Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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• 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 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. 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.

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. 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.

BOX 14-6 Example of the application of the clinical reasoning framework