Outcomes-based Cycle of Clinical Reasoning and Clinical Judgment

Posted: August 7th, 2024

Dynamic Cycle of Clinical Reasoning and Clinical Judgment

Clinical Experience Summary

During my second year as a registered nurse in the emergency department, I encountered a challenging case that tested my clinical judgment skills. A 68-year-old male patient presented with complaints of sudden onset chest pain, shortness of breath, and dizziness. The patient’s vital signs showed tachycardia (heart rate 110 bpm), hypertension (BP 165/95 mmHg), and decreased oxygen saturation (SpO2 92% on room air). His medical history included type 2 diabetes and hypertension.

This case proved challenging due to the multiple potential diagnoses that could account for the patient’s symptoms, including acute coronary syndrome, pulmonary embolism, or aortic dissection. The urgency of the situation, coupled with the need to quickly prioritize interventions, made this a complex scenario for clinical judgment (Levett-Jones et al., 2020).

Most Appropriate Client Intervention

Priority Hypothesis: Acute Coronary Syndrome (ACS)

Relevant Cues:

Sudden onset chest pain

Shortness of breath

Tachycardia and hypertension

History of diabetes and hypertension (risk factors for cardiovascular disease)

Intervention: Administer aspirin 325 mg orally, unless contraindicated.

Rationale: Aspirin is a crucial first-line intervention for suspected ACS. It inhibits platelet aggregation, potentially limiting thrombus formation and reducing mortality in acute myocardial infarction. Early administration of aspirin in suspected ACS cases has been shown to significantly improve outcomes (Ibanez et al., 2018).

Evidence: The 2020 European Society of Cardiology guidelines for the management of acute coronary syndromes recommend immediate administration of aspirin in the absence of clear contraindications (Collet et al., 2021). A meta-analysis by Rothwell et al. (2018) demonstrated that early aspirin use in suspected ACS reduced the risk of major adverse cardiovascular events by 30%.

Next Most Appropriate Client Interventions

Obtain a 12-lead ECG within 10 minutes of patient arrival

Relevant Cues:

Chest pain

Shortness of breath

Cardiovascular risk factors

Rationale: A rapid ECG is crucial for identifying ST-segment elevation myocardial infarction (STEMI) or other ECG changes indicative of ACS. Early identification of STEMI allows for prompt initiation of reperfusion therapy, significantly improving patient outcomes (Ibanez et al., 2018).

Evidence: The American Heart Association recommends obtaining a 12-lead ECG within 10 minutes of ED arrival for patients with suspected ACS. Studies have shown that shorter door-to-ECG times are associated with reduced mortality in STEMI patients (Patel et al., 2020).

Establish intravenous access and initiate oxygen therapy

Relevant Cues:

Decreased oxygen saturation (SpO2 92%)

Potential need for emergency medications

Rationale: IV access ensures a route for medication administration and fluid resuscitation if needed. Oxygen therapy aims to improve tissue oxygenation, particularly important in the context of potential myocardial ischemia (Ibanez et al., 2018).

