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CNA253 Professional Practice 3
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CNA253 Professional Practice 3
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Course Code: CNA253
University: University Of Tasmania
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Country: Australia
Questions:
Clinical reasoning case-study rubric(Robert Brown)
Explains relevant underlying physiology/pathophysiology related to the health status of the individual and demonstrates understanding of the relationship between the health issues presented.40%
Demonstrates a high-level of application of knowledge to the case, that accurately and comprehensively explains the students’ understanding of the underlying pathophysiological mechanisms related to the patient’s condition.
Accurate application of knowledge that indicates a high-level understanding of relevant pathophysiological mechanisms related to the patient’s condition.Mostly accurate application of knowledge that indicates a reasonable level of understanding of relevant pathophysiological mechanisms related to the patient’s condition. Some scope to detail additional relationships within the case study.
Demonstrates a satisfactory application of mostly accurate knowledge regarding some of the relevant pathophysiological mechanisms. Scope for additional depth and analysis.
Provides insufficient and/or confused knowledge that does not clearly demonstrate an understanding of relevant pathophysiological mechanisms.
Demonstrates ability to appropriately apply the clinical reasoning cycle to inform and evaluate nursing care40%
Demonstrates an exceptional understanding and application of all componentsof the clinical reasoning cycle to the case that indicates an emerging capacity to think like a registered nurse.The plan of care detailed provides evidence of high-level thinking around relevant course of actions and impact/s on future nursing practice.
Demonstrates a strong understanding of the application ofmost components ofthe clinical reasoning cycle to the case that indicates an emerging capacity to think like a registered nurse. Details an appropriate,relevant course of actions and impact/s on future nursing practice.
Demonstrates a clear but sometimeslimitedunderstanding of the application of clinical reasoning with some capacity to think like a registered nurse, but scope for more depth.
Demonstrates a satisfactory approach to applicationof some elementsof the clinical reasoning with some capacity to think like a registered nurse, but scope for more depth.Paper is not aligned with the clinical reasoning cycle and/or demonstrates poor understanding of its application and does not clearly address and/or acknowledge the patient problem.
Answers:
Robert Brown
Consider the patient situation
Mr Robert Brown is a 30 year old male who was hit by a car that failed to give way whilst he was crossing at a pedestrian crossing. The impact caused him to be thrown into a nearby garden bed. Passers-by came to his aid immediately. They helped him up and noticed he was bleeding from a laceration to the back of the head. He sustained no other obvious injuries. An ambulance was called. He has been at hospital for nearly 24 hours and was transferred to your ward overnight. It is now 0800 and you have just come on shift. You enter his room and he seems to be unsure of where he is (requires orientation) and keeps asking other patients the location of his dog (whom Robert was walking at the time of the accident).
Collect Cues
Review:
The next phase of clinical reasoning cycle is reviewing the given information
The laceration at the back of head was attended.
Pain control with Paracetamol
No neurological deficit
Active bleeding was stopped, wounds were cleaned and dressed.
Gather new information (patient assessment):
Upon undertaking an assessment of Mr Brown you obtain the following new information:
Vital signs
BP: 160/95
Pulse: 111bpm
RR: 18
SaO2: 98%
Temp 36.6
Other data
GCS: 13 (patient seems confused/agitated) and keeps rubbing at his head and mumbling that it hurts. Whilst his movements seem purposeful, he does not obey commands or accurately answer specific questions). There appears to be no GCS documentation since transfer to the ward.
Patient in bed opposite refers to Mr Brown and tells you: ‘that poor young bloke, he’s been up half the night. He keeps going on about his dog and gets lost when he goes to the bathroom’
Wound chart: no further documentation evident. However, upon looking at Mr Browns head wound from a distance, dressing appears blood soaked and has partly come off. There are smears of blood on his pillow.
Recall:
The condition of Mr Browns suggests that he is having difficulty in functioning, sleeping, understanding and sleeping. The condition signifies that he might have developed cerebral haemorrhage after being hit by the car.
Process Information
Interpret:
Normal
Abnormal
Absence of active bleeding
No to mild headache
Can understand properly and respond to the questions
Aware of surroundings and properly oriented
Active bleeding seen
Moderate to severe headache
Difficulty in understanding and responding to questions
Confused and disoriented
Relate& Infer:
Relate the two most significant abnormal findings to the underlying physiology/pathophysiology to justify why it is considered abnormal in this context.
