Clinical Assessment and Diagnostic Reasoning Case Studies

For this unit we had two case studies, then given further information, and then had to utilise the new information for part B of the case studies. I received a Pass for the first essay, a Distinction each for the second and third essays

Please note my writings are published for educational purposes only, all of my works have been submitted to Turnitin so please do not copy and paste or you will be flagged for plagiarism. My reference list is included at the bottom.

Case Study 1A Brendan (PASS)

Methods of gathering further information.
Gathering information for new patients typically begins with handover. Handover is a fundamentally important part of clinical practice in which patient information is communicated between nurses, generally at shift changeover (Matic et al., 2011). Studies have shown that various factors including poor communication, interruptions, high workload and noise can negatively impact the quality of patient information given verbally (Matic et al., 2011; Manser, & Foster, 2011). A review of progress notes entered by other nurses and medical staff should then be undertaken, as well as reviewing patient history, charts, investigation results and prior assessments (Levett-Jones, 2018). While taking new observations Brendan should be asked if he is thirsty, where his pain is, about his mental state and perform a complete A – G assessment (Cathala & Moorley, 2020). A urinalysis can be performed to check for abnormalities (Health Direct, 2020), and a bladder scan should be given to rule out blockage (The Royal Children’s Hospital Melbourne, 2020). A fluid challenge can be given to establish volume depletion (Cecconi et al., 2011) and further diagnostic tests such as an arterial blood gas test and ultrasounds can be ordered by Brendan’s GP.

Brendan’s immediate and short-term problems.
Bleeding is among the common complications after abdominal surgery that needs prompt attention to prevent becoming life-threatening (Hébert et al., 2019). Brendan’s observations may alternatively indicate a deficiency in fluid volume that can result in hypovolaemic shock (Nursing Times, 2011). Combined with his hyperglycemia this can also result in a life-threatening situation (Stoner, 2017). Some of Brendan’s observations are also symptoms of sepsis (O’Connell, 2018), this should also be further investigated. Brendan has been overusing his PCA due to increased pain levels. PCA morphine use has been shown to be reduced after surgery when additional pain relief such as paracetamol or NSAIDs are used (Maund et al., 2011) and may aid in lowering Brendan’s pain level and self-administration of PCA. In the short term, Brendan needs to be able to tolerate a normal diet and a return of normal bowel function before he can be discharged from hospital (Sindell et al., 2012).

How clinical reasoning has been applied.
In paragraph one stage 2 of the Clinical Reasoning Cycle (Levett-Jones, 2018) has been used to obtain additional information and begin thinking about how best to treat Brendan. In paragraph two stage 4 has been used to identify potential issues that will need immediate or short-term treatment (Levett-Jones, 2018). In this paragraph stage 3 has been used to process the information that has been collected and apply reasoning to identify the best course of treatment for Brendan (Levett-Jones, 2018). Narrative reasoning has been applied to collect more information from Brendan via communication (Boyer, Tardif & Lefebvre, 2015). Prior to colorectal surgery patients are required to undergo bowel preparations which can cause dehydration (Moghadamyeghaneh et al., 2014). Since Brendan’s symptoms point to a fluid deficiency after a partial colectomy procedure, inductive reasoning has been applied to hypothesise that although he could be septic or bleeding internally, Brendan is more likely to be hypovolaemic (Ingham-Broomfield, 2015) and should be given additional IV fluids. Deductive reasoning has then been applied to conclude that giving Brendan supplementary pain relief may lower his self-administering of morphine (Ingham-Broomfield, 2015). 

