NUR4153CBE Clinical Reasoning and Clinical Judgment
Deliverable 1 - How is Clinical Decision Making Influenced?
Competency
Evaluate factors integral to clinical reasoning.
Scenario
You are working as a charge nurse on a medical-surgical unit in an acute healthcare facility. One of the staff nurses who recently from bereavement leave has been assigned to care for an elderly client, newly diagnosed with stage IV pancreatic cancer. While you are visiting with the client, the nurse is completing her assessment. The client requests assistance to set up hospice care, complete an advanced directive, and reach out to his estranged daughter. The nurse stated, “I can get you the paperwork for the advance directive, but I can’t call your child for you, I am not a social worker.” The nurse leaves the room and asks to speak with you stating, “I can’t care for this client, I need my client assignment changed now or else I will go home."
As the charge nurse, you step in and change the nurse’s client assignment and offer to assist the client with his requests. Later, you have the opportunity to debrief with the nurse regarding her reaction and decisions regarding the client’s requests and make some recommendations on how the nurse could have responded differently. You write up a summary of the events and include the follow-up conversation with the nurse.
Instructions
Compose a written memo of the situation and debrief for the employee’s personnel file. Include the following in the summary:
Analysis of the internal and external cues impacting the responses of the staff nurse and the charge nurse.
Describe how these factors influenced the clinical decision making of both nurses.
Emotional intelligence action plan for the nurse based on interactions observed with the client and the charge nurse.
Include self-compassion and compassion toward others.
Include an alternative response from the staff nurse and charge nurse.
Resources
How do you compose a memo?
How can I make a Research Appointment with a Rasmussen College Librarian?
Rasmussen Writing Guide
APA Guide
NUR4153CBE Clinical Reasoning and Clinical Judgment
Deliverable 2 - The Impact of Relational Inquiry
Competency
Explain the impact of relational inquiry when recognizing and analyzing cues to action in the process of clinical reasoning.
Scenario
You are a nursing student in a BSN Program, currently enrolled in a Leadership course. As part of your current immersion experience, you are working with the charge nurse in the operating room. In pre-op on the first day of this clinical experience, you observe an upset client refusing to sign a surgery consent unless a small religious object could accompany him and stay attached to his body. This object is a key component of his cultural beliefs, and he will cancel the surgery if he is unable to keep the religious object attached to his body. The charge nurse states, “Let me check and see what we can do, I will need a bit of time to collaborate with others and see if we can identify a solution.” You observe the charge nurse gather a team of nurses in the pre-op area and begin reviewing the policy and procedure manuals for the facility to determine if a solution can be identified to allow the object to be taken into the operating room. While the healthcare team was looking for a solution, someone recommended that the object is wrapped in non-conductive material, and applied to the client under a sterile dressing. According to policy, this would work with Surgeon approval.
Instructions
In post-conference, you debrief with a faculty member and discuss this powerful example of healthcare team members working together to support and respect a client’s unique cultural needs and belief system. The clinical faculty tells you to complete a clinical journal entry which describes the process involved in this example of professional practice. Include the following in your journal entry:
Explain how relational inquiry was applied in this situation to promote the process of clinical reasoning.
From context and culture
Optimization of health and well-being
Collaborating across differences
Do you believe this action was appropriate, and why or why not?
Provide a supporting argument to defend choice for appropriate or non-appropriate response by the nurse and include personal biases.
Resources
APA Guide
Nursing Research
Hamilton, S. (2016). Reflective writing: a user-friendly guide. British Journal Of Nursing, 25(16), 936-937.
McMillan-Coddington, D. (2013). Reflection through journal writing to educate registered nursing students on patient care Click for more options . Teaching And Learning In Nursing, 863-67. doi:10.1016/j.teln.2012.09.004
Regmi, K., & Naidoo, J. (2013). Understanding the processes of writing papers reflectively. Nurse Researcher, 20(6), 33-39.
NUR4153CBE Clinical Reasoning and Clinical Judgment
Deliverable 3 - Clinical Reasoning Appropriate for the Situation
Competency
Integrate modes of inquiry to generate and evaluate hypotheses in the context of clinical reasoning.
Scenario
You recently finished new graduate orientation in the emergency room (ER) of a rural, 60-bed hospital, and tonight is the first shift you have worked independently. The Intensive Care Unit of the hospital has only four beds and usually sends the sickest clients in need of complex care to a regional medical facility located 50 miles from your location. During orientation, you were told repeatedly the purpose of treatment in this ER is triage, stabilize, and send home or send to a larger network facility.
Tonight your first client is an 82-year-old female named Ruth. Ruth was dropped off at the ER by a neighbor who said that she had nausea and vomiting for a week. Her husband was recently admitted to an Alzheimer’s Unit at a local Long-Term Care facility, and the neighbor thought stress was making it hard for Ruth to eat, but tonight she vomited up fresh blood and appeared dizzy. The neighbor also brought in a bag of medication she found in the home but was unsure which medication belonged to Ruth or her husband.