Based on your interpretation of all the information/cues presented, form an overall opinion on what may be happening and justify your answer
When a person is hit on head violently, then loss of cognitive abilities gives few possible diagnoses like haemorrhage. Mr. Brown was a perfectly normal person before the accident but after the accident he had difficulty in understanding what was being said to him and he also failed to obey the commands. It suggests that some of his brain area which is related to the function of comprehension is affected. However, his memory remains intact as he could recall walking his dog. Also he was unaware of his surroundings, he looked confused and disoriented which further suggested a possibility of internal injury of brain as these symptoms would not have appeared if it was only a superficial wound.The bleeding which smeared Mr. Brown’s pillow and didn’t stop suggests an cerebral haemorrhage. In normal condition if it was a superficial wound like thought by the professional, the bleeding would have stopped. But the continuous bleeding suggests that blood is oozing from inside and on accumulation the blood mass can dissect through and compress adjacent brain tissues which can result in neuronal dysfunction. If the haematoma is large or grows to be large if not unattended can raise cranial pressure. Pressure from supratentorial hematomas and the accompanying edema may cause transtentorial brain herniation, compressing the brain stem and often causing secondary hemorrhages in the midbrain and pons (Foresberg et. al, 2014). Also, if a rupture of the hemorrhage occurs into the ventricular system, blood can lead to acute hydrocephalus. The hematomas can grow to block the 4th ventricle and may cause acute hydrocephalus, or they can dissect into the brain stem. The hematomas that are more than 3 cm in diameter may cause midline shift or herniation. Herniation, midbrain or pontine hemorrhage, intraventricular hemorrhage, acute hydrocephalus, or dissection into the brain stem can impair consciousness and cause coma and death(Tanner, 2006).The bleeding leads to compression of brain and prohibiting the flow of oxygen-rich blood into the brain tissue. The lack of oxygen can result in brain swelling. The extra pressure created as a result of the reduced oxygen results in death of brain cells.
Predict:
What may happen to your patient if you take NO action and why?
Mr. Brown suffers from an internal injury in brain which was not attended to on his admission. He developed a complication possibly a haematoma was developed. The haematoma can grow to be massive if not attended immediately. The developed haematoma will require immediate surgery for its removal and if not operated then the areas of the brain it affects can lose its function. Mr. Brown can become irreversible cognitively impaired, may slip into indefinite period of coma or even die.
Identify the Problem/s
List in order of priority at least three key nursing problems
1. Improper wound management
2. Lack of reporting of newly developed symptoms to senior professionals
3. Lack of review of Mr. Brown’s condition in night
Establish Goals & Take Action
From the above (identify problems), use the top 2 nursing problems identified and for each of these establish one goal and thenlist related actions you would undertake, including detailing any relevant nursing considerations
Problem 1
Goal
Related actions
Rationale
Improper wound management
Providing a proper wound care following all the steps of wound management guidelines.
Training should be given to the nurses for proper wound management and a review of wound management should be done regularly.
Information regarding wound assessment and care can be provided to the nurse in the form of memo, flyers, etc.
The regular training keeps the nurses informed with the updated practices and guidelines of wound management and avoids the chances of error.
Problem 2
Goal
Related actions
Rationale
Lack of reporting of newly developed symptoms to senior professionals
Development of a formal and effective communication system between healthcare professionals from top-down hierarchy.
Involving the policy makers in developing an efficient procedure for enhancing the flow of communication which will include penalty in cases of miscommunication or failing to communicate.
Nurses should be made more comfortable in addressing the senior professionals by adopting an open door policy.
The breakdown of communication system can result in failure of the organisation. In particular it affects the safety of the patient and violation of his/her rights.
Evaluate outcomes& Reflect on new learning
Briefly describe how you would evaluate the effectiveness of the care providedand reflect on how this encounter has informed your nursing practice if you were to encounter a similar situation in the future
The care provided to Mr. Brown was of substandard nature risking his life and not adhering to the guidelines of patient safety. If the service provision was effective in Brown’s case his case may have been saved from developing complications.
However, I learnt from Mr. Brown’s case that no wound should be taken lightly and a proper wound assessment and management should be undertaken. I also believe that it is important to review patients regularly as the patient may develop certain symptoms or develop complications later. It becomes important to communicate and document accurately regarding the condition of the patient so that the doctors can his condition accurately and formulate therapeutic interventions. In future, if I will ever encounter such situation I will ensure that I have assessed the wound properly and will regularly check on the patient or ask the other nurse on shift to check on patient’s condition timely(Meissner, 2011).
References
Abel, W., & Freeze, M. 2006.Evaluation of concept mapping in an associate degree nursing program.Journal of Nursing Education, 45 (9), pp. 356-364.
Allen, G., Rubenfeld, M. G., &Scheffer, B., 2004. Reliability of assessment of critical thinking.Journal of Professional Nursing, 20 (1), pp. 15-22.
Banning, M. (2008). The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students. Nurse Education Today , 28, 8-14.