References:
Boyer, L., Tardif, J., & Lefebvre, H. (2015). From a medical problem to a health experience: How nursing students think in clinical situations. Journal of Nursing Education, 54 (11), 625-632. https://doi.org/10.3928/01484834-20151016-03
Cathala X, & Moorley C. (2020, January 6). Performing an A-G patient assessment: a practical step-by-step guide. Nursing Times. 116(1), 53-55. https://www.nursingtimes.net/clinical-archive/assessment-skills/performing-an-a-g-patient-assessment-a-step-by-step-guide-06-01-2020/
Cecconi, M., Parsons, A., & Rhodes, A. (2011). What is a fluid challenge? Current Opinion in Critical Care. 17(3), 290-295. https://doi.org/10.1097/MCC.0b013e32834699cd
Health Direct. (2020, July 3). Urine tests. https://www.healthdirect.gov.au/urine-tests
Hébert, J., Eltonsy, S., Gaudet, J., & Jose, C. (2019). Incidence and risk factors for anastomotic bleeding in lower gastrointestinal surgery. BMC Research Notes, 12(1). https://doi.org/10.1186/s13104-019-4403-0
Ingham-Broomfield, R. (Becky) (2015). A nurses’ guide to qualitative research. Australian Journal of Advanced Nursing, 32(3), 34-40.
Levett-Jones, T. (2018). Clinical reasoning: What is it and why it matters. In Clinical Reasoning: Learning to think like a nurse (pp. 4-13). Pearson.
Manser, T., & Foster, S. (2011). Effective handover communication: an overview of research and improvement efforts. Best practice & research Clinical anaesthesiology, 25(2), 181-191. https://doi.org/10.1016/j.bpa.2011.02.006
Matic, J., Davidson, P. M., & Salamonson, Y. (2011). Bringing patient safety to the forefront through structured computerisation during clinical handover. Journal of clinical nursing, 20(1‐2), 184-189. https://doi.org/10.1111/j.1365-2702.2010.03242.x
Maund, E., McDaid, C., Rice, S., Wright, K., Jenkins, B., & Woolacott, N. (2011). Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. British journal of anaesthesia, 106(3), 292–297. https://doi.org/10.1093/bja/aeq406
Moghadamyeghaneh, Z., Phelan, M. J., Carmichael, J. C., Mills, S. D., Pigazzi, A., Nguyen, N. T., & Stamos, M. J. (2014). Preoperative dehydration increases risk of postoperative acute renal failure in colon and rectal surgery. Journal of Gastrointestinal Surgery, 18(2), 2178-2185. https://doi.org/10.1007/s11605-014-2661-7
Nursing Times. (2011). Measuring and managing fluid balance. Nursing Times. https://www.nursingtimes.net/clinical-archive/nutrition/measuring-and-managing-fluid-balance-15-07-2011/
O’Connell, K. (2018, August 31). Sepsis: Symptoms, Effects, and Causes. Healthline. https://www.healthline.com/health/sepsis
Sindell, S., Causey, M. W., Bradley, T., Poss, M., Moonka, R., & Thirlby, R. (2012). Expediting return of bowel function after colorectal surgery. The American journal of surgery, 203(5), 644-648. https://doi.org/10.1016/j.amjsurg.2011.12.007
Stoner, G. D. (2017). Hyperosmolar hyperglycemic state. American family physician, 96(11), 729-736. https://www.aafp.org/afp/2017/1201/p729.html
The Royal Children’s Hospital Melbourne. (2020). Clinical Guidelines (Nursing): Indwelling urinary catheter – insertion and ongoing care. The Royal Children’s Hospital Melbourne. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Indwelling_urinary_catheter_insertion_and_ongoing_care/

Case Study 2A Molly (DISTINCTION)

Methods of gathering further information.
Gathering further information for Molly after receiving handover should proceed with reviewing medical progress notes, previous charts, history and investigation results (Levett-Jones, 2018). Molly should be questioned further about her chest pain to investigate the cause and if she has pain anywhere else. Why Molly fell might provide some insight into her symptoms, did she fall because she could not see clearly due to cataracts or because she grew lightheaded? Does Molly have any history of heart conditions, and has she been prescribed other medications for this if so? Assessments for Molly within the Registered Nurse scope include blood glucose levels, complete A – G assessment, pain scale, Braden Scale for pressure injury risk, and delirium assessment tools such as Delirium Rating Scale or Confusion Assessment Method (Smith et al., 2017). Molly’s symptoms easing when she rests may be an indication of Orthostatic Hypotension so an orthostatic stress assessment should be performed to evaluate her blood pressure response (Shaw & Claydon, 2013). Further diagnostic tests such as an electrolyte panel should be ordered to detect electrolyte imbalances.

Molly’s immediate and short-term problems.
Molly’s immediate concerns include heart failure, post-operative delirium and pressure ulcers (Flikweert et al., 2017), however delirium is the most common complication experienced after hip fracture surgery (Smith et al., 2017). In addition, successfully managing pain is crucial to minimising the risk of delirium and improving recovery time (Abou-Setta et al., 2011). As Molly has many of the risk factors of delirium such as her age, cognitive impairment and vision impairment, appropriate early nursing interventions (including IV fluid, oxygen, pain relief and more frequent vitals observations) should be focussed on reducing the degree of delirium (Boddaert et al., 2014). Skin integrity should be assessed frequently along with reviewing pressure area care and implementing pressure-relieving interventions and position changes. Molly’s short-term problems include electrolyte imbalances and urine retention (Flikweert et al., 2017), and she might benefit from having a nursing assistant assigned to monitor her directly and aid with mobilisation.