When you enter the room to begin the assessment, you find a frail woman sitting in a wheelchair with apparent labored breathing. She appears dirty with matted hair clothed in a bathrobe with numerous food stains and has a heavy smell of cigarette smoke. You notice the chart has a highlighted area noting the client has only Medicaid for insurance. You ask her if she understands why she is in the ER and she asks, “Where is my husband? He is usually home by now.”
Past medical history:
Two pack per day smoker for 58 years
Type I Diabetic
Assessment data:
Blood pressure: 178/98
Heart rate: 84 beats per minute
Oxygen saturation: 84
Temperature: 101.8 degrees Fahrenheit
Hyperactive bowel sounds in all 4 quadrants
An open wound on the bottom of right foot
Instructions
You are feeling overwhelmed with your first client but remember first you need to evaluate internal and external cues to develop a priority hypothesis to guide clinical reasoning. Create notes for this client’s plan of care including:
Design a hypothesis for each of the four modes of inquiry: empirical, ethical, aesthetic and sociopolitical.
Prioritize the most relevant hypothesis aligned with data in the scenario and demonstrate appropriate clinical reasoning.
Design an evaluation plan for the priority hypothesis.
NUR4153CBE Clinical Reasoning and Clinical Judgment
Deliverable 4 - Make the Best Choice for the Right Situation
Competency
Determine appropriate responses when integrating situated cognition into clinical reasoning.
Scenario
One week ago, you started your dream job as an orthopedic nurse at a Level 1 Trauma Center in a metropolitan city of 3.7 million people. The hospital has ranked as the #5 Trauma Orthopedic Specialty Unit in the United States for eight years. At this point during orientation, you are permitted to care for one stable client per 12-hour shift. Today you start your shift with Ryan; a 25-year-old admitted through the Emergency Room after a motor vehicle accident with rollover resulting in a fractured right femur, multiple rib fractures, sternal bruises, and multiple abrasions. He is two hours post-op from an open reduction internal fixation of the right femur and appears alert and oriented. When you enter the room his first statement is, “Can someone please get me a cigarette or a patch; I have not had a smoke since yesterday morning!”
Assessment Data:
The client is sitting up in bed with thigh-high anti-embolism stockings on the left leg only.
Dressings to multiple abrasions appear dry.
Urine in Foley Bag amber colored and urinary output in the past 2 hours 40cc
Pain reported as 8 on a scale of 10 with a goal of 5
Vital signs:
BP 130/80
Heart Rate 92
O2 Sats 94% on 4L Nasal Cannula
Blood Gases:
pH 7.32
PaCO2 53 mmHg
HCO3 22mmol/L
Pao2 84mm Hg
Physician’s Orders:
Bed Rest Only
Clear Liquid Diet
Oxygen to maintain Spo2 of 92% or greater
ABGs repeated every 4 hours
Discontinue PCA and consult pain management
Administer tetanus and flu immunizations before discharge
Administer 1-2mg Morphine IV every 4-6 hours as needed for breakthrough pain
As you review the assessment data and physician orders, you plan client care and determine six nursing interventions you believe are appropriate and should be completed in this order within the next hour:
Administer 2mg Morphine IV now for breakthrough pain
Apply anti-emoblism stockings bilaterally
Call the physician to get an order for Nicotine Patch and report decreased urinary output with amber urine
Input consult for pain management into the electronic order system
Decrease O2 to 2L Nasal Cannula and continue Sp02 monitoring
Administer tetanus immunization
Instructions
As you write down the proposed interventions, the nurse manager stops by to check on your progress and asks you a few questions regarding your decisions. The nurse manager is disappointed and states, “One of these actions is not correct I want you to write down what you believe is the best choice from your list to do immediately and the action you believe is incorrect and should not be done. I will be back in 10 minutes to discuss your thoughts."
On a document provide detailed responses to these questions:
What is the best action to perform first from the six actions identified as part of planned client care for this particular client?
What is the best action to perform second from the six actions identified as part of planned client care for this particular client?
What is the best action to perform third from the six actions identified as part of planned client care for this particular client?
What is the best action to perform fourth from the six actions identified as part of planned client care for this particular client?
What is the incorrect action?
NUR4153CBE Clinical Reasoning and Clinical Judgment
Deliverable 5 - Clinical Judgment is a Dynamic Process
Competency
Modify clinical judgment within an iterative, outcome-based cycle of clinical reasoning and client needs.
Scenario
As part of the clinical portion of your BSN Capstone course in your senior semester, you have the opportunity to attend a two-day seminar with senior nursing students from other academic institutions. The theme of this seminar is the application of clinical judgment to determine the best evidence-based solutions for nursing practice.
