Appropriate clinical reasoning ensures that the patient receives the right intervention at the right time and for the correct reasons (Rossiter, 2013). In addition, the use of evidence-based practice (EBP) guarantees that the chosen intervention is right in terms of effectiveness supported by research findings. The clinical reasoning cycle (Levett-Jones, 2012) is a useful framework to guide the clinical reasoning process. The purpose of this essay is to apply this framework in the planning of nursing care to address dyspnea in Mr. Thompson, a 70-year-old gentleman admitted to the coronary ward with congestive heart failure (CHF). This essay will also describe the integration of EBP in care planning.
Clinical Reasoning Cycle
The patient was considered by reviewing the patient’s background information and performing a visual survey. Mr. Thompson is an older adult and lives with his spouse who is his primary caregiver. He is fully alert and breathless when speaking. His wife is at bedside to assist him. The ED diagnosis was acute exacerbation of CHF and admission was recommended which meant that he was at a high risk for suboptimal outcomes (Yancy et al., 2013). It also meant that the primary goal of intervention was to stabilize him and prevent further morbidity and mortality (Yancy et al., 2013).
Cue and information collection was accomplished by reviewing the ED handover report and the patient’s chart and performing an assessment. Mr. Thompson presented to the ED for shortness of breath and cough that began 3 days ago. He had a prior diagnosis of CHF and was prescribed oral medications. Significant findings were severe high blood pressure (219/112), tachypnea (36), SpO2 of 91%, sinus tachycardia, respiratory acidosis, and bilateral pulmonary congestion on CXR. He also had pitting ankle edema and peripheral cyanosis. His digoxin level was below the therapeutic range because he had not taken his medications for at least 6 days. His sodium was at the lower threshold of low at 135. Intravenous access was established and Mr. Thompson was given IV diuretics, an ACE inhibitor, and digoxin. He was also put on oxygen via facemask.
On assessment, vitals were BP 162/91, HR 98, Temp 37.3, RR 30, and SpO2 of 93%. He reported orthopnea but no pain. Crackles were heard on the lung bases bilaterally. He still had pitting ankle edema and peripheral cyanosis. Sputum was whitish in color and frothy. Baseline weight was taken because this data was missing but is essential in evaluating care effectiveness (Yancy et al., 2013). There was also no data on urine output and thus monitoring was instituted. Prior knowledge on the pathophysiology of CHF was recalled. It was further recognized that physiological changes associated with aging rendered the patient at a higher risk of medication toxicity and adverse effects (Brenes-Salazar et al., 2015).
Processing the information, pulmonary edema is a common feature of CHF (Yancy et al., 2013), and impaired gas exchange was an appropriate nursing diagnosis. This was inferred from the chief complaint, patient history, and the subjective and objective data. However, the etiology must be clearly established to inform the interventions. To prevent errors, other possible diagnoses were considered. While pneumonia could manifest with most of the clinical findings, it is associated with fever and greenish sputum. The CBC also did not show an increase in the WBC. Acute COPD was also a possible diagnosis but the patient was negative for lung hyperinflation on physical exam and CXR. Discrimination of the information highlighted the importance of relating Mr. Thompson’s current medical and nursing diagnoses with his behavior, namely medication non-adherence. Gaps in the information thereby included the factors that contributed to non-adherence which assist in individualizing patient education.
The facts and inferences were synthesized in the nursing diagnosis of impaired gas exchange related to impaired gas diffusion associated with fluid accumulation in the alveoli and pulmonary interstitium brought about by medication non-adherence and disease exacerbation. This diagnosis was manifested by radiography, lung auscultation, cough, orthopnea, sputum characteristics, oximetry, cyanosis, and the respiratory pattern. The goals were thereby multiple: reduce the respiratory rate below 20, increase the SpO2 to 94% or higher, absence of adventitious breath sounds, absence of coughing and cyanosis, greater patient-reported ease in breathing, normal ABG and radiography results.
There are short- and long-term actions were taken to achieve these goals. Supplemental oxygen continued to be administered to correct the patient’s hypoxemia (Sepehrvand & Ezekowitz, 2016). However, the risk of hyperoxia exists for continued supplementation despite ABG or SpO2 normalization (Sepehrvand & Ezekowitz, 2016). As such, these parameters were tightly monitored. Administering Mr. Thompson’s medications correctly and in a timely manner was a key intervention as these promote fluid elimination and improved heart functioning (Yancy et al., 2013). Monitoring for adverse effects was also important (Brenes-Salazar et al., 2015) especially for digoxin which is safe and effective only when the levels fall within a narrow range (McLeod-Glover, 2016). To this end, knowledge of the adverse effects associated with the patient’s medications was important. A sodium restricted diet helps ease lung congestion and was coordinated with the dietary department (Abraham & Murrill, 2013; Yancy et al., 2013). The patient was also positioned with the head-end of the bed elevated to address orthopnea. The outcomes were evaluated by comparing measurements to the baseline or identifying trends.
Conclusion
The clinical reasoning cycle structures the clinical decision-making process to enable nursing care planning. In an older adult with acute CHF, the clinical reasoning cycle led to the nursing diagnosis of ineffective gas exchange. The literature was searched to identify EBPs in promoting gas exchange. Guidelines and studies were found that supported the chosen interventions.
References
Abraham, J., & Merrill, A. (2013). Effectiveness of a sodium restricted diet on reducing weight gain and edema formation in adult patients with chronic heart failure: A systematic review. JBI Database of Systematic Reviews and Implementation Reports, 11(4), 187-196. Retrieved from http://journals.lww.com/jbisrir/Abstract/2013/11040/Effectiveness_of_a_Sodium_Res tricted_Diet_on.4.aspx
Brenes-Salazar, J.A., Alshawabkeh, L., Schmader, K.E., Hanlon, J.T., & Forman, D.E. (2015). Clinical pharmacology relevant to older adults with cardiovascular disease. Journal of Geriatric Cardiology, 12, 192-195. doi:10.11909/j.issn.1671- 5411.2015.03.018
Levett-Jones, T. (2012). Clinical reasoning. Newcastle, Australia: Pearson Education.
McLeod-Glover, N. (2016). Digoxin toxicity: Case for retiring its use in elderly patients? Canadian Family Physician, 62(3), 223-228. Retrieved from http://www.cfp.ca/content/62/3/223.full
Rossiter, R. (2013). The clinical reasoning cycle: A tool for building excellence in nursing practice (conference paper). Retrieved from https://www.researchgate.net/publication/270816721_The_Clinical_Reasoning_Cycle _A_Tool_for_Building_Excellence_in_Nursing_Practice
Sepehrvand, N., & Ezekowitz, J.A. (2016). Oxygen therapy in patients with acute heart failure: Friend or foe? JACC: Heart Failure, 16, 30159-30170. doi: 10.1016/j.jchf.2016.03.026.
Yancy, C.W., Jessup, M., Bozkurt, B., Butler, J., Casey, D.E., Wilkoff, B.L. (2013). 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 128(16), 1-300. http://dx.doi.org/10.1161/CIR.0b013e31829e8776