Burns, H., O’Donnell, J., &Artman, J., 2010. High-fidelity simulation in teaching problem solving to 1st year nursing students: A novel use of the nursing process. Clinical Simulation in Nursing, 6, 87-95.
Chabeli, M. (2007). Facilitating critical thinking within the nursing proces framework: A literature review. Health SA Gesondheid, 12 (4), 69-89.
Di Vito-Thomas, P. (2005). Nursing student stories on learning how to think like a nurse. Nurse Educator, 3, 133-136.
Duchscher, J. (2003). Critical thinking: Perceptions of newly graduated female baccalaureate nurses. Journal of Nursing Education, 42 (1), 14-27.
Ellermann, C., Kataoka-Yahiro, M., & Wong, L. (2006). Logic models used to enhance critical thinking. Journal of Nursing Education, 45 (6), 220-227.
Facione, N., &Facione, P. (1996). Externalizing the critical thinking in knowledge development and clinical judgment.Nursing Outlook, 44, 129-136.
Facione, P. (1990). Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction. Research findings and recommendations.
Ferguson, L., Yonge, O., & Myrick, F. (2004). Students’ involvement in faculty research: Ethical and methodological issues. International Journal of Qualitative Methods, 3 (4), 1-14.
Forsberg, E., Ziegert, K., Hult, H., &Fors, U. (2014). Clinical reasoning in nursing, a thinkaloud study using virtual patients – A base for an innovative assessment.Nurse Education Today, 34, 538-542.
Glynn, D. (2012). Clinical judgment development using structured classroom reflective practice: A qualitative study. Journal of Nursing Education, 51 (3), 134-139.
Goudreau, J., Boyer, L., & Letourneau, D. (2014). Clinical nursing reasoning in nursing practice: A cognitive learning model based on a think aloud methodology. Quality Advancement in Nursing Education, 1(1), 1-18.
Gruppen, 2002. Clinical Reasoning. Dordrecht: Springer International Handbook of Research in Medical Education.
Kuiper, R., &Pesut, D. (2004).Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: Self-regulated learning theory.Issues and Innovations in
Lee, M., &Brysiewicz, P. (2009). Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students.Nurse Education Today, 29, 389-397.
Levett-Jones, T., Hoffmann, K., Dempsey, J., Yeun-Sim Jeong, S., Nobel, D., Norton, C., Hickey, N. (2010). The ‘five rights’ of clinical reasoning: An educational model to
Marchigiano, G., Eduljee, N., & Harvey, K. (2011). Developing critical thinking skills from clinical assignments: A pilot study on nursing students’ self-reported perceptions.Journal of Nursing Management, 19, 143-152.
Meissner, 2011.Exploring indigenous health using the clinical reasoning cycle: a student paper.Contemporary Nurse, 37(1), pp.82-9.
Newark: American Philosophical Association.
Newton, S., & Moore, G. (2013).Critical thinking skills of basic baccalaureate and accelerated second-degree nursing students.Nursing Education Perspectives, 34 (3), 154-158.
Nursing Education, 45 (4), 381-391.
Paans, W., Sermeus, W., Nieweg, R., & Van Der Schans, C. (2010). Determinants of the accuracy of nursing diagnoses: Influence of ready knowledge, knowledge sources, dispostion toward critical thinking, and reasoning skills. Journal of Professional Nursing, 26 (4), 232-241.
Parsons, S., & Teel, V. (2012). Double testing: A student perspective. Nursing Education Perspectives, 34 (2), 127-128.
Tanner, C. (1998). State of the science: Clinical judgment and evidence-based nursing practice: Conclusions and controversies. Communicating Nursing Research, 31, pp. 14-26.
Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45 (6), pp. 204-211.
Thompson, C., &Stapley, S. (2011). Do educational interventions improve nurses’ clinical decision making and judgement? A systematic review. International Journal of Nursing Studies, 48, pp. 881-893.
Thorne, S. (2008). Interpretive description. Walnut Creek, CA: Left Coast Press.
Van Horn, R. (2000). The reflective process in nursing clinicals using journaling and dialogue. Andrews University, pp. 1-179.
Wangensteen, S., Johansson, I., Bjorkstrom, M., & Nordstrom, G. (2010). Critical thinking dispositions among newly gradated nurses.Journal of Advanced Nursing, 66 (10), 2170-2181.
Wilkinson, J. (2012). Nursing process and critical thinking. Upper Saddle River, NJ: Pearson.
Wotton, K., Davis, J., Button, D., & Kelton, M. ,2010. Third-year undergraduate nursing students’ perceptions of high-fidelity simulation.Journal of Nursing Education, 49 (11), pp. 632-639.
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