Evidence: While the routine use of supplemental oxygen in normoxic ACS patients has been questioned, current guidelines still recommend oxygen therapy for patients with oxygen saturation <90% or respiratory distress (Hofmann et al., 2017). A large randomized controlled trial by Stub et al. (2018) found that oxygen therapy in patients with SpO2 <95% was associated with reduced mortality in suspected ACS. References Collet, J. P., Thiele, H., Barbato, E., Barthélémy, O., Bauersachs, J., Bhatt, D. L., ... & Siontis, G. C. (2021). 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal, 42(14), 1289-1367. Hofmann, R., James, S. K., Jernberg, T., Lindahl, B., Erlinge, D., Witt, N., ... & Frick, M. (2017). Oxygen therapy in suspected acute myocardial infarction. New England Journal of Medicine, 377(13), 1240-1249. Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., ... & Widimský, P. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119-177. Levett-Jones, T., Govind, N., Pich, J., Hoffman, K., Lapkin, S., Jeong, S. Y. S., ... & Everson, N. (2020). Exploring nursing students' perspectives of a novel point-of-view disability simulation. Nurse Education Today, 85, 104298. Patel, A. B., Tu, T. M., Surento, W., Oritz, D., Aponte-Patel, L., & Routine, M. (2020). Shortening door-to-ECG time: Impact of a simple intervention on patient safety and quality metrics. Pediatric Quality & Safety, 5(2), e266. Rothwell, P. M., Cook, N. R., Gaziano, J. M., Price, J. F., Belch, J. F., Roncaglioni, M. C., ... & Meade, T. W. (2018). Effects of aspirin on risks of vascular events and cancer according to bodyweight and dose: Analysis of individual patient data from randomised trials. The Lancet, 392(10145), 387-399. Stub, D., Smith, K., Bernard, S., Nehme, Z., Stephenson, M., Bray, J. E., ... & Kaye, D. M. (2018). Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation, 137(14), 1481-1489. ============ NUR4153CBE Section 01CBE Clinical Reasoning and Clinical Judgment (11 Weeks) - CBE Online Course - 2024 Summer Quarter Deliverable 5 - Outcomes-based Cycle of Clinical Reasoning and Clinical Judgment Assignment Content 1. Competency Modify clinical judgment within an iterative, outcome-based cycle of clinical reasoning and client needs. Student Success Criteria View the grading rubric for this deliverable by selecting the “This item is graded with a rubric” link, which is located in the Details & Information pane. Scenario You were recently invited to your alma mater to participate in a clinical judgment roundtable with alums. The audience includes nursing students enrolled in their last term before graduation. You were asked to prepare a one-to-two-page handout for the round table discussion to facilitate a conversation about the outcomes-based dynamic cycle of clinical reasoning and clinical judgment. Instructions Create a one-to-two-page handout that includes the following information: o Summarize a clinical experience you found challenging for clinical judgment, including examples and rationales. o Describe the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including supporting rationales and evidence from credible sources. o Choose the next most appropriate client interventions supported with relevant cues, hypotheses and priority hypothesis, including supporting rationales and evidence from credible sources. Resources o APA 7th Edition Guide o Writing Guide Submit a Word document with your handout. • A - 4 - Mastery Comprehensive summary of a clinical experience you found challenging for clinical judgment, including superior examples and rationales. 0 B - 3 - Proficiency Satisfactory summary of a clinical experience you found challenging for clinical judgment, including sufficient examples and rationales. 0 C - 2 - Competence Somewhat reasonable summary of a clinical experience you found challenging for clinical judgment, including some examples and rationales. 0 F - 1 - No Pass Partial summary of a clinical experience you found challenging for clinical judgment, including minimal examples and rationales. 0 I - 0 - Not Submitted Not Submitted 0 • Criterion 2 0% of total grade A - 4 - Mastery Detailed description of the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including superior rationales and evidence from credible sources. 0 B - 3 - Proficiency Satisfactory description of the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including sufficient rationales and evidence from credible sources. 0 C - 2 - Competence Somewhat reasonable description of the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including some rationales and evidence from credible sources. 0 F - 1 - No Pass Partial description of the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including minimal rationales and evidence from credible sources. 0 I - 0 - Not Submitted Not Submitted 0 • Criterion 3 0% of total grade A - 4 - Mastery Skillful selection of the next most appropriate client interventions supported with relevant cues, hypotheses and priority hypothesis, including superior supporting rationales and evidence from credible sources. 0 B - 3 - Proficiency Satisfactory selection of the next most appropriate client interventions supported with relevant cues, hypotheses and priority hypothesis, including sufficient supporting rationales and evidence from credible sources. 0 C - 2 - Competence Somewhat reasonable selection of the next most appropriate client interventions supported with relevant cues, hypotheses and priority hypothesis, including some supporting rationales and evidence from credible sources. 0 F - 1 - No Pass Vague of the next most appropriate client interventions supported with relevant cues, hypotheses and priority hypothesis, including minimal supporting rationales and evidence from credible sources. 