NUR 4153-Deliverable 7-The Dynamic Process of Clinical Judgement

NUR 4153-Deliverable 7-The Dynamic Process of Clinical Judgement

Rank the three scenarios provided in order of priority related to which client you will assess first, second, and third.

The first patient is JR, a 55- 55-year-old male admitted 8 hours prior for a 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. The second patient is EH, a 40-year-old female admitted within the past hour with acute onset severe right upper quadrant pain and vomiting for 36 hours. Waiting on labs, ECG monitoring showing occasional premature ventricular contracts (PVCs). The third patient is BW, 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.

I will assess the EH, the 40-year-old female first, and BW, the 21-year-old male second. I will assess JR, the 55- year-old male, after assessing the first two patients.

Defend your selection for the three ranked scenarios.

 EH is in severe pain, and she has been vomiting for 36 hours, which is a high risk for electrolyte imbalance and severe dehydration. She is also showing symptoms of possible gallbladder inflammation/Acute Cholecystitis, which is an emergency and requires surgery. She needs immediate attention for pain management, electrolyte replacement, cardiac monitoring, and further tests to determine the root cause of her symptoms.

I will assess the BW, the 21-year-old male second. He is diagnosed with influenza and running a fever, and a chest x-ray revealed mild infiltrates in the left lower lobe. Infiltrates in the lung indicate the possibility of lower respiratory tract illness and secondary infection that can lead to serious complications and mortality (Schub et al., 2018). A further chest x-ray should be ordered to rule out pneumonia. He needs antipyretics to reduce the fever. He also may need to be started on antibiotics and antivirals if indicated.

I will assess JR, the 55- 55-year-old male, last because he is the most stable patient of all three. JR’s troponin levels are normal. Usually, an elevated troponin level would cause concern as raised troponin levels indicate myocardial infarction. Still, since his levels are normal, it is not a serious issue (American Board of Emergency Medicine, 2021). The 12 lead ECG indicated evidence of prior right anterior wall myocardial damage; however, that is not a priority concern at this time.

Review the data below for the priority client to determine what to assess first.

 I will assess EH and address the acute pain she is experiencing first. EH reported a very high level of pain, 10/10. It is imperative to make sure the patient is comfortable and the pain is managed before progressing to other assessments. After EH’s pain is controlled, I will assess the abdominal X-ray results that show diffuse gas throughout the small intestine. I will also assess the hyperactive bowel sounds EH has in all four quadrants and abdomen that are painful to touch. Priority labs that need immediate attention are her Potassium levels (2.9 mmol/L), indicating hypokalemia. EH glucose is high (188 mg/dL). She also has high amylase (185 unit/L), high alkaline Phosphate (155 unit/L), high protein (8.6 g/dL), and high bilirubin (3.5 mg/dL) levels (American Board of Emergency Medicine, 2021).

Formulate three hypotheses based on the cues provided.

 Based on the cues provided, I have formulated three hypotheses. The first hypothesis is to contact the physician immediately to get an order for pain medication to manage acute pain. The second hypothesis is to contact the physician to get an order for potassium replacement to bring the patient’s potassium level back to normal range. The third hypothesis is to arrange imaging and diagnostic tests to confirm precise organ inflammation to start prompt treatment and reduce complications.

Contact the physician immediately to get an order for pain medication to manage acute pain.

EH reported acute onset of severe right upper quadrant pain. The best way to determine the pain level is the patient’s statement. EH’s pain level is ten based on a 1-10 scale. She is in intense pain. Patients suffering from acute pain have a human right to pain management (Cohen et al., 2021). According to the National Academies of Sciences, Engineering, and Medicine (2019), pain causes severe physical and emotional distress, harms the quality of life, and affects sleep, physical functioning, and mental health. Inadequate pain management can lead to increased morbidity, delayed recovery, extended opioid use during and after hospitalization, and increased cost.

It is challenging to communicate with a patient who is in intense pain and unable to comprehend questions or provide answers, which creates difficulty in assessing the patient’s symptoms. Furthermore, suboptimal pain management leads to an increased risk of progression to chronic pain later. It is a fundamental duty of a nurse to alleviate the suffering of patients with severe acute pain. Based on this hypothesis, I will call the physician immediately to order a strong pain medication and recommend an opioid analgesic.

NUR 4153-Deliverable 7-The Dynamic Process of Clinical Judgement

Contact the physician to get an order for potassium replacement to bring the patient’s potassium level back to normal range.

Potassium creates energy for cellular function throughout the human body’s cardiovascular, skeletal, and nervous systems. The normal serum potassium range is 3.5 to 4.5 mEq/L. Severe hypokalemia can lead to membrane hyperpolarization, inducing life-threatening circumstances, including dysrhythmias and muscle weakness, leading to respiratory or cardiac failure. EH’s Potassium level is 2.9 mmol/L, which is critically low and can lead to serious complications. Her ECG is showing occasional premature ventricular contracts (PVCs), which can be a result of severe hypokalemia (Conley et al., 2021). Based on these external and internal cues, I would contact the provider to obtain an order for electrolyte replacement and start intravenous potassium as soon as possible (Conley et al., 2021). I will continue cardiac monitoring for EH and monitor for any worsening symptoms.

