Nursing Clinical Judgment
Relational inquiry is a well-thought-out, skilled activity that calls for relational orientation, a solid knowledge basis, sophisticated inquiry, observational and analytical abilities, and strong clinical skills, including clinical judgment, decision-making, and clinical competence (Doane et al., 2020). Nursing practice is guided by relational inquiry to enable efficient clinical decision-making that will promote and maximize each patient’s health and well-being. Each person must consider how each clinical choice will be impacted by the interactions of the intrapersonal, interpersonal, and environmental dimensions and how each choice would possibly alter those outcomes. I will be using relational inquiry in a circumstance and analyzing how it was used to direct my nursing care and problem-solving to better understand how it operates.
In addition to Type II DM, COPD with O2 dependence, essential main HTN, peripheral neuropathy, neurogenic bladder with a foley catheter, and recurrent UTIs, 76-year-old Robert lives in a skilled care home. According to my CNAs, working my first-week shift on a Monday, he refused to get out of bed for breakfast this morning. Robert was not one to skip meals, so this instantly made me aware of the situation. The CNAs did not notice anything else odd about him then, so I carried on down my current path and rounded on the remainder of my residents.
I noticed that Robert seemed more tired than usual when I attempted to give him his morning pills. I quickly checked to ensure Robert’s O2 concentrator was operating correctly and that the NC’s prongs were appropriately positioned on him. I measured the following vital signs (VS): BP 132/88, temp 97.4, pulse 118, O2 sat 84 percent on 2 LPM through NC, RR 20, CBG 128. When I verified these data and noticed that his O2 saturation had not improved, I raised his flow rate to 4 LPM. As a result, his O2 saturation climbed to 94 percent, and his heart rate fell to 112. According to a respiratory examination, lung sounds to the anterior bilateral lobes were decreased. According to my evaluation, Robert was aware and oriented X2 (to person and location), which was outside his baseline. His arms’ skin also had a cold, clammy feeling about it.
I immediately told the doctor about the change in his health state and my observations. The doctor and I agreed that a UTI or pneumonia should be the first thing we rule out. The doctor gave me the following directives: Give Rocephin 2 gm through IM Injection once today. Chest x-ray 2-view PA and LAT, Lab for CBC with diff, UA with C&S to be collected via a direct catheter after obtaining all necessary lab specimens, provide.
To prevent the flora from Robert’s urine from being contaminated, the Foley catheter was replaced before collecting the urine sample. Some would object that replacing the Foley catheter could spread new or more germs to the region; however, this was done following facility practice, and if the catheter had been in place for more than 14 days, it should have been replaced before specimen collection (Centers for Disease Control and Prevention [CDC], 2021).
The urine sample was brought to the lab, the resident was taken to the neighborhood hospital for lab work, and a chest x-ray, and the Rocephin was given after returning to the Nursing facility.
The resident remained afebrile during the shift, and the doctor and I agreed that we were safe keeping him in the facility as long as he did not develop a temperature and his symptoms did not become worse. The next day, when I returned for my shift, Robert was the same as the day before less alert and lucid than usual but still receptive and easily stimulated by verbal cues. He also refused to get out of bed for meals, and his intake remained low. His O2 requirements remained excessive, increasing from the typical 2 LPM to 4 LPM, and his lung sounds did not alter from yesterday. His blood pressure was a little lower than usual today, and the first rounds of VS at 7:00 were as follows: BP 120/84, temperature 97.7, pulse 111, RR 18, and O2 at 4 LPM through NC were all within normal ranges. At 8:00 a.m., the resident doctor phoned to check on Robert. She offered the following instructions once I transmitted the information to her: Azithromycin 500 mg PO once more, followed by 250 mg PO three more times daily. Three more days of Rocephin 1 GM through IM INJ QD. The fresh orders were started right away and carried out as directed. I was reassembling the Rocephin when one of my assistants remarked that I seemed a little troubled. She inquired what was happening, and I replied that I was growing worried since Robert was not getting better despite being on two antibiotics. VS at 1030: BP 112/80, Temp 97.98, Pulse 110, RR 18, O2 sat 93 percent on 4 LPM through NC; despite our treatments, his blood pressure continued to decline. I phoned the doctor to give her an update, and she requested that I talk with the patient’s family to choose how they wanted to proceed with treatment: either we start an IV and keep him at home, or we send him to the ER for assessment and care. After the family asked him to be sent to the emergency room, Robert was ultimately treated for sepsis owing to a UTI and pneumonia.
