Clinical Decision Part B. Essay Example

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In the clinical setting, nurses face situations that require them to make decisions using clinical reasoning skills whose effectiveness have a positive impact on patient outcomes. Distinguishing between a clinical problem that needs immediate attention and one that is less acute is among the key things to understand in such a patient to ensure proper care is offered. The clinical reasoning model is a dynamic process that gives a cycle of decisions and actions which in real life may occur concurrently without clear demarcations of each step from others, (Haugen & Galura, 2011). Time is very crucial in all these steps especially in stroke patients hence need to merge all above in context of time, (Minchin & Wensley, 2003)

Cerebrovascular disease caused an estimated 6.2 million deaths in 2008 worldwide, translating to 11% of all deaths (WHO, 2012). Under the WHO classification, Australia is part of Western Pacific region where stroke is still a portion on healthcare burden. There were 8,304 deaths due to stroke in 2010 in Australia (74% of all deaths due to cerebrovascular disease) and also there has been on the rise in stroke events by 6% attributable in part to the rise in aging population. In 2009–10, there were over 35,300 hospitalizations for stroke with 25,800 hospitalized for rehabilitative care. In addition to deaths and disability, the health-care expenditure for stroke in Australia was $606 million in 200-2009 accounting for 0.5% of total health-care expenditure (AIHW, 2012). Stroke can be ischemic, hemorrhagic or both, ischemic stroke accounts for 87% of all cases (Rosamond, 2008).

Transient ischemic attack is a temporary focal loss of neurologic function and is an early warning of a potentially progressive stroke; this was the nursing diagnoses attributed to ineffective brain perfusion due to decreased cerebral blood flow, early diagnosis is necessary to save a life (Marler, 1999). Initial nursing goals included a rapid evaluation and stabilization by immediate stabilization of the airway, breathing, and circulation (ABCs), assessment of neurological deficits and possible comorbidities. The neurological assessment includes establishment of symptom onset and review of history and a rapid screen using Glasgow coma scale (GCS) and findings such as papillary response and size, facial droop, arm drift and abnormal speech.

The overall goal is not only to identify patients with possible stroke but also to exclude stroke mimics (conditions with stroke like symptoms) (Minchin et al, 2003), identify other conditions that require immediate intervention, and determine potential causes of the stroke for early secondary prevention. Importantly, early implementation of stroke pathways and/or stroke team notification should occur at this point. With a prior (Transient Ischemic Attacks) TIAs and risk factors of stroke; Age, hypertension, diabetes and history of smoking cigarettes (Nicol & Thrift, 2005). This is a patient who urgent actions are mandatory to either reverse or prevent progression of brain ischemia to a completed stroke whose neurological outcome is poor. More than 60% of strokes are associated with Hypertension and Diabetes Mellitus and 50% are preceded by TIA, hence elderly man had a high risk of progression to stroke from TIA.

The risk of another stroke is 5-10% in the first week and 15% in the first one year (Nicki, Brian & Stuart, 2010). It should be borne in mind that stroke patients require the highest level of care available in the shortest time possible. The involvement of the left arm and speech points towards a left sided lesion and a review of prior CT Scans are necessary as ischemic and hemorrhagic strokes have different management and progression (NSF, 2010 & Debbie, Deidre, Jeffrey, Spilker, Nanette, Elaine & Pamela, 2009). Also breathing is affected and this could originate centrally such as increase intracranial pressure due to intracerebral hemorrhage or inability to maintain a patent airway due to the disability from the lesion. Airway management and high flow oxygen therapy took the first priority in this scenario as optimizing oxygenation from the low saturation enhances the neuronal pump activity by providing more blood oxygen levels. This means more oxygen available for brain extraction slowing irreversible brain damage. This part of action which was done swiftly was more stimulated by the breathing difficulty but achieved an improvement in patient’s clinical state (Thurman, 2002). Other problems associated with neurological deficits are impaired physical mobility, verbal communication, swallowing and continence and have to be borne in mind. Psychological problems from perceived loss of function may occur including depression.

The background of diabetes also makes sugar control levels mandatory as hypoglycemia can cause neurological signs and symptoms which are easily reversible by dextrose infusion; however the symptoms are usually bilateral making this unlikely but glucose control levels have to be ascertained. These needed checking of the sugar levels and prior control status and the insulin infusion doses and rates as well as consider ketoacidosis that can occur with insufficient insulin therapy. Sugar levels should therefore have been immediately checked even before patient was referred to hospital from nursing home. Though this was out of focus it is uncommon in patient with such condition and requires consideration since hyperglycemia also results to a higher volume of brain infarction (NSF, 2010, Debbie et al 2009 & Fauci, Kasper, Braunwald, Jameson, Loscalzo, Hauser, Longo, 2008).

