Clinical Reasoning

Clinical Reasoning Order Description I have chosen a patient that is suffering from Acute Myleod Leukemia and is due for a platelet infusion in which he has a suspected bacteria reaction. C. The writing up of this assessment should accord with the stages of the clinical reasoning cycle as follows:— Stage 1: Consider the patient’s situation In this section, briefly describe the person, their context and situation. This description should be:— 1. Person-centred and empathic. For example, the person is referred to by name (an appropriate pseudonym), not as “patient X” or “the patient” or “John Doe”. This should also continue and be apparent throughout the entire case study. 2. Relevant but succinct. This means that overall, irrelevant or less relevant information is not included at the expense of important, relevant information. 3. Appropriate. Include a brief statement explaining why you have selected this person for your case study. 4. Well written and clearly presented (especially when explaining time frames), logically ordered, specific and coherent (makes sense to the reader). Given that you will know more about the person than you include in this brief consideration of your patient’s situation, the reasons that certain information is included while other information is not included should be purposeful and clearly apparent. Nothing that is vitally important has been omitted. Stage 2: Review, Gather & Recall Review current information In this section, briefly present relevant details from your review of current information. For example, those pertaining to your patient’s medical and social history, results of investigations, findings from previous assessments etc. This should be: 1. Succinct but relevant to the “triggering” event or situation. Overall, the most important information is included and has not been omitted at the expense of less relevant information (may be some occasional lapses). Reasons for the information reviewed are purposeful and clearly apparent. 2. All data has normal ranges that are (mostly) correctly APA source referenced. 3. No vitally important information has been omitted or is unclear (of if something important is missing provide an explanation for its absence). No irrelevant information has not been included. 4. Well written and clearly presented (for example, use a table to show trends and/or time frames), logically ordered, specific (for example, does not use terms such as “within normal limits” or “between the flags” or “poor” or “increased” etc. as substitutes for actual data) and coherent (makes sense to the reader). ?????????? ??NURS2102: Clinical Practice 2A Callaghan, Ourimbah and Port Macquarie Nth Coast Inst Semester 1 - 2016 ?Collect cues (gather new information) In this section, present the data that you collected from your (supervised) assessment of your patient. This should comprise:— 1. Exactly which assessments you performed/cues you collected and the data obtained for each. 2. Which tools were used (where relevant). 3. Information/cues obtained from communicating therapeutically with your patient. 4. Abnormal cues clearly identified (use a different colour), normal ranges specified and source referenced. 5. A correct rationale (reason) is given for each cue that you collect. That is, demonstrate that the cue collection relates to the patient’s clinical situation and also support this with evidence if needed. 6. Relevant cues are not omitted at the expense of less relevant or irrelevant ones. If something relevant is omitted give a reason. 7. Well written and clearly presented, (for example, using a table for data), logically ordered, specific (for example, do not use terms such as “within normal limits” or “between the flags” or “poor” or “increased” etc. as substitutes for actual data) and coherent (makes sense to the reader). No vitally important cues have been omitted. Recall knowledge In this section, identify 2 cues from your cue collection that are abnormal OR of concern for this person at this time, and explain what is happening to cause those abnormal cues. If there are many, focus on the main ones that you think are most important. This explanation should be:— 1. Correct and sufficiently detailed to explain the underlying causes of the abnormal cues. 2. Supported by evidence effectively utilised from least two relevant high quality sources per cue from the nursing or health literature (textbooks and or journal articles). 3. Related back to the patient’s situation. 4. Well written using paragraphs effectively. 5. Written in your own words (paraphrased) with proficient APA citation skills. Please carefully consider the meanings of the directive term “explain” as follows: a. “To give details of”. b. “To make plain or intelligible; to clear of obscurity or difficulty”. c. “To assign a meaning to, state the meaning or import of; to interpret”. d. “To make clear the cause, origin or reason of; to account for”. Explain [Def 1]. (nd). In Oxford English Dictionary Online. Retrieved 8th October 2015 from https://www.oed.com/view/Entry/66595?redirectedFrom=explain#eid Stage 3: Process information In this section, use any two of the following elements of this stage of the CRC to make sense of the information that you have collected, to come to an understanding of what is happening and/or what needs prevention and explain how you have done so: Interpret: analyse data (cues) to come to an understanding of signs and symptoms/compare normal vs. abnormal; Discriminate: distinguish what is relevant from what is not and/or recognise inconsistencies and/or identify what is most important/recognise gaps in cues collected; Relate: cluster cues together to identify relationships between them; Infer: make deductions or form judgments that flow logically and/or consider alternatives and consequences; ????Page 15 of 21 ??NURS2102: Clinical Practice 2A Callaghan, Ourimbah and Port Macquarie Nth Coast Inst Semester 1 - 2016 ?Predict: an outcome...ie what might happen to the patient in this situation if the appropriate action is not taken. This explanation should entail:— 1. Effective use of your first identified element. 