The initial assessment led to my internal cues of knowledge and experience that O2 saturations lower than 86 percent are an emergency and require immediate assessment and treatment. The following external cues triggered these internal cues: decreased oxygen saturation, mild tachycardia, and decreased level of consciousness. Body tissues struggle to get oxygenated when SpO2 is less than 85%. (Workman, 2021). Even though I had taken care of Robert’s urgent oxygenation needs, I was aware that we still needed to identify the underlying reason for the hypoventilation. The results of his respiratory evaluation were inconclusive since there was too much time between the last respiratory assessment I gave Robert and the one I gave him today. Robert does not require routine respiratory checks because his breathing is usually steady.
Robert’s history of COPD and other characteristics were important considerations when he was sent to the nearby hospital for urosepsis a month ago. The doctor and I used our understanding of the patient’s medical history (internal cues) with the patient’s current subjective data to determine the best course of action (external cues). To check for an infection, the doctor prescribed a chest X-ray, UA with C&S, and CBC with diff. Using this evidence, we may infer that the doctor hypothesized that hypoxia, a symptom of acute idiopathic illness, was caused by hindered gas exchange. She told me that since bacteria are less usually found in culture-based tests gathered after antibiotic medication, I should only administer the Rocephin after all the lab tests are finished. If samples were taken as soon as possible, ideally before medications, the production of bacteria might increase, providing information for better antibiotic choices (Harris et al., 2017).
I knew that although maximal plasma concentration of a single IM dosage of Rocephin is achieved 2-3 hours after administration, its effects may not be as quick as those of a younger person due to the pharmacokinetics of the drug when I went back for my next shift and saw that Robert had not improved. A patient’s geriatric status, renal and hepatic function, tissue type and distribution, chronic disease (such as diabetes), and pharmacokinetics—the process by which drugs are distributed throughout the body—all impact. (Drug.com, 2022). Knowing this, besides the fact that Robert showed no symptoms of his health getting worse (external signals), the addition of another antibiotic gave me enough confidence (internal cues) to continue keeping an eye on him at home.
Clinical reasoning is an iterative, recursive, non-linear concurrent information processing model. Nurses constantly “update” their thinking and reasoning about what is happening and how patients react while continuously and iteratively monitoring them. My worry grew as I checked on Robert throughout the day and noticed his blood pressure dropping. I started to worry that Robert could be experiencing sepsis, a severe reaction to an infection in its early stages. It is a medical emergency that might endanger life. Sepsis-causing infections typically begin in the gastrointestinal system, urinary tract, skin, or lungs. Sepsis can quickly cause tissue damage, organ failure, and death if not treated promptly. Symptoms include tickling of the heart, hypotension, disorientation, SOB, and cold, clammy skin (Centers for Disease Control and Prevention [CDC], 2021).
I encountered some intrapersonal and interpersonal conflict when I phoned the doctor to give her an update on Robert’s health, and she requested me to speak with the family about how to proceed with treatment (in-house IV fluids or send to the ER). Robert’s medical demands were beyond what we could safely offer; therefore, I immediately hoped that the family would opt to have him sent to the ER. To prevent possibly exposing our people to COVID, our DON had advised us to try our best to treat our residents in-house. In addition, I recalled a day when I was an LPN, and my DON had complained that I sent our residents out too quickly and that they could have treated that patient in-house first.
When I started to worry that Robert could be showing signs of sepsis, I realized that our institution was not set up to give him the required care. We can infer from the doctor’s request (to speak with the patient’s family about a course of treatment) that, in addition to suspecting sepsis, her secondary hypothesis was a lack of fluid volume associated with an acute idiopathic illness as shown by changes in mental status, a drop in blood pressure and pulse pressure, and an increase in heart rate (Ladwig et al., 2019).
I was concerned about putting an IV on Robert even though an IV fluid shortage is often simple to treat. My expertise with starting IVs is minimal (internal signals), and Robert was already a problematic patient to start, even though he is not unfamiliar with pain or discomfort. He has Type II diabetes and no visible or easily felt veins (external cues). Second, if I repeatedly failed to stick, I would remove IV access sites that the hospital’s ER or medical-surgical staff needed (if the family decided to send him to the ER). Third, I was worried that even if I had successfully established an IV and IV fluids, sepsis might still be masking itself (by regulating his blood pressure and heart rate), delaying early treatment that might save his life.
I wanted to provide Robert and my DON with excellent care. I had to put Robert’s needs first to be a good nurse to him. Robert’s requests, the outcomes of my evaluations, and what I believed we could safely give would all decide what was in his best interest. The patient receiving nursing care is the nurse’s top priority. Where disagreement continues, the nurse’s dedication to the patient does not waver (Code of Ethics PDF, 2015). Being an excellent nurse to my DON involves a variety of considerations but ultimately comes down to making sure my residents receive the best care possible by avoiding pain and suffering and transferring them to a facility that can give higher-level care when necessary. The problem with this is that it calls for clinical judgment. The definition of clinical judgment is the visible result of thoughtful consideration and judgment. It is an iterative process that uses nursing expertise to monitor and evaluate current circumstances (internal and external cues), recognize and rank client concerns, and develop the best evidence-based solutions to provide safe client care (Dunham & Currier, 2019).
The capacity to recognize (internal and external) cues shown and utilize them to provide care that will enhance their health and welfare is necessary for sound clinical decision-making. We must use safe practice based on the ongoing process of questioning how to continue by employing relational inquiry to be competent, skilled nurses. This informs our clinical decision-making by allowing us to assess our knowledge and ignorance (Doane et al.., 2020).
References
Centers for Disease Control and Prevention. (2021, November 19). Strategize initiatives. https://www.cdc.gov/hai/prevent/cauti/indwelling/strategize.html
Centers for Disease Control and Prevention. (2022, May 3). Sepsis is a medical emergency. Act fast. https://www.cdc.gov/sepsis/what-is- sepsis.html#:~:text=Sepsis%20is%20the%20body’s%20extreme,%2C%20skin%2C%20o r%20gastrointestinal%20tract.
Code of ethics pdf. (2015). ANA. https://www.nursingworld.org/coe-view-only
Doane, G,H., & Varcoe, C. (2020). How to nurse: Relational inquiry in action (2nd ed.). https://ambassadored.vitalsource.com/books/9781975166120
Drug.com. (2022). Rocephin. https://www.drugs.com/pro/rocephin.html (Original work published 2000)
Dunham, M., & Currier, J. (2019). Clinical Judgement Model Video Transcript [PDF]. NCSBN Leading Regulatory Excellence. https://ncsbn.org/Transcript_NGNTalk_Episode06.pdf
Harris, A. M., Bramley, A. M., Jain, S., Arnold, S. R., Ampofo, K., Self, W. H., Williams, D. J., Anderson, E. J., Grijalva, C. G., McCullers, J. A., Pavia, A. T., Wunderink, R. G., Edwards, K. M., Winchell, J. M., & Hicks, L. A. (2017). Influence of antibiotics on the detection of bacteria by culture-based and culture-independent diagnostic tests in patients hospitalized with community-acquired pneumonia. Open Forum Infectious Diseases, 4(1). https://doi.org/10.1093/ofid/ofx014
Ladwig, G. B., Ackley, B. J., & Makic, Mary Beth Flynn. (2019). Mosby’s Guide to Nursing Diagnosis e-book (6th ed.). Mosby.
The Essentials of clinical reasoning for Nurses: Using the outcome present state test model for reflective practice. (2017). Experts@Minnesota. https://experts.umn.edu/en/publications/the-essentials-of-clinical-reasoning-for-nurses- using-the-outcome
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Question 
Clinical judgment in our daily practice can influence how we (nurses) take care of our patients. Our everyday care of our patients also incorporates ethical care and charting.
Nursing Clinical Judgment
Why should nursing include evidence-based practice in their daily routine?