Moreover hypertensive emergencies can occur resulting in cerebral ischemia and neurological deficits hence the significance of checking blood pressure control levels. IV furosemide infusion was given which achieved a drop in blood pressure and patient symptoms improved. Lowering of blood pressure rapidly and to levels out of auto regulatory range can complicate to ischemia and cause above clinical scenario (Semplicini, Maresca, Boscolo, Sartori, Rocchi, Giantin, Forte & Pessina, 2003;
Rose & Mayer, 2004). However the blood pressure was 278/136mmHg which necessitated a rapid reduction which ideally requires careful infusion of IV drugs such as Labetalol. This is because potential errors are bound to happen during infusion of drugs such as that for furosemide as opposed to ideal set up where blood pressure reduction goals are identified and matched with drug dose titrations. Though we did not have in mind autoregulatory changes that happen with rapid pressure reductions, fortunately our patient improved. This raised more questions as to whether the patient had more than one pathology including silent angina (due to diabetic neuropathy) and pulmonary edema.

Other nursing goals apart from stabilizing the patient and monitoring neurologic status frequently ( to assess the evolution of the Cerebrovascular Accident) include attaining maximum physical functioning, self-care activities and skills, maximize communication abilities, maintain adequate nutrition, avoid complications of stroke and achieve adequate patient and family coping with the situation. Rehabilitative care is important in this patient to limit disability and improve overall prognosis (NSF, 2010). These include speech therapy and physical therapy such as ambulation and strengthening motor functions. Other nursing actions to be considered in a stroke patient include patient positioning such as head elevation to help reduce intracranial pressure, frequent turning to prevent pressure ulcers and splintage to prevent contractures(Clark and Sandra et al, 2010). Ensure urinary catheterization for monitoring urinary output and to achieve continence and also provide preventive skin care measures however risk of urinary tract infection exists and has to be considered. Adequate nutrition and hydration improve the general physiological status and overall functional outcome (Debbie et al, 2009).

In this case treatment goals after immediate stabilization include: prevention, drug therapy, surgical therapy (when indicated) and Rehabilitation (AIHW). In cerebral ischemic episodes, which this case later turned out to be usually has compensatory hypertension that wanes in about 2 weeks time and rarely warrants a BP reduction unless in severe levels as above. Long term lowering of BP lowers the risk of both ischemic and hemorrhagic stroke which should be ensured once the emergency and immediately life threatening issues have been addressed (Rose et al 2004). Anticonvulsant therapy for seizure prophylaxis was not instituted in our care as we could not anticipate this with its effects of worsening ischemic brain damage. It is however recommended in cases of recurrent seizures (NSF, 2010).

Urgent CT scan after rapid supportive care was later done in hospital after doctor on call was notified by the senior nurse’s intervention. The scan also enabled early institution of aspirin and clopidogrel which are antiplatelet agents that prevent the risk of secondary stroke (Thurman & Jauch, 2002). Prejudices that could hinder objective approach include dementia in such age that could account for this presentation as well as attributing limb deficits in use to osteoarthritis and both can become a red herring to detecting Cerebrovascular (CVAs) accidents which can be disabling or fatal. However recognition of this and rapid referral was a lifesaving measure but not due to risk of bleeding no thrombolysis was done and patient progressed well when he was brought back to our care. The patient was previously on antiplatelets and artovastatin treatment for two months after an episode of TIA but stopped due to what was later found to be due to pill burden. This identified an area of weakness in linking patient history, past and current conditions to the current care as this would have detected compliance problems and remedies them earlier. Therefore, understanding the antiplatelet and lipid lowering agents as part of treatment goal is necessary as they reduce thrombosis and atherosclerosis respectively (NSF, 2010 & Thurman et al, 2002).

Also cardiovascular risk factors that overlap with those of stroke mean that cardiovascular source of ischemia is likely such as a thrombus from the heart due to arrhythmias such as atrial fibrillation and atherosclerosis of carotid vessels could occur making the examination of the system essential including but not limited to BP, Pulse rate and rhythm (Graham, Fiona& Colin,2013).Irregular rate and/or rhythm would easily identify arrhythmias and doing a rapid ECG monitoring would give further help in knowing the underlying problems. The ECG showed features of an old infarct and areas of ischemia despite the fact that the patient had no angina (Rosamond, 2008 & NSF, 2010). This supports existing diabetic neuropathy. This makes ECG monitoring an important aspect of nursing care as early detection of acute coronary syndromes in such elderly patient saves lives and also the improves the overall patient outcomes (NSF, 2010 & Debbie et al 2009). Presence of atrial fibrillation would warrant anticoagulant therapy with coumarins such as warfarin.

Decision making was in this case dependent on experience and more influenced by patient’s condition which guided most actions. Prior interventions including patient history is very crucial. If pertinent prior history, medications and comorbidities are not identified and recorded, they will be skipped and deficits due to this gaps lead to poor patient care. Aspects of history which we latter added to the patient information helped in improving the overall outcome of the patient. Digital storage and storage of information should be used to enhance this. Hospital factors such as protocol, facilities and staffing determine what decisions and actions are taken as they all determine the effectiveness of actions taken (Minchin et al, 2003).

Planning after immediate assessment is essential especially for long term plans after emergency management of life threatening problems. The collection of information and cues was not thorough enough as the history of anticoagulant drug use was not enquired immediately as this would change the use of any thrombolytics and antiplatelets and could warrant an immediate CT scan. This was an important learning point to me; that patients may destabilize any time, without warning. This demands one to be alert, courageous and rational in all decisions and actions.

Of importance was that from a few vital signs and neurological complains a relation was made to identify TIA or stroke as a likely pathology. This however cannot be firmly distinguished from other mimics and a rapid screening neurological assessment is necessary to give the likely clue whether it is upper or lower motor neuron pathology and also to identify the areas that need supportive care. Limb paresis, incontinence and other functional aspects determine the need for care such as pressure sore prevention measures, bladder and bowel care and nutritional aspects in case of dysphagia. The supportive care had these action deficits as well as temperature control, which worsens the brain damage if fever occurs resulting in higher brain temperature and larger area of brain damage (NSF, 2010 & Nicki et al 2010).

Education and encouraging the patient on preventive measures is also an important nursing management action. These include healthy diet, weight control, and regular exercise, stop smoking, and limit alcohol consumption, routine health assessment and control of risk factors. Providing this preventive care through health education activities based on identified
learning needs and information on stroke using appropriate and available resources. This also enables early detection and referral after stabilization of identified high risk patients as was done. Patient education also includes giving clear explanations for all care and treatments and encouragement by maintaining
motivation and stimulation of patient’s interest in self-enhancing activities while keeping focus on improvements.
Also assist the patient in accepting and adapting to disability in case they develop. (Hacke et al 2000; Fauci et al 2008, Page et al., 2011 & NSF, 2010).

Also some aspect of history of alcohol use and trauma to the head is important and was missed. CVAs can lead to limb weakness and instability and predispose to falls that can cause fatal subdural bleeding if not recognized early (Jauch, Saver, Khatri, Qureshi, Rosenfield & Wintermark, Yonas, 2013). On the other hand alcoholism causes tendency to injuries and falls with risk of intracranial bleeding. Alcohol itself is also a risk factor for stroke if excessive amounts are taken. Not thinking of such possibilities leads to a point of standstill and even takes one to drawing board if what is expected happens not to be. Lesson is a broad minded approach to patient care is not an option but almost a necessity.

Given the emergency actions were fairly executed, this include getting the vital parameters and oxygen treatment as well as rapid ambulance transfer to hospital (Mosley, Nicol, Donnan, Patrick, Dewey, 2007). However, it should be noted that routine use of supplemental oxygen is not recommended in acute stroke patients who are not hypoxic (NSF, 2010). However, assistance from nearby nurse was quite sluggish, which in emergency set up requires rapid and orderly actions to ensure no lives are lost or complications develop.

Evaluating outcomes of intervention measures in this case before hospital is mainly via measuring vital signs such as BP, respiratory rate, oxygen saturation, clinical examination of systems especially nervous system and cardiovascular system. Evaluation was only done using vital signs and few cognitive aspects and therefore a good screening assessment is necessary in such situation to identify several functional deficits before definitive measures can be done after patient is stable. Ability to perform of simple exercises and self care by patient with minimal or no supervision is also an important evaluation tool. (Stroke Unit Trialists’ Collaboration, 2007)

To achieve better clinical outcomes in emergency issues like we had, several nurses are needed to work together on different problems to speed up the actions and also prepare the patient for relevant interventions. Also more than one attendant means ease of calling for help and other urgent measures without leaving the patient in a compromised state and also saves time (Torunn & Hamilton, 2011). Warning systems such as alarms and pagers are very helpful in seeking assistance but are underutilized as happened in this case. Encouraging a link between the ward alarm systems and ambulance services in the future is an advantage as it saves time and brings synergy created by commotion during emergency times. Recognizing the need to transfer such patients to stroke centers gives them a chance to better care and improved outcome (Bucknall, 2003).

In a patient with Cerebrovascular accident speed in problem identification, making nursing goals, instituting actions timely and effectively frequent monitoring and evaluation is necessary especially early stabilization, urgent CT scan, giving relevant medication and neurological assessment. . The effects are likely to be futile especially where a single person offers care without order and plan. This could be compounded by confusing and dynamic clinical status and patient information (known by nurse) hence multiple interacting and competing goals as well as challenging ways to effect this. Decisions lead to actions and effects that lead to further information (a cycle) that decisions have to be based on. This shows how the entire process is interrelated. Various elements such as time, workload pressure, personal factors (stress), and hospital standards of operation and patient factors influence decisions making which is an essential component of good nursing practice (Simmons, 2003). Proper understanding of basic and clinical sciences, objective critique and rational clinical decisions are all part of sound clinical reasoning and ultimately improved patient care (Haugen et al 2011.).
The use of a critical thinking decision making framework enables new nurses and nurse students to be more accountable for their clinical decisions and encourage the development of their clinical knowledge and improves their acumen as that of experienced nurses (ANMC).


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