NUR4153CBESection 01CBE Clinical Reasoning and Clinical Judgement (6 Months) – CBE – 2020 Winter Six Month 2

Deliverable 1 – How is Clinical Decision Making Influenced?

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.

Deliverable 2 – The Impact of Relational Inquiry

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.

Deliverable 3 – Clinical Reasoning Appropriate for the Situation

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.

Grading Rubric