Instructions
For a clinical judgment roundtable with faculty and students that is sponsored by your academic institution, you must prepare one scenario based handout to promote robust discussion regarding the application of clinical judgment as an outcomes-based dynamic cycle of clinical reasoning and client needs. The handout must contain these components:
Describe a clinical situation where you applied an outcome-based cycle of clinical reasoning to select what you considered the “best” client intervention based on information available.
Include relevant external and internal cues and hypotheses
Discuss the outcomes based, iterative cycle of clinical reasoning you applied after the initial intervention to select the next “best” interventions appropriate for the particular situation based on client needs.
Rationales and evidence based findings were included to support choices for the next “best” interventions
NUR4153CBE Clinical Reasoning and Clinical Judgment
Deliverable 6 - Lifelong Learning is Part of Nursing Practice
Competency
Evaluate the importance of personal and professional lifelong learning, including the interrelationships of clinical reasoning and clinical judgment.
Scenario
As a BSN prepared Registered Nurse, you are due to renew your license for the first time. You and your manager overhear other nurses complaining about the continuing education requirement. Your manager suggests you create a handout for the staff lounge bulletin board regarding the importance of lifelong learning as it pertains to clinical reasoning and judgment. To help you get started, she suggests you read the Institute of Medicine (IOM) report titled The Future of Nursing: Leading Change, Advancing Health (2010) so that you will understand “why” it is so important.
Instructions
Read Section 4 of the IOM report (2010) titled Transforming Education here and respond to the following questions in a Word document.
Describe an initiative that resulted from the IOM report.
Discuss the impact of the identified initiative.
Summarize the interrelationships that exist between lifelong learning, clinical reasoning, and clinical judgment.
Resources
How can I make a Research Appointment with a Rasmussen College Librarian?
Rasmussen Writing Guide
APA Guide
NUR4153CBE Clinical Reasoning and Clinical Judgment
Deliverable 7 - The Dynamic Process of Clinical Judgement
Competencies
Evaluate factors integral to clinical reasoning.
Explain the impact of relational inquiry when recognizing and analyzing cues to action in the process of clinical reasoning.
Integrate modes of inquiry to generate and evaluate hypotheses in the context of clinical reasoning.
Determine appropriate responses when integrating situated cognition into clinical reasoning.
Modify clinical judgement within an iterative, outcome-based cycle of clinical reasoning and client needs.
Scenario
You are a student in the last term of a BSN Program. You are preparing for an end of term exam. To help you prepare, your instructor developed three real world clinical scenarios to provide opportunities for you to apply clinical reasoning and clinical judgement. The instructor stated, “You received reports on these clients. Decide which one you need to see first and then make appropriate nursing decisions based on relevant information to promote positive client outcomes.”
The three scenarios include:
Patient one - JR is a 55 year old male admitted 8 hours prior for 24 hour hold to evaluate for possible myocardial infarction. Serial Troponins within normal range and 12 lead ECG indicated evidence of prior right anterior wall myocardial damage
Patient two – EH is a 40 year old female admitted within the past hour with acute onset severe right upper quadrant pain and vomiting for the past 36 hours. Waiting on labs, ECG monitoring showing occasional premature ventricular contracts (PVCs).
Patient three - BW is a 21 year old male athlete admitted yesterday with fever of 103 and diagnosis of influenza. He rested well overnight. Morning chest x-ray revealed mild infiltrates in left lower lobe.
Instructions
Record your answers to these statements.
Rank the three scenarios provided in order of priority related to which client you will assess first, second and third.
Defend your selection for the three ranked scenarios.
Review the data below for the priority client to determine what to assess first.
Chest X-ray no abnormalities noted
Abdominal X-ray :diffuse gas throughout the small intestine
Hyperactive bowel sounds in all 4 quadrants and abdomen painful to touch
Pain level 10/10
Sodium (Na+) 147 mmol/L
Potassium (K+) 2.9 mmol/L
Chloride (Cl-) 100 mmol/L
Magnesium (Mg2+) 1.4 mg/dL
Calcium (Ca2+) 9.2 mg/dL
Phosphorus (P+) 2.3 mg/dL
Glucose 188 mg/dL
Serum albumin 3.0 g/dL
Amylase 185 unit/L
Serum Creatinine 0.5 mg/dL
BUN 15 mg/dL
Alkaline Phos. 155 unit/L • Protein 8.6 g/dL Bilirubin 3.5 mg/dL
Formulate three hypotheses based on cues provided
Select the priority hypothesis
Defend your selection
Describe an evaluation plan for the priority hypothesis based on expected client outcomes
Describe the next steps in the clinical judgement model including:
Actions if satisfied with client outcomes
Actions if not satisfied with client outcomes
