Unit III Thoughtful practice and the process of care
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BOX 14-6 Example of the application of the clinical reasoning framework
The clinical situation:
You are a nurse working in an
emergency department.
Matthew is an active 5-year-old boy who has a history of
asthma that is well controlled with a bronchodilator and
preventer that he takes twice daily through a metered
dose inhaler (MDI). He has been visiting his grandparents
on their rural property, where there are many dogs and
cats that Matthew is not used to, and on the third day of
his visit he began to complain of increasing shortness of
breath with no relief from his inhalers. His grandparents
are alarmed, as this is the first time he has had an attack
while staying with them. First impressions of Matthew
are that he is pale, agitated and short of breath, which is
extremely frightening and is increasing his anxiety. In
addition, his grandparents are frantic, further increasing
Matthew’s anxiety levels and shortness of breath.
The question:
What strategies might help you to decrease
Matthew’s anxiety and lead to improved oxygenation?
1.
The answers to the
question
will provide the
information that helps develop the strategies that
will become the focus of care. The strategies rely on
detecting early indications of poor oxygenation. This
will involve an assessment of Matthew’s respiratory
function and his oxygenation, and an assessment of
the options available to reduce his anxiety levels
and to help his grandparents provide optimal
support.
2.
You consider the
knowledge
that you have that will
help you to make decisions about this issue. You
review what you know about asthma, as follows:
•
Asthma is a chronic respiratory illness characterised
by reversible inflammation of the airways, broncho-
constriction and airflow obstruction.
•
Management of asthma is centred on maintaining
oxygenation, administration of bronchodilators and
corticosteroids and identifying and treating triggers
such as infection or allergies.
•
Matthew’s onset of asthma becoming worse
following contact with pets may suggest an allergic
trigger for his asthma.
•
Anxiety is an early indicator of hypoxia, and is
caused by decreased oxygen supply to the brain.
You also draw on your practice knowledge, and review
your skills gained through clinical experience. You
recall the following:
•
Observations of respiratory dysfunction include
respiratory rate (increased or decreased) and use of
accessory muscles of breathing.
•
Increased anxiety levels result in increased oxygen
requirements, and may exacerbate ineffective
breathing patterns.
•
Pulse oximetry will assist in identifying hypoxaemia.
•
Oxygen saturation should be greater than 95% on
room air.
You now draw on your therapeutic relationship skills
gained through interaction with children in this age
group. You also review your experiences in assessing
respiratory function. Can you recall any other
situations when you needed to calm the relatives of a
patient? If so, what worked for you then? In this case,
you aim to do the following.
•
Keep Matthew calm and reduce his anxiety by not
asking him questions and making him talk, to assist
with reducing his breathlessness.
•
Keep his grandparents informed about his
management, to alleviate their anxiety and enable
them to provide calming support.
3.
The key
problems
you may have identified include
Matthew’s breathing difficulties, his and his
grandparents’ anxiety, and the possibility that anxiety
is reducing Matthews’ oxygenation so that he is now
possibly hypoxic.
4.
The
resources
you may have identified might include
senior nursing staff to assist with the interpretation of
their deficiencies. Experienced clinicians know that learning
through reflection is continuous, and expect their practice to
present challenges that demand new knowledge. Critical
thinkers know what help they need to assist their reasoning
and how to tap into resources. Key resources include expe-
rienced clinicians, texts and journals, research findings,
institutional policies and procedures, and professional
groups and writings.
Make clinical judgements and decisions on a
course of action
Ultimately, you must identify alternative judgements or
decisions, weigh the merits of each and reach a conclusion.
It is helpful to try to predict the consequences of your major
options before concluding your reasoning. You will also
need to evaluate the option you have selected as your deci-
sion begins to influence your actions.
Box 14-6 illustrates the use of the five considerations
above to facilitate clinical reasoning about a typical patient
situation. The merit of reasoning through each of the options
is that the action that meets the person’s needs is often the
one that is not the most readily apparent. Because clinicians
are accountable for patient care, flawed reasoning is danger-
ous even for someone new to nursing and clinical practice.
The clinical reasoning framework illustrated in Figure 14-3
is applied to the scenario outlined in Box 14-6, to help you
think through each of the steps.
