Clinical Reasoning Cycle And Vital Sign Management

Clinical Reasoning Cycle

Consider the patient situation

In this section, provide a relevant and concise description of your observation of the context and patient situation.  

The patient is Sandra Smith, a 33-year-old female who presented with per vaginal bleeding. She has an IV cannular in her left hand with a normal saline IV fluid running at 125mls per hour. She has menstrual pads in situ and has been on bedrest since admission.

Collect cues and/or information

Review

Record current information (eg handover, patient history etc,  

She is passing 500mls of bleed per hour. She has a past history of endometriosis, hypotension and childhood asthma. Previous procedures included laparoscopic incision of endometrial tissue, colonoscopy, and appendectomy. On assessment important positives included elevated heart rate at 100 bpm, respiratory rate at 29, temperature of 38.5⁰Cand a pale diaphoretic appearance with pain of 8/10. She also has not passed urine since admission.

Gather new information – In the video, the nursing student gathers the current vital signs – record this information

Recall knowledge – What do the vital signs measured by the nurse in the video mean

Cue

(vital sign)

Definition

Use your own words supported with references

Factors that may affect this cue

Use your own words supported with references

Normal range (adult)

Terminology used to describe abnormal cue

Patient’s vital sign

Respiratory rate

This is the measure of a persons breathing per minute with one respiration being an inspiration and a corresponding expiration (Flenady, Dwyer and Applegarth, 2016)

Metabolic acidosis due to inadequate perfusion causes a hyperventilation as the patient tries to eliminate excess acid (Mikhail, 2015).

12 -20 breaths/minute

Hyperventilation

Hypoventilation

29 breaths per min

Oxygen saturations

This is a measure of the amount of oxygen in blood hence the level that is delivered to tissues (Jubran, 2015).

The metabolic acidosis make is hard to maintain a high oxygen saturation

(Fein, 2014).

97 – 100%

Hypoxemia

95 %

Heart rate (pulse)

This is the measure of the how fast the heart is beating with one cycle being diastole plus the corresponding systole. It is measured by palpating the radial artery for radial pulse (Oh, Hong & Lee, 2016).

Due to blood loss and low perfusion, there is a sympathetic nervous system stimulation which causes the release of catecholamine; adrenaline and norepinephrine (Kreimeier, 2016). This causes vasoconstriction, increased heart rate (above 100 bpm) and increased heart contractility. With this, there is adequate cardiac output which increases the tissue perfusion.

60 -100 bpm

Tachycardia

Bradycardia

110 bpm

Blood pressure

His is the measure of the pumping force of the heart against the resistance of the blood vessels (Guyton, 2015)

The blood pressure remains normal as compensation is occurring. There is activation of the renin-angiotensin-aldosterone system that leads to increased anti-diuretic production which in turn causes water retention. However, with increasing blood loss the pressure will fall as vasodilation due to anaerobic respiration occurs (Hinkle & Cheever, 2013)

130 to 90/85

Hypertension

hypotension

100/60 mmHg

Temperature

This is a measure of the bodies hotness or coldness and gives an indication of the bodies core temperature (Kushimoto et al, 2014)

Brain hypoperfusion due to haemorrhage resets the core body temperature imparing normal thermoregulation (Balk, 2015).

36.5 to 37.2⁰C

Hypothermia

Fever

38.5⁰C

Error 1

During blood pressure measurement, the student placed the blood pressure cuff below the cubital fossa, at the upper forearm instead of the required position just above the cubital fossa. This error leads to overestimation, underestimation or even guessing of values since the correct sounds cannot be heard correctly (Handler, 2009).

Error 2

During pulse rate measurement the thumb was used to measure which is incorrect. The thumb having its own pulsation interferers with the pulse being measured making the reading inaccurate (Glynn and Drake, 2014).

Error 3

The method of measuring respiratory rate was incorrect as she made the patient aware of the process. The awareness of breathing by the patient makes the reading inaccurate compared to if the rate was counted while the patient is un aware (Glynn and Drake, 2014)

Error 4

Inappropriate documentation protocol as the student did not record her results after every measurement but waited till the end of the assessment to do so. This is not standard practice as she could forget the correct readings and instead document incorrect figures (Fuller, Fox, Lake, & Crawford, 2018).

The standard 4 provides for comprehensive assessment to guide decisions. Inappropriate documentation of assessments will impair this principle. If an assessment is done but not documented accurately, it renders the assessment inaccurate and an inaccurate assessment should not be used to inform nursing practice (Stevens & Pickering, 2010).  The assessment won’t be holistic, relevant or accurate (Collins et al, 2013). As a general rule in nursing, something not documented is considered not done. Good documentation is also crucial for clinical communication. Working in partnership with others to assess, prioritize and manage patients is required by the standards of practice no 4. This involves handover reports, patient information, previous assessment and results. This ensure continuity of care without loss of information (Stevens & Pickering, 2010). Another requirement of the standard is the assessment of resources available to inform planning. This involves accurate documentation of all available resources, the management of this resources and their use.

The lessons learned in this assessment are numerous. The first important lesson is the use of the clinical reasoning cycle in the approach and management of a patient. This systematic approach as used in this assessment is more holistic, appropriate and simple to follow. The cycle follows eight simple steps that if applied to different clinical scenarios help in the management of patients. The second lesson is the importance of vital signs measurement in the assessment of patients, the identification of normal and abnormal vitals, and how errors in the measurement can greatly affect these readings. From this, good clinical skills in the measurement of vital signs need to be learned or improved to provide quality measurements. Also, the importance of vital signs will not be underestimated. The third lesson is the importance of accurate documentation in provision of quality nursing care and meeting nursing standards of practice. With this information, implementation of good, concise and regular documentation shall be a priority in the clinical setting. The final lesson is the use of evidence-based research in clinical practice and the importance of evidence-based resources in clinical nursing. This will help inform my clinical reasoning in the clinical area.