sickest clients in need of complex care to a regional medical facility located 50 miles from your location. During orientation, you were told repeatedly the purpose of treatment in this ER is triage, stabilize, and send home or send to a larger network facility.

Tonight your first client is an 82-year-old female named Ruth. Ruth was dropped off at the ER by a neighbor who said that she had nausea and vomiting for a week. Her husband was recently admitted to an Alzheimer’s Unit at a local Long-Term Care facility, and the neighbor thought stress was making it hard for Ruth to eat, but tonight she vomited up fresh blood and appeared dizzy. The neighbor also brought in a bag of medication she found in the home but was unsure which medication belonged to Ruth or her husband.

When you enter the room to begin the assessment, you find a frail woman sitting in a wheelchair with apparent labored breathing. She appears dirty with matted hair clothed in a bathrobe with numerous food stains and has a heavy smell of cigarette smoke. You notice the chart has a highlighted area noting the client has only Medicaid for insurance. You ask her if she understands why she is in the ER and she asks, “Where is my husband? He is usually home by now.”

Past medical history:

Two pack per day smoker for 58 years
Type I Diabetic

Assessment data:

Blood pressure: 178/98
Heart rate: 84 beats per minute
Oxygen saturation: 84
Temperature: 101.8 degrees Fahrenheit
Hyperactive bowel sounds in all 4 quadrants
An open wound on the bottom of right foot
Instructions

You are feeling overwhelmed with your first client but remember first you need to evaluate internal and external cues to develop a priority hypothesis to guide clinical reasoning. Create notes for this client’s plan of care including:

Design a hypothesis for each of the four modes of inquiry: empirical, ethical, aesthetic and sociopolitical.
Prioritize the most relevant hypothesis aligned with data in the scenario and demonstrate appropriate clinical reasoning.
Design an evaluation plan for the priority hypothesis.
Resources
APA Guide NUR4153 Clinical reasoning Deliv 3 Material
Evaluating Hypotheses
To evaluate hypotheses formed through clinical judgment the nurse must
be able to filter information gathered into relevant data sets. The nurse
must consciously and cognitively process outcome data sets inclusive of:
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Professional beliefs;
Professional values;
Experiential and cognitive knowledge;
The context of the client situation;
Multimodal perspectives; and
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Curiosity.
Cue Clustering
A key component of processing information from outcomes is cue
clustering related to the discipline specific problem and nursing
interventions. The purpose of clustering cues is the facilitation of pattern
and trend recognition. The nurse must include data over time as an
iterative process to evaluate hypotheses. Once cues are clustered, the
nurse must integrate outcomes-focused thinking as a strategy for
juxtaposing outcome criteria with current, relevant information to evaluate
hypotheses (Kupier and O’Donnell, 2017).
For example, a priority hypothesis for an insulin dependent Type I
Diabetic with a stage II foot ulcer, hyperthermia, neutrophilia and blood
glucose of 210 mg/dL is: administer insulin and blood glucose will
decrease to the appropriate range.
The hypothesis is problem specific, realistic and correct if the outcome in
one hour reveals an expected decline in blood glucose. If the blood
glucose did not decline in one hour the nurse must reframe the context of
the situation, gather more cues and cluster information such as:
When evaluating a hypothesis with unexpected results, cues are
organized into appropriate data and through the application of clinical
judgment the nurse generates a new hypothesis. This generation,
evaluation and generation cycle for hypotheses is iterative and driven by
an evaluation process for expected and achieved outcomes.
Outcomes and Nursing Clinical Judgment
Nurses know clinical judgment is a required competency for optimal
client outcomes in a complex healthcare environment. Graan, Williams,
and Koen (2016) explored the perceptions of clinical judgment among
professional nurses who often mentored undergraduate nursing
students. The results aligned with outcomes and evaluation of
hypotheses were interesting.
Nurses in this study identified priority actions when gathering and
clustering cues aligned with outcomes:
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Remain present in the client interaction through active listening and
respect for client needs;
Never lose sight of doing what the best for the client, a key to
ethical nursing practice is;
Maintain a relationship with outcome data points and realistic
expections is always searching for more effective methods to
manage a situation; and
Stay focused on prioritization and problem solving.
To evaluate hypotheses, nurses in this study identified these key
strategies:
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Manage a situation according to your judgment, take charge and
be confident;
Take time to build a relationship with a client for collaboration to
evaluate hypotheses accurately;
Trust your intuition and look for extra information to support
decision flexibility if new hypotheses are necessary.
The researchers found the nurses’ overall perceptions of clinical
judgment simplistic and enmeshed within nursing practice focused on
tasks. For example, professional nurses in the study gathered and
prioritized cues with the primary intent to create interventions rather than
follow through with the evaluation of hypotheses aligned with
interventions.
Opportunities must increase for integration of clinical judgment into
nursing education as a central component of the teaching and learning
process. In particular nurses in practice and school need to actively
investigate their ideas regarding cue gathering and clustering
(interpretation of outcomes) and evaluation of hypotheses (capacity for
knowledgeable, appropriate decision making). Also, nursing scholars
must continue to question why and how nursing clinical judgment affects
client outcomes and nurse decision making.
References:
Kuiper, R., O’Donnell, S. M., Sigma Theta Tau International, Pesut, D. J.,
& Turrise, S. L. (2017). The Essentials of Clinical Reasoning for Nurses.
Indianapolis, IN Sigma Theta Tau International.
Van Graan, A. C., Williams, M. J. S., & Koen, M. P. (2016). Professional
nurses’ understanding of clinical judgment: A contextual inquiry. Health
SA Gesondheid, 21(1), 280–293. doi- 10.1016/j.hsag.2016.04.001

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