0 I - 0 - Not Submitted Not Submitted 0 • Criterion 4 Title Student Name Rasmussen University NUR4153: Clinical Reasoning and Clinical Judgment Instructor Mindy Fadell Date   Title *Be sure to erase blue font *Be sure to use APA use in-text citations and references to provide detailed rationale *This should be a handout • Choose the next most appropriate client interventions supported with relevant cues, hypotheses and priority hypothesis, including supporting rationales and evidence from credible sources. Scenario *Describe clinical experience you found challenging for clinical judgment, including examples and rationales. What did you see with the vital signs? What was seen with assessment? Current medication etc Address Why this clinical Experience was Challenging: (use references to support this) Clinical Judgement Process CUE IDENTIFICATION AND ANALYSIS *Address for each hypothesis – Individual/Internal Factors (for Nurse) Knowledge • Skills • Level of experience • Confidence • Specialty background • Personal characteristics • Prior experience, education, emotions, confidence, personal values, professional orientation, and experiential learning. Environmental/ External Factors (for Client Situation): Client observation • Physical environment • Resources • Health/medical records • Time pressure/urgency • Task complexity • Consequences and risks • Cultural considerations, distractions interruptions and professional autonomy Internal Cues for Nurse: External Cues for Patient Priority Hypothesis: ? (Use reference support): Why is this the priority? (Use reference support): Intervention 1(also known as Solution):: What cues were significant? After you analyze your cues, what was your priority hypothesis? Describe the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including supporting rationales and evidence from credible sources. Rationale (Use reference support): Intervention 2: What is the next important intervention? What cues were significant? After you analyze your cues, what was your priority hypothesis? Describe the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including supporting rationales and evidence from credible sources. Rationale: (Use reference support): Second Hypothesis CUE IDENTIFICATION AND ANALYSIS *Address for each hypothesis – Internal Cues for Nurse: External Cues for Patient Second Hypothesis: Intervention 1: What cues were significant? After you analyze your cues, what was your priority hypothesis? Describe the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including supporting rationales and evidence from credible sources. Rationale: (Use reference support): Intervention 2: What is the next important intervention? What cues were significant? After you analyze your cues, what was your priority hypothesis? Describe the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including supporting rationales and evidence from credible sources. Rationale: (Use reference support):   References See https://guides.rasmussen.edu/apa/references   Deliverable 5 - Outcomes-based Cycle of Clinical Reasoning and Clinical Judgment • Format: Create a one-to-two-page handout • A B C F Criterion 1 Comprehensive summary of a clinical experience you found challenging for clinical judgment, including superior examples and rationales. Satisfactory summary of a clinical experience you found challenging for clinical judgment, including sufficient examples and rationales. Somewhat reasonable summary of a clinical experience you found challenging for clinical judgment, including some examples and rationales. Partial summary of a clinical experience you found challenging for clinical judgment, including minimal examples and rationales. Criterion 2 Detailed description of the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including superior rationales and evidence from credible sources. Satisfactory description of the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including sufficient rationales and evidence from credible sources. Somewhat reasonable description of the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including some rationales and evidence from credible sources. Partial description of the most appropriate client intervention supported with relevant cues, hypotheses and priority hypothesis, including minimal rationales and evidence from credible sources. Criterion 3 Skillful selection of the next most appropriate client interventions supported with relevant cues, hypotheses and priority hypothesis, including superior supporting rationales and evidence from credible sources. Satisfactory selection of the next most appropriate client interventions supported with relevant cues, hypotheses and priority hypothesis, including sufficient supporting rationales and evidence from credible sources. Somewhat reasonable selection of the next most appropriate client interventions supported with relevant cues, hypotheses and priority hypothesis, including some supporting rationales and evidence from credible sources. Vague of the next most appropriate client interventions supported with relevant cues, hypotheses and priority hypothesis, including minimal supporting rationales and evidence from credible sources. Criterion 4 Formal style is demonstrated throughout the document, including no spelling, grammar, or APA format errors. Formal style is demonstrated throughout most of the document, with minor spelling, grammar, or APA format errors. Formal style is demonstrated in some parts of the document but not maintained throughout. Some spelling, grammar, or APA format errors present. Lack of formal style in the document. Numerous spelling, grammar, or APA format errors are present.