How clinical reasoning has been applied.
Stage 2 of the Clinical Reasoning Cycle (Levett-Jones, 2018) has been used to consider how to gather new information to determine the appropriate nursing interventions for Molly. Stage 4 of the Clinical Reasoning Cycle (Levett-Jones, 2018) has been used to establish which problems need immediate interventions and which are short term problems. In this third paragraph, Stage 3 of the Clinical Reasoning Cycle (Levett-Jones, 2018) has been used to begin processing the collected information into the most relevant inference of cues collected. Since Molly has many risk factors for delirium and is experiencing confusion, agitation, dyspnoea and tachycardia, inductive reasoning has been used to presume she may be experiencing post-operative delirium. However as some of her symptoms ease upon laying down, orthostatic hypotension may also be the cause of her symptoms. Deductive reasoning been applied to advocate appropriate assessments and interventions to prevent pressure injuries due to decreased mobility following hip fracture surgery. Narrative reasoning has been applied to converse with Molly for further information.

References
Abou-Setta, A. M., Beaupre, L. A., Rashiq, S., Dryden, D. M., Hamm, M. P., Sadowski, C. A., … & Jones, C. A. (2011). Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Annals of internal medicine, 155(4), 234-245. https://doi.org/10.7326/0003-4819-155-4-201108160-00346
Boddaert, J., Raux, M., Khiami, F., & Riou, B. (2014). Perioperative management of elderly patients with hip fracture. Anesthesiology, 121(6), 1336-1341. https://doi.org/10.1097/ALN.0000000000000478
Flikweert, E. R., Wendt, K. W., Diercks, R. L., Izaks, G. J., Landsheer, D., Stevens, M., & Reininga, I. H. F. (2017). Complications after hip fracture surgery: are they preventable? European Journal of Trauma and Emergency Surgery, 44(4), 573–580. https://doi.org/10.1007/s00068-017-0826-2
Levett-Jones, T. (2018). Clinical reasoning: What is it and why it matters. In Clinical Reasoning: Learning to think like a nurse (pp. 4-13). Pearson.
Shaw, B. H., & Claydon, V. E. (2013). The relationship between orthostatic hypotension and falling in older adults. Clinical Autonomic Research, 24(1), 3–13. https://doi.org/10.1007/s10286-013-0219-5
Smith, T. O., Cooper, A., Peryer, G., Griffiths, R., Fox, C., & Cross, J. (2017). Factors predicting incidence of post‐operative delirium in older people following hip fracture surgery: a systematic review and meta‐analysis. International journal of geriatric psychiatry, 32(4), 386-396. https://doi.org/10.1002/gps.4655

Case Study Part B (DISTINCTION)

Case Study 1: Brendan
Problems
Brendan’s problems are hyperkalemia, hypertension, hyperglycemia and impaired renal function. Brendan’s bradycardia, hyperglycemia, high serum potassium level and an electrocardiogram (ECG) showing rhythm changes are clinical indications of moderate hyperkalemia. Common factors contributing to hyperkalemia include hyperglycemia, medication use and impaired renal function (Viera & Wouk, 2021). ACE inhibitors can increase potassium levels due to angiotensin II suppression decreasing the levels of aldosterone causing potassium to be retained instead of excreted and Brendan has been taking Ramipril, which is an ACE inhibitor. Uncontrolled diabetes is another factor in which insulin resistance can prevent potassium from entering cells; Brendan’s repeated high blood sugar levels and being slightly overweight are indicative of undiagnosed diabetes. Hypertension and diabetes are often experienced together and share common causes (Cheung & Li, 2012). Decreased estimated glomerular filtration rate (eGFR), increased creatinine levels and elevated glycated haemoglobin (HbA1c) levels are indications of Chronic Kidney Disease (CKD) (Ceriello et al., 2017). Other risk factors for CKD are Brendan’s age, gender, being of Indigenous Australian descent, history of smoking, hypertension and potential undiagnosed diabetes (Kazancioğlu, 2013).