Arrange imaging and diagnostic tests to confirm precise organ inflammation to start prompt treatment and reduce complications.

EH presented with acute onset severe right upper quadrant pain and vomiting for the past 36 hours. She also has hyperactive bowel sounds in all four quadrants, and her abdomen is painful to touch. The signs and symptoms indicate the possibility of Acute cholecystitis. Severe right upper quadrant pain with nausea, vomiting, and fever is most common in acute cholecystitis. A classic sign of cholecystitis is the Murph’s sign, which is right upper abdominal pain with deep palpation (Powell, 2016).

Other clinical findings reveal elevated liver enzymes. EH’s Amylase is 185 unit/L, Alkaline Phosphate is 155 unit/L, and Bilirubin is 3.5 mg/dL., which are all very high. High bilirubin levels indicate a build-up of bile in the gallbladder. Liver enzymes and elevated alkaline phosphatase (ALP) indicate severe cases of gallbladder inflammation. Acute cholecystitis is an emergency that originates from gallbladder inflammation. Acute cholecystitis can be diagnosed by imaging tests such as abdominal ultrasound, MRI, and CT scan (Powell, 2016). Early diagnosis and treatment can help reduce rates of morbidity, mortality, and expenses.

Select the priority hypothesis and defend your selection.

The priority hypothesis is to contact the physician immediately to get an order for pain medication to manage acute pain. EH’s rating of pain is 10/10, indicating that she is experiencing extreme pain. A patient who is in intense pain cannot communicate and cannot comprehend questions or provide answers, which creates difficulty in assessing the patient’s symptoms.

Leaving a patient with such extreme pain is also inhumane. One of the ethical principles stated by the American Nurses Association (2015) is goodwill, which refers to the nurse’s duty to provide a balance of benefits versus harm to the patient. To let a patient continue suffering extreme pain and not provide relief breaks the nurse’s duty of beneficence.

Describe an evaluation plan for the priority hypothesis based on expected client outcomes and the next steps in the clinical judgment model.

The expected client outcome for pain management is relief from pain or decreased pain, improved vital signs, and improved mood/behavior. The best way to determine the pain level of a patient is the patient’s statement. I will follow up with EH within thirty minutes of administering the pain medication to determine whether the intervention helped reduce her pain to an acceptable level.

If the pain medication improved EH’s pain to an acceptable level., I will begin working on potassium replacement to bring the patient’s potassium level back to a normal range and initiate appropriate imaging and diagnostic tests to confirm her medical diagnosis for further treatment.

If the pain medication did not reduce EH’s pain to an acceptable level., I will notify the physician and arrange for additional dosing of pain medication or try another pain medication. I will also offer non-pharmacologic pain interventions such as ice packs and a quiet room.

Following the clinical judgment model, I will continue to follow up and take appropriate interventions until the patient reaches a satisfactory comfort level and reduces pain.

References

 American Board of Emergency Medicine (2021). Normal Laboratory Values for Examinations. Retrieved from https://www.abem.org/public/docs/default-source/default-document- library/laboratory-normal-values.pdf?sfvrsn=1b54c9f4_8

American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. American Nurses Association.

Cohen, B., Ruth, L., Preuss, C. (2021). Opioid Analgesics. StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459161/

Conley, R., Rich, R. L., & Montero, J. (2021). Safety of a Nurse-Driven Standardized Potassium Replacement Protocol in Critically Ill Patients with Renal Insufficiency. Critical Care Nurse, 41(2), e10–e16. https://doi.org/10.4037/ccn2021549

Interpreting Common Lab Values. (2016). ISNA Bulletin, 43(1), 8–11.

National Academies of Sciences, Engineering, and Medicine (2019). Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK554977/

Powell, L. (2016). Acute Cholecystitis: Diagnosis, Management, and Complications. Retrieved from https://eds.b.ebscohost.com/eds/ebookviewer/ebook/bmxlYmtfXzEzNTY3MTNfX0FO0?sid=6ade90e7-3e92-49f2-8c32-18c0564efe64@sessionmgr101&vid=2&format=EB&rid=1

Schub, T. & Lawrence, P. (2018). Influenza: An Overview. Retrieved from https://eds.a.ebscohost.com/eds/pdfviewer/pdfviewer?vid=6&sid=65cb638c-1b81-445a-813b-f08d51a81444%40sdc-v-sessmgr01

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NUR 4153-Deliverable 7-The Dynamic Process of Clinical Judgement

Evaluate factors integral to clinical reasoning.

Explain the impact of relational inquiry when recognizing and analyzing cues to action in the process of clinical reasoning. Integrate modes of inquiry to generate and evaluate hypotheses in the context of clinical reasoning.

Determine appropriate responses when integrating situated cognition into clinical reasoning.

Modify clinical judgment within an iterative, outcome-based cycle of clinical reasoning and client needs.

Scenario

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:

Patient one – JR is a 55-year-old male admitted 8 hours prior for the 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.

Patient two – 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).

Patient three  –  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.

Instructions

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 four quadrants and abdomen painful to touch

Pain level 10/10

Sodium (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

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