NUR 4153-Deliverable 3-Clinical Reasoning Appropriate for the Situation
According to Dr. Campbell-O’Dell, during the live class, a hypothesis is a plan of action. When creating an idea, we use the four modes of inquiry: empirical, ethical, aesthetic, and sociopolitical. By implementing these modes, it helps to develop the integration of the different methods of investigation. In this scenario, the nurse’s specific plan of action follows those four modes of inquiry (Doane & Varcoe, 2014). Hire our assignment writing services in case your assignment is devastating you.
Empirical
In this scenario, empirical data was presented upon observation of an 82- year old elderly patient with acute confusion and labored breathing patient has been a two-pack-a-day smoker for 58 years and is a type 1 diabetic. The neighbor reports the Patient had an episode of nausea and vomiting earlier in the week, and tonight vomited up fresh blood and became dizzy. The Patient appears unkempt, with matted hair, food-stained clothing, and a heavy cigarette smell. The assessment data is as follows: blood pressure 178/98, heart rate 84 beats per minute, oxygen saturation 84, temperature 101.8 degrees Fahrenheit, and hyperactive bowel sounds in all four quadrants. The Patient also has an open wound on the bottom of the right foot. Based on the Patient’s assessment data, the hypothesis could be that the patient has chronic bronchitis, as evidenced by fresh blood in vomit and low oxygen saturation with a history of smoking. Possible bronchitis and smoking have contributed to the severe inflammation of the airway and blood in vomit due to punctured capillaries in the lung; the forced breathing results from the low O2 saturation. This Patient shows evidence of failure to maintain/follow the medication regime, resulting in uncontrolled blood pressure and diabetes, leading to peripheral neuropathy, contributing to the wound on the right foot.
Minor injuries usually go unnoticed until they develop into more severe injuries due to the damaged nerve endings caused by type 1 diabetes (Donges et al., 2019).
Based on these findings’ Patient would need a chest x-ray, labs drawn, ABGs, and blood cultures to rule out or confirm sepsis and blood glucose levels checked and monitored as this could contribute to the Patient’s confusion. Patient would need supplemental O2 to increase O2 sats to a safe level; consult with WOC to evaluate an open wound on the right foot’s bottom. Admission due to acute confusion, ineffective breathing pattern, self-care deficit/failure to thrive, and medication regime noncompliance. Ethical
82- year elderly Patient arrives at the ER with acute confusion, labored breathing -O2 sat in the low 80s, and an open wound on the bottom of the right foot, dirty with the heavy odor of smoke. The ethical mode of inquiry is that the staff is violating the code of conduct in the emergency room (ER) from observation from the case study that the Patient is having a heavy smell of smoke, which indicates that the Patient might be smoking in the ER and yet no one asked her to stop smoking in the hospital premises. As nurses, we must use a humanistic approach when faced with challenges to meet patients’ needs. In this scenario, reaching out to next of kin or locating a health care surrogate to aid in assistance best for the Patient. Ethical conflicts also may arise when there are financial barriers between our view and the best possible medical care; patients’ chart shows that Medicaid only insinuates patients may have issues paying for treatment. Placing physicians in the ethical dilemmas of their professional and ethical obligations; therefore, working with a social worker to find the best health coverage for her socioeconomic status is essential.
Sociopolitical
The 82-year-old female who lives alone arrives at the emergency department and appears frail, with labored breathing, elevated BP, and acute confusion, with obvious signs of failure to thrive. The patient’s hair is matted, and she is clothed in a dirty, food-stained robe with a heavy odor of cigarettes’ The husband was recent admission to long-term care; the Patient has no help at home with respect. Based on the sociopolitical mode of inquiry, the hypothesis could be that the Patient has a poor income source as the provider points out the Patient only has Medicaid as health insurance ( a government-supported program that supports individuals’ health care expenses of individuals with poor source of income.) Also, given in the data, the husband has Alzheimer’s and has been admitted to LTC. Indicating that she no longer has his payment, which reduces the overall income, making it very low and unable to meet expenses. It would be favorable to the Patient to have a social worker evaluate her Situation following treatment and consult with the physician to find the suitable options available to her position. These options could include assistance with financial needs for adequate insurance coverage through government programs she may qualify for, home care, or assisted living programs to help with the self-care deficit and medication regime. Recommendation for consults in the morning after treatment is initiated and continue to monitor.