2. Effective use of your second identified element. 3. Logically flow from Stage 2. 4. Addresses the significance of these results for this person at this time. 5. Well written using paragraphs effectively. 6. Written in your own words (paraphrased) with proficient APA citation skills. Stage 4: Identify nursing problems/issues In this section, synthesise information (facts and inferences) from the previous stages and make a definitive nursing diagnoses of your patient’s two main problems. These can be either actual or at risk diagnoses. The diagnosis or diagnoses should:— 1. Be written as two separate statements that identify the patient’s two main nursing problems. 2. Be written in either three part form (problem, aetiology, signs and symptoms) or two part form (problem, aetiology) depending on whether they are ‘actual’ or ‘at risk’ diagnoses. 3. Clearly relate to and arise from your Stage 2 cue collection and Stage 3 processing. 4. Be priorities given the patient’s clinical situation and have been arrived at in partnership with the person or clearly reflect what is most important to them. Note: For a guide to formulating and writing nursing diagnoses please refer to the following source: Berman, A., Snyder, S. J., Levett-Jones, T., Dwyer, T., Hales, M., Harvey, N., ... Stanley, D. (2016). Kozier and Erb's fundamentals of nursing (3rd Aust. ed.). Frenchs Forest, Australia: Pearson. Chapter 13 pp.235-244. Stage 5: Establish goals In this section, state briefly what your goals are for each of your nursing diagnoses. Identify 2 goals for each. The goal(s) should be:— 1. Appropriate, given your patient’s clinical picture presented thus far and clearly reflect the diagnoses of problems in Stage 4. 2. SMART (specific, measurable, achievable, realistic, timely) Stage 6: Take action In this section, state and explain the four (4) most appropriate priority nursing actions that you would take in order to address your patient’s problem(s) and achieve the goal(s) you have set in Stage 5. Support each action with evidence from the literature. All four actions should be:— 1. Within the scope of nursing practice. 2. Clearly explained, specific, and include a verb; [ie. what the nurse would actually do must be clearly apparent]. 3. Effective in addressing your patient’s identified problem(s) (actual or potential), safe, person centred and correct given the patient’s clinical picture presented thus far; 4. Each action is explained/supported using evidence from at least two different high quality sources such as journal articles (eg. systematic reviews, individual research and/or discussion papers) from the nursing or health literature (two for each action = 8 in total for this section); 5. One of the four actions should involve discussion with a member of the inter-professional healthcare team, including the reasons for the consultation, and what this would entail. 6. Well written using paragraphs effectively. 7. Written in your own words (paraphrased) with proficient (mostly correct) APA citation skills. ???????Page 16 of 21 ??NURS2102: Clinical Practice 2A Callaghan, Ourimbah and Port Macquarie Nth Coast Inst Semester 1 - 2016 ?1. 2. 3. Notes: 1. 2. 3. 4. 5. 6. Your greatest strength and that you did very well. An aspect that needs most improvement. Your reflection should be honest, realistic, genuine and insightful as to how you will address the aspect needing improvement, and be consistent with your case study. Please make use of the resources on academic literacy, assignment research and writing, and referencing at NURS2102 Blackboard<Academic Literacy Resources. Information regarding additional assistance is also available via your UoN launchpad MySupport button. Paragraphs are designated by an extra space and begin with a topic sentence. While it is appropriate to present data in tables, these should also be explained or put in context. More than the occasional use of dot points is not appropriate. Even though the stages of the CRC provide the overall structure for this case study, these sections should link coherently to each other. The organisation of information within sections should also be coherent and logical so that it flows and makes sense to your reader. Please do not single space lines or use small or difficult to read fonts. Don’t forget APA rules for correct use of abbreviations. A reference list is mandatory (“proficient APA citation skills” includes the reference list). Sources such as Wikipaedia and the Better Health Channel are unacceptable and should not be used. Stage 7: Evaluate outcomes ?In this section, explain how you would evaluate the effectiveness of your actions (ie. how you would know that the situation was improving or a particular risk has been prevented). In doing so identify at least one and up to two specific outcome measures by which you would assess the effectiveness each of your actions. These should be:— 1. Correct ie. clearly relate to the goal(s) identified in Stage 5 and actions in Stage 6. 2. Clear, specific and measurable (numerically or observable). Stage 8: Reflection In this section, reflect on the clinical reasoning that you have undertaken for this case study. In your reflection specifically and realistically identify and discuss one aspect of your performance that you consider to be:— ?