The Dynamic Process of Clinical Judgment
You are a student in the last term of a BSN Program. You are preparing for an end-of-term exam. To help you prepare, your instructor developed three real-world clinical scenarios to provide opportunities for you to apply clinical reasoning and clinical judgment. The instructor stated, You received reports on these clients. Decide which one you need to see first and then make appropriate nursing decisions based on relevant information to promote positive client outcomes.
The three scenarios include:
1) JR is a 55- year-old male admitted 8 hours prior for 24-hour hold to evaluate for possible myocardial infarction. Serial Troponins within normal range and 12 lead ECG indicated evidence of prior right anterior wall myocardial damage.
2) EH is a 40-year-old female admitted within the past hour with acute onset severe right upper quadrant pain and vomiting for the past 36 hours. Waiting on labs, ECG monitoring showing occasional premature ventricular contracts (PVCs).
3) BW is a 21-year-old male athlete admitted yesterday with a fever of 103 and a diagnosis of influenza. He rested well overnight. Morning chest x-ray revealed mild infiltrates in the left lower lobe.
Record your answers to these statements.
Rank the three scenarios provided in order of priority related to which client you will assess first, second and third.
Defend your selection for the three ranked scenarios.
Review the data below for the priority client to determine what to assess first.
Chest X-ray no abnormalities noted
Abdominal X-ray :diffuse gas throughout the small intestine
Hyperactive bowel sounds in all 4 quadrants and abdomen painful to touch
Pain level 10/10Sodium (Na+) 147 mmol/L
Potassium (K+) 2.9 mmol/L
Chloride (Cl-) 100 mmol/L
Magnesium (Mg2+) 1.4 mg/dL
Calcium (Ca2+) 9.2 mg/dL
Phosphorus (P+) 2.3 mg/dL
Glucose 188 mg/dL
Serum albumin 3.0 g/dL
Amylase 185 unit/L
Serum Creatinine 0.5 mg/dL
BUN 15 mg/dL
Alkaline Phos. 155 unit/L â€¢ Protein 8.6 g/dL Bilirubin 3.5 mg/dL
Formulate three hypotheses based on cues provided
Select the priority hypothesis
Defend your selection
Describe an evaluation plan for the priority hypothesis based on expected client outcomes
Describe the next steps in the clinical judgment model including:
Actions if satisfied with client outcomes
Actions if not satisfied with client outcomes
We must rank the clients. Defend the selections using information from supporting literature stating why we chose them. Review the data given above for the chosen client first. Third, we must form 3 hypotheses based on internal and external queues in the scenario and data. Select the priority hypothesis (what we will focus on). Describe an evaluation plan based on the expected outcome. How we will evaluate the plan – Goal, method of data collection, data analysis, frequency of collection. Last step – were actions satisfied or not and what to do about it.
The Dynamic Process of Clinical Judgment
The priority order for seeing the patients would be 2, 3, 1. The second scenario is the most critical, thus prioritizing it. The patient is in acute pain is vomiting regularly. Hence, her condition warrants close monitoring and further collection of clinical data and subjective information. Next, one should attend to BW. He has a high fever and a positive influenza diagnosis. Given his age and physical condition, he is slightly more resilient than EH and can wait a little longer before receiving nursing interventions. Nonetheless, the nurse should still meet him and discuss a care plan after the physician prescribes medication. Meeting the patient will also help assess if he has developed any new symptoms. Finally, the nurse should attend to scenario 1. While JR potentially has a severe condition (myocardial infarction), he has the least demand for urgent nursing care. He is on a twenty-four-hour observation hold, for which eight hours have already gone by without any reported exacerbation. Therefore, the nurse will meet him accompanied by a physician to record data on his heart function and obtain samples for the next serial troponin test. Hence, his situation requires urgent nursing care the least.