NUR 4153-Deliverable 3-Clinical Reasoning Appropriate for the Situation
Aesthetic
An 82-year-old elderly patient arrives at the Emergency Department by car- via a neighbor. The neighbor reported that she had been nauseous and vomiting for a week- possibly due to stress related to her husband’s admission to an LTC facility for Alzheimer’s. The Patient appears unkempt, and unable to obtain much history from the Patient; she is experiencing acute confusion. The neighbor also stated that the Patient has not been eating much and experienced bloody vomit and dizziness. The Patient smokes two- packs of cigarettes per day and has an open wound on the bottom of their right foot. The hypothesis for this mode of inquiry wound falls in line with the ethical way of inquiry: to research if the Patient has any health care surrogates, next of kin, question about advanced directives, and or living will. Will admit the patient and continue to monitor them.
Most Relevant Hypothesis
The most appropriate hypothesis that aligns with the scenario is the hypothesis made from the empirical mode. The Patient presents in the ER, where the healthcare professionals’ priority is to provide necessary medical interventions to improve their condition. The Patient suffers from chronic bronchitis, as evidenced by blood in vomit, labored breathing, high blood pressure, smoking, and peripheral neuropathy apparent by the wound on the right foot. The Patient appears to be declining and needs immediate treatment and interventions. Administer Bronchodilator to reduce symptoms and increase the Patient’s O2 saturation. Apply O2- improved O2 sats- keep sats above 90. The patients’ confusion could be related to possible Bronchitis, UTI, dehydration, and hypoglycemia (type 1 diabetic). The Patient will need diagnostic tests and lab work orders, including a BMP and a urine sample. Also, a demand for PIV to start her on IV maintenance fluid- for possible dehydration needs (Donges et al., 2019). The patient’s BP is high, with the possibility of noncompliance with the medication regime for a few days by now- the Patient cannot let us know the last time taken. It could contribute to her elevated blood pressure readings. The Patient did have a Lopressor bottle brought in by a neighbor, and the bottle was empty.
Accu checks to assess blood glucose levels, treat them appropriately, and continue to monitor them. Debridement of a large wound on the bottom of the right foot, then dressed follow-up with WOC in am for more in-depth orders – possible decreased circulation due to type 1 diabetes and smoking.
Evaluation plan
To evaluate these hypotheses’ outcomes, the nurse would reassess the Patient’s respiratory status, check for the inflammation level, and administer bronchodilators. Monitor effectiveness by using a bronchoscope and pulse oximeter; the level of oxygen saturation should improve following a bronchodilator. The care provider will also check for the level of blood glucose and then administer insulin. Blood glucose and cognitive status will monitor the effectiveness of insulin. Peripheral neuropathy: – evaluating the presence of sensation in the lower part of the right and left leg. In this, the care provider will ask the patient to move her left/right leg/foot and pinch some parts to check for the presence/loss of sensation. To evaluate the efficacy of wound management interventions, observe the wound for signs of healing/infection. Monitor status, recheck all vitals, and pay close attention to
outcomes. Document improved vitals and ones that continue to decline. The provider will immediately modify the care plan if the signs of infection are present in the wound (Donges et al., 2019). BP needs to be brought down and controlled. The Patient has a self-care deficit apparent by their current physical state; follow up with a social worker tomorrow to address socioeconomic needs as the chart states only Medicaid for insurance, which indicates low economic status and need for assistance. Overall plan- The patient needs to be admitted with continuous monitoring and update the care plan following doctor evaluation at the bedside. The goal is to get her back to baseline mentation, raise O2 sats, lower BP, and continue wound care and healing. Evaluation of the patient’s ability to go home or go to a transitional care unit to assist with a self-care deficit (Donges et al., 2019).
References
Doane, G.H., Varcoe, C. (2014) How to Nurse: Relational Inquiry with Individuals and Families in Shifting Contexts. [Bookshelf Ambassadored]. https://ambassadored.vitalsource.com/#/books/9781469872209/
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing Care Plans: Guidelines for individualizing-client care across the life -span: Vol. 10th edition
Pagana, K. D., & Pagana, T. J. (2016). Mosby’s Manual of Diagnostic and Laboratory Tests (Third ed.). Elsevier.
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Question 
NUR 4153-Deliverable 3-Clinical Reasoning Appropriate for the Situation
Integrate modes of inquiry to generate and evaluate hypotheses in the context of clinical reasoning.
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. Usually, it 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 to 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 apparently 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 four quadrants
An open wound on the bottom of the 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.