Goals/Plan
The goals for Brendan are to have his heart rate return to a normal rhythm, vital signs within normal parameters and have his pathology results within normal ranges. His heart rate needs be continuously monitored as high potassium levels lower myocardial conduction and bradycardia can lead to cardiac arrest (El-Sherif & Turitto, 2011). As Brendan’s high potassium level of over 6mmol/L and an abnormal ECG result warrants urgent medical care, he should be administered calcium gluconate and either insulin with glucose or albuterol (Viera & Wouk, 2021). Calcium gluconate protects the myocardium from the effects of high potassium concentration while insulin, glucose and albuterol promote the movement of potassium into cells (Mushiyakh et al., 2012). A loop diuretic such as furosemide can be given to stimulate potassium excretion and renal clearance. Brendan’s hypertension medication should be reviewed, his diabetes managed, and he should be informed about limiting intake of dietary sources of potassium. Pathology tests including serum potassium, creatinine and eGFR, blood gas analysis and urine output should be regularly conducted and monitored to evaluate the efficacy of treatment.

Reflection
Beginning this case study assignment was daunting for me, I felt overwhelmed by the information and doubted my ability to complete it successfully. Starting on Part A of Brendan I felt like I had to cite every source of information I wrote about as I was literally getting all my information from the literature because I have no background in healthcare prior to beginning my degree and thus felt I had no previous knowledge. Feedback for part A indicated I did not need to cite as much so I took this on board and attempted to trust that my recalled knowledge from prior living experience and learning would help me be less reliant on the literature to form my conclusions and used more sparingly to fill in the gaps and affirm my conclusions. Looking ahead I will remember that while researching literature is important to clinical practise, being able to remember what I already know is just as important to make the appropriate clinical judgement.

Case Study 2: Molly
Problems
Molly’s problems are suspected pulmonary embolism, chest pain, hypoxia, high risk for pressure injury and anaemia. Molly’s positive D-Dimer test confirms the existence of a thrombus and her ECG shows changes consistent with pulmonary embolism (PE). Chest pain and hypoxia are clinical presentations of PE along with syncope, delirium and tachycardia (Morrone & Morrone, 2018). Acute PE is a potentially life-threatening condition that needs prompt diagnosis (Morrone & Morrone, 2018). Molly’s normal troponin levels indicate an absence of injury to the heart muscle; however this needs to be retested at regular intervals to monitor for changes (Ferrari et al., 2012). Molly’s Waterlow Score of 20+ indicates she is at a very high risk of pressure area injuries (Webster et al., 2011). Molly’s Sp02 remains a little low despite being on a non-rebreather mask, the current rate of 70% might need to be adjusted to deliver a higher rate of oxygen. Molly also has a low haemoglobin (Hb) level which may have been caused by the Heparin she was prescribed or a poor diet.

Goals/Plan
The goals for Molly are to have arterial blood gases (ABG) within normal ranges, Sp02 at or above 90%, normal respiration, normal Hb levels and stable heart rate. The primary plan for Molly is to confirm the presence of a pulmonary embolism. As per the medical report a V/Q scan now needs to be performed to detect PE and if confirmed Molly should begin thrombolytic therapy to dissolve the clot and restore normal blood flow (Zuo et al., 2021). Although the underlying cause of Molly’s anaemia needs to be determined, the primary treatment that needs to be given to normalise her Hb levels is a blood transfusion (Busti et al., 2019). Additional plans are to commence continuous monitoring of ECG and troponin levels and Molly should be placed in the High Dependency Unit for around the clock monitoring. New ABGs should be ordered to assess the need for increasing the delivery rate of oxygen through the non-rebreather mask. A Risk Management Plan for preventing pressure injuries should also be implemented (Lovegrove et al., 2018).

Reflection
In the first part of Molly’s case study, I found how easy it is to display an ascertainment bias. Because of her elderly age and some of the initial information presented for her case study I focused too much on delirium and did not place enough importance on the potential for heart failure. Because of this I did not identify heart failure as an immediate problem that needed further nursing assessments to determine the cause. This failure to recognise the important deterioration cues meant that I did not adequately identify what nursing interventions Molly needed imminently which in a clinical setting could have a very poor outcome. I have learnt that I need to more carefully review all the available information to determine the appropriate questions to ask and assessments to perform in order to effectively evaluate which symptoms are most important and not just focus on a few that appear likely to fit with a patient’s age and situation. In my future practise I will be more aware of the need to disregard bias from my clinical process. 

References
Busti, F., Marchi, G., Zidanes, A. L., Castagna, A., & Girelli, D. (2019). Treatment options for anemia in the elderly. Transfusion and Apheresis Science, 58(4), 416-421. https://doi.org/10.1016/j.transci.2019.06.018
Ceriello, A., De Cosmo, S., Rossi, M. C., Lucisano, G., Genovese, S., Pontremoli, