Nursing Clinical Reasoning Errors

I need you to find two clinical reasoning errors from my interventions in part B file and go with the instructions.

Introduction (300 words)

Provide a very brief overview of your clinical encounter that highlights where the error/challenge/missed opportunity occurred (300 words).

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Body (700 words)

Upon reviewing the module content and your previous paper, identify TWO clinical reasoning errors that best aligned to, or potentially could have occurred during your encounter that contributed to why that encounter was challenging or perhaps did not go to plan.

Describe those TWO clinical reasoning errors chosen and discuss how these may have occurred and why. How were the errors eventually remedied? how could they have been mitigated? How could it have impacted on patient outcomes if the error was not identified? In this section you may have to recall elements/assessment data from your clinical encounter to contextualise your discussion.

Conclusion (500 words)

‘Reflect on and process new learning’

From your exploration, consider your future nursing practice. What did you learn? what would you do differently next time? What strategies will you use? How has this enhanced your clinical reasoning skills? This forms a reasonable portion of your paper and therefore you need to demonstrate deep reflection here. Saying ‘I would read more about…..’, etc is not sufficient. We really need to see the encounter as a whole. What have you learnt from this that has better enabled you to ‘think like a registered nurse’.

In addition to the information provided in the unit outline, a rubric is provided to guide your preparation of this assessment task. Word counts for each section are to be considered as a guideline.

Criterion High Distinction (HD)
Provides a contextualised overview of the clinical encounter that clearly highlights the points where the nominated clinical reasoning errors occur. 20% clearly and correctly identified two clinical reasoning errors with robust justification for their application to your clinical encounter.

You have demonstrated exceptional understanding of clinical reasoning errors.
Demonstrates an understanding of relevant clinical reasoning errors associated with the clinical encounter and its impact on patient outcomes. 30% Demonstrates an exceptional understanding of relevant clinical reasoning errors through clear succinct definitions, exploration and alignment to clinical encounter that highlights impact/s on patient outcomes.
Demonstrates the ability to reflect on own professional practice to inform future nursing practice as a beginning level practitioner 30%

 Demonstrates capacity in critical reflection through sound reasoning and inquiry.

Critical reflection has directly, clearly and logically informed requirements for future practice.
Uses appropriate scholarly literature to substantiate findings throughout. Uses Harvard referencing style 10% Accurately references all sources using the Harvard style. Outstanding use of appropriate academic literature that substantiates thinking and arguments that considers evidence-based practice relevant to the encounter.
Writes in a clear and concise academic style that is succinct, logical and coherent. 10% Communicates with a highly evolved academic writing style with strong evidence of planning.

The paper is exceptionally logical, insightful and balanced and is consistently expressed in a clear and fluent manner with minimal or no spelling/grammar errors.

Practice Portfolio of Evidence PART B: Clinical Encounter Analysis

Consider the patient situation/context

(@150 words)

Provide an overview of the encounter. What happened, how it occurred, what was it that alerted you to the fact that you needed to take action in the encounter.

 During the fourth week of my placement at the theatre operating room, particularly, in the recovery room, we had a 61-year-old male patient, 62 kg weight. Mr. P admitted for Transurethral resection of the prostate (TURP) and a prostate biopsy. Before surgery began, he had IV Midazolam 0.25 mg/kg in anesthetic bay, and during surgery he had IV Fentanyl 200 mcg, Propofol 100 mcg/kg/min IV, Rocuronium 40mg, Ondansetron 4mg, Paracetamol 1g, Parecoxib 40mg, and IV Hartmann’s Solution 500 ml. Shortly after surgery, Mr. P was transferred to the recovery room, and his observation was within acceptable limits. After a while, he removed his IV cannula by accident, prompting the anesthetist to be informed and another IV cannula inserted as the patient need it for postoperative analgesia. After 10 minutes we realized that the blood pressure of Mr. P was too low (hypotensive) 90/45 mmgH, tachycardia 120 b/m, tachypnoea 26 b/m, hypothermia 35.9 C, Spo2 93 %, and capillary refill > 3 Second. Also, he looked pale and eventually fainted. Immediately, the RN as informed while I checked his wound dressing FOR any sign of bleeding from the surgical site. From the examination, I noticed it was dry and the dressing was equally intact. I decided to do manual vital signs which were similar to the monitor.
Review (@150 words)

What key information was already available to you and how did this influence your thinking? (eg: handover, history, charts, result of test, assessments, medical orders

etc.).

Gather(@150 words)

What was the new information you gathered from additional assessment?

Dot points are fine for this section

Recall(@200 words)

Recall and apply your existing knowledge to the above situation to ensure you have a broad understanding of what is/may be occurring before proceeding with the rest of the cycle.

What was telling you that the encounter was presenting you with a problem that required resolution?

Use scholarly, evidence-based literature/clinical guidelines and/or policy/NSQHS materials to substantiate your discussion

 Review:

Pt. came from theatre room after surgery with:

· BP 125/85

· RR 19

· HR 65

· SPo2 97%

· Temp 37 C

· CR < 2 Second.

· Dressing pack in the site of surgery dry and intact with a cold pack on it.

· On O2 mask 2 litters.

· On PRN fentanyl 200 mcg IV.

· Worm to touch.

· The surgery period was one hour.

· Indwelling catheter (IDC) connected.
Relevant medications (where relevant): (not included in word count)

· IV Midazolam 16 mg

· Fentanyl 200 mcg

· Propofol 100 mcg/kg/min IV

· Rocuronium 40mg

· Ondansetron 4mg

· Paracetamol 1g

· Parecoxib 40mg

· IV Hartmann’s Solution 500 ml
Gather:

Objective data:

· BP 90/45 mmgH (hypotension).

· RR 26 b/m (tachypnoea).

· HR 120 b/m (tachycardia).

· Temp. 35.9 C (hypothermia).

· Capillary refill > 3 Second.

· Spo2 94%

· Pale in colour

· Urine output 25 to 30ml / h. (Oliguria)

· Surgical site dry and dressing intact.

· Tongue furrowed and mouth dry.

· BGL 4.1 mmol

· Anxious

· Skin condition (Poor skin turgor)

· Indwelling catheter (IDC) connected.

· Use of accessory muscles

· GCS 13

Subjective data:

· Pain score 3/10 stated by patients.

· Fainting

· Dizzy

· Restlessness

· Thirst.

· Sore throat

· Nothing by mouth for 14 hours.
Recall:

In the case of Mr. P., Anaesthetic medications, which make the patient sleep during the procedure, can cause a significant drop in blood pressure when the patient coming off of the drugs (Dinges et al. 2019). Despite the effectiveness of the drug in reduction of pain, it can result in adverse side effects including dizziness, fainting, feeling cold and headache (Dinges et al. 2019). Tachycardia is a compensatory mechanism for hypotension (Elliott 2017). Hypotension might be due to decrease in fluid volume in the body (Jarvis 2019). In the case of Patient P, there was a decline in the overall body temperature, and this was followed by fainting and reduction in blood pressure (Mossello et al. 2015). Poor skin turgor, which is slowly returned back to its normal situation when pinched, and the decreased in urine output indicates dehydration (Jarvis 2019). In addition, fainting and dizziness, in this case, might be caused by inadequate blood supply to the brain, which is a sign of serious condition, it is due to deficient fluid volume in the body (Jarvis 2019). Furthermore, capillary refill >3 seconds indicates dehydration and impaired peripheral perfusion due to vasoconstriction and also might be a sign of shock (Jarvis 2019). Vasoconstriction in this situation response to low blood circulation and evidenced by cool extremities and also can be caused by hypothermia (Shinozaki et al. 2019). Finally, tachypnoea in this case might be caused by the anxiety and the body organs and tissues not getting enough oxygen (Park & Khattar 2019).
Process Information(@400 words)

Interpret, relate and infer from the information gathered to demonstrate an overall understanding of the clinical encounter to determine the two main nursing problems.

Predict (@100 words)

What could/would have happened in your encounter if you were to have taken NO action and why?

Use scholarly, evidence-based literature/clinical guidelines and/or policy/NSQHS materials to substantiate your discussion

 Interpret, Relate and Infer:

The assessment of Mr. P indicates the following parameters after surgery 90/45 mmgH, tachycardia 120 b/m, tachypnoea 25 b/m, hypothermia 35.9 C. The patient shows a drop-in blood pressure and a decline in body temperature. The heart resting rate was 120 beats per minute. Based on the presenting results, there is a need to conduct a comprehensive analysis to identify the normality of the data. The normal blood pressure rate is 120/80mmHg and up to 139/89mmHg (Jarvis 2019). However, in the case of Mr. P, he presented with a BP of 90/45 mmgH which was way below the normal rate. That was an indicator of an abnormality. As for the tachycardia, a rate of 60 to 100 beats per minute can be considered as normal (Estes 2013). However, in the case of Mr. P, he was having a rate of 120 b/m which was slightly beyond the normal beats for an adult. In addition, a body temperature of 37.0 C can be considered normal (Jarvis 2019). Though, following the assessment of Mr. P, he presented with a body temperature of 35.9 C which was a decline. Indeed, this was depicted by the fact that he felt cold and had to be provided with a warm blanket to help raise his body temperature. Finally, Mr. P depicted abnormality in the breathing rates as evidenced by an increase to 26 breaths per minute, while the normal range is 12 to 20 breaths per minute (Estes 2013). Based on the analysis of the data, it is evident that the patient had a problem hence the need to come up with an intervention. Indeed, the patient was presenting with a medical problem since the initial assessment presented figures out of the usual range. The clinical encounter presented, including a decline in body temperature, low blood pressure, increase in beats and breaths per minute confirm the state of the patient. The information is essential since it offers insight into the condition of the patient. The presenting nursing problems, fainting could be largely due to the reduced blood pressure as the patient lacked adequate oxygen supply for normal body functioning (Clarke et al. 2015). Mainly it can be attributed to inadequate breathing as shown by extreme values. In addition, the patient experienced hypothermia prompting the nursing care team to provide a blanket. The data taken shows a reduction in the body temperature and this could be a confirmation of the presenting reduced body temperature.
Predict:

If no action been taken, it would be an increased risk of stroke, cardiac arrest or death. Tachycardia can result in a complication and the patient would have been at risk in the event that the issue was not addressed (Elliott 2017). Further, the drop in the patient’s blood pressure could have exposed Mr. P to damage of brain because of lack adequate supply of oxygen. Adequate oxygen supply is essential in carrying out normal physiological functions (Park & Khattar 2019). However, Mr. P was at risk of losing on that and it could have possibly led to further complications that are life-threatening. Oliguria which is < 30 ml/h of urine may lead to acute kidney injury if left untreated (Estes 2013).
Identify the Problem/s List in order of priority two key nursing problems that required resolution (not included in word count)
Problem 1 Deficient fluid volume may be related to intraoperative fluid loss, hemorrhage, or preoperative and postoperative nothing by mouth status, evidenced by cold peripheral in touch, oliguria, low blood pressure, poor skin turgor, and CR > 3 seconds.
Problem 2 Ineffective breathing patterns may be related to increased work of breathing, primary medical problem, and fatigue evidenced by low oxygen saturation, and patient looking pale in colour, tachypnoea, use of accessory muscles, restlessness and change in level of consciousness.
Establish Goals & Take Action
(@125 words for each rationale section). Other sections not included in word count

Work through the two nursing problems identified and establish one goal and then rationalise with scholarly, evidence-based literature/clinical guidelines and/or policy/NSQHS materials the related nursing actions you did/would undertake.
Problem 1 Goal Related nursing actions Rationale
Deficient fluid volume may be related to intraoperative fluid loss, hemorrhage, or preoperative and postoperative nothing by mouth status, evidenced by cold peripheral in touch, oliguria, low blood pressure, poor skin turgor, dry mouth, thirst, and CR > 3 seconds. Maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, prompt capillary refill, stable vital signs, good skin turgor, and moist mucous membranes within 30 minutes. Placed the patient in a position that allowed the legs to be above the heart

Assess HR and BP.

Assess level of consciousness.

Assess RR, breath sounds, and rhythm.

chest pain assessment.

Palpate peripheral pulses; note capillary refill and skin color, turgor, and temperature.

Monitor urinary output and specific gravity.

Administer IV fluids, as ordered, such as:

Isotonic solutions such as 0.9% NaCl (normal saline) and 5% dextrose/water

.

 to increases venous return and promotes diuresis, and maintain blood flow to vital organs (Meng’anyi, Omondi & Muiva 2017).

significantly reduced BP and compensatory tachycardia in response to decreased cardiac output (Gulanick & Myers 2016).

Older patients are especially susceptible to reduced perfusion. Hypoxia and reduced cerebral perfusion are reflected in restlessness, irritability, and difficulty concentrating. (Meng’anyi, Omondi & Muiva 2017).

Rapid, shallow breathing is characteristic of reduced cardiac output (Gulanick & Myers 2016).

The decrease in cardiac output can reduce myocardial perfusion, causing chest pain (Gulanick & Myers 2016).

Pale, clammy, cold skin is secondary to the compensatory rise in sympathetic nervous system stimulation and low cardiac output and oxygen desaturation (Estes 2013).

A decreased urinary output may indicate insufficient renal perfusion or hypovolemia. The renal system compensates for low blood pressure by retaining water. Oliguria is a typical sign of reduced renal perfusion (Meng’anyi, Omondi & Muiva 2017).

IVF therapy provides rapid circulatory enhancement, even though the advantage may be temporary because of increased renal clearance (Gulanick & Myers 2016).
Problem 2 Goal Related nursing actions Rationale
Ineffective breathing patterns may be related to increased work of breathing, primary medical problem, and fatigue evidenced by low oxygen saturation, and patient looking pale in colour, tachypnoea, use of accessory muscles, restlessness and change in level of consciousness. The patient maintains an effective breathing pattern, as evidenced by relaxed breathing at a normal rate and depth and absence of dyspnoea. Blood gas results within patient’s normal parameters. The patient verbalizes the ability to breathe comfortably without the sensation of dyspnoea within 30 minutes. Use pulse oximetry to check oxygen saturation and maintain Spo2 > 94%.

Assess and record respiratory rate

Assess for the use of accessory muscles.

Observe the level of consciousness.

Assess ABG levels

Assess for the sensation of dyspnoea

Provide reassurance by remaining with the patient during acute incidents of respiratory distress.

 Pulse oximetry is a helpful instrument to detect changes in oxygenation (Doenges, Moorhouse & Murr 2014).

alteration in breathing pattern detects early signs of respiratory compromise (Gulanick & Myers 2016).

The work of breathing increases greatly as lung compliance decreases. Moving air in and out of the lungs becomes increasingly more difficult, and passive ventilation is no longer adequate to meet oxygenation needs (Doenges, Moorhouse & Murr 2014).

Agitation, irritability, and confusion can be primary indicators of inadequate oxygen to the brain (Estes 2013).

To monitor ventilation and oxygenation status (Meng’anyi, Omondi & Muiva 2017).

The sensation of dyspnoea is linked with hypoxia and might cause anxiety, which leads to increased oxygen demand and may further affect the pattern of breathing (Jarvis 2019).

Anxiety can be reduced in the presence of a trusted person, thereby reducing oxygen requirements (Doenges, Moorhouse & Murr 2014).
Evaluate outcomes (@100 words)

Evaluate the outcomes of your clinical encounter including the effectiveness of the care provided with supporting evidence-based literature

 The clinical encounter has provided fundamental insight regarding the entire process of managing a critical situation. As a nurse, there is a need to prepare for any encounter one is likely to experience as evidenced in the case of Mr. P. The clinical encounter was appropriate in informing how to address situations and bring issues to control. The care provided to the patient was effective and essential in helping manage the patient. The care was supported by literature further highlighting the fundamental role of evidence-based practice in improving the care and management of patients. The care delivered was appropriate in enabling the nurses avert the life-threatening condition of the patient.

References:

Clarke, H, Poon, M, Weinrib, A, Katznelson, R, Wentlandt, K & Katz, J 2015, ‘Preventive analgesia and novel strategies for the prevention of chronic post-surgical pain’, Drugs, vol. 75, no. 4, pp. 339-351.

Dinges, H-C, Otto, S, Stay, DK, Bäumlein, S, Waldmann, S, Kranke, P, Wulf, HF & Eberhart, LH 2019, ‘Side effect rates of opioids in equianalgesic doses via intravenous patient-controlled analgesia: a systematic review and network meta-analysis’, Anesthesia & Analgesia, vol. 129, no. 4, pp. 1153-1162.

Doenges, ME, Moorhouse, MF & Murr, AC 2014, Nursing care plans: guidelines for individualizing client care across the life span, FA Davis.

Elliott, P 2017, Defining tachycardia-induced cardiomyopathy: life in the fast lane, Journal of the American College of Cardiology, 0735-1097.

Estes, MEZ 2013, Health assessment and physical examination, Cengage Learning.

Gulanick, M & Myers, JL 2016, Nursing Care Plans-E-Book: Diagnoses, Interventions, and Outcomes, Elsevier Health Sciences.

Jarvis, C 2019, Physical Examination and Health Assessment E-Book, Elsevier Health Sciences.

Meng’anyi, LW, Omondi, LA & Muiva, MN 2017, ‘Assessment of nurses interventions in the Management of Clinical Alarms in the critical care unit, Kenyatta National Hospital, a cross sectional study’, BMC nursing, vol. 16, no. 1, p. 41.

Mossello, E, Pieraccioli, M, Nesti, N, Bulgaresi, M, Lorenzi, C, Caleri, V, Tonon, E, Cavallini, MC, Baroncini, C & Di Bari, M 2015, ‘Effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs’, JAMA internal medicine, vol. 175, no. 4, pp. 578-585.

Park, SB & Khattar, D 2019, ‘Tachypnea’, in StatPearls [Internet], StatPearls Publishing.

Shinozaki, K, Capilupi, MJ, Saeki, K, Hirahara, H, Horie, K, Kobayashi, N, Weisner, S, Kim, J, Lampe, JW & Becker, LB 2019, ‘Low temperature increases capillary blood refill time following mechanical fingertip compression of healthy volunteers: prospective cohort study’, Journal of clinical monitoring and computing, vol. 33, no. 2, pp. 259-267.
 
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