After reviewing the patient’s diagnostic test results, the nurse must determine what to assess first. The data reveals that the patient is in severe pain (10/10 on the measurement scale). Her abdomen is also tender to touch. Therefore, one should start with pain assessment. The nurse should determine if the pain has reduced since the last measurement. One should also check if any of the clinicians or other nurses had provided any intervention to alleviate the pain. If not, the nurse should consult the physician to determine the appropriate action. Next, the nurse should focus on the abdominal sounds and gas. While the two may be related to the pain, their changes could be significant. The patient could have passed the gas, relieving some of the tension in their abdomen. Such a development could also be critical to the physician. Finally, the nurse should focus on the blood work. The test results show abnormal ion levels for most minerals, indicating impaired nutrient absorption and movement in the bloodstream. Thus, the nurse should be ready to participate in a parenteral nutrition line placement if the physician deems it necessary (Itzhaki & Singer, 2020). The patient’s blood glucose is also high (188mg/dL), indicating prediabetes (Mayo Clinic, 2020). Hence, it may be necessary to engage in blood sugar control interventions after addressing the acute symptoms. Finally, the bilirubin level of 3.5 mg/dL is almost three times higher than the normal range (1.2 mg/dL) (Wehbi, 2019). Bilirubin is a catabolic compound that is crucial to clearing waste products in the liver. Hence, the high levels signify a problem with liver function. Thus, the nurse should beware of taking any actions that might further jeopardize the patient’s liver status.
The three hypotheses, in order of priority, are:
- The patient’s pain level will impede her participation in the care process
- The patient’s diffuse gas will pass eventually, resulting in relief of abdominal discomfort
- The patients’ rampant vomiting will result in dehydration.
Pain is an essential consideration in providing nursing care. The patient’s recorded 10/10 pain level suggests that the patient is delirious and cannot actively discuss a care plan (Shaikh, 2021). Hence, the nurse must consider the most beneficial interventions to the health outcomes without the patient’s preferential contribution. The clinician may also recommend a sedative, meaning that the patient will not be able to provide her input to the care process. However, the caregiver should monitor the pain levels regularly when the patient is conscious. A decline in her pain experience could be a vital sign of recovery, encouraging further clinical action. It will also help the nurse determine the point at which to engage the patient in developing the next steps of the care process.
The first step of the evaluation plan is gathering more data to support the hypothesis. For instance, the nurse should observe the patient’s abdomen to determine swollen or red sections. Such an observation will help monitor the pain more objectively, especially if the physician chooses to prescribe a sedative. While only a conscious patient can provide reliable data on their pain experience, changes in swellings and tenderness could suggest variations in potential pain for an unconscious individual.
Next, the nurse should review the ECG data. Initially, the patient had occasional premature ventricular contractions. Thus, it will be vital to evaluate how her heart functions after sedation. Furthermore, regular monitoring of the ECG output will inform the nursing and medical team if the initial cardiac anomalies constitute a significant concern or were related to the pain experience or mineral and protein imbalance in the blood.
If the patient undergoes a successful treatment plan, the nurse must engage her in an education session to discuss health maintenance. One should advise her on the safe physical activities she can perform. Additionally, the nurse should enlighten the patient on pain and swelling awareness to allow early and timely alleviation of any post-treatment complications. One should also engage the patient in a discussion on lifestyle adjustment. Such a critical gastro-intestinal health issue may require changes in dietary patterns and activity levels to avoid recurrence. Therefore, the nurse should collaborate with the patient and her family in creating a practical lifestyle that aligns with her cultural preferences and daily routines. In so doing, the nurse will have successfully empowered the patient to maintain her well-being.
Itzhaki, M. H., & Singer, P. (2020). Advances in Medical Nutrition Therapy: Parenteral Nutrition. Nutrients, 12(3), 717; https://doi.org/10.3390/nu12030717
Mayo Clinic. (2020, Oct. 30). Diabetes. https://www.mayoclinic.org/diseases-conditions/diabetes/diagnosis-treatment/drc-20371451
Shaikh, J. (2021, Jun. 3). What Is a 10 on the Pain Scale? https://www.medicinenet.com/what_is_a_10_on_the_pain_scale/article.htm
Wehbi, M. (2019, Nov. 18). Bilirubin. https://emedicine.medscape.com/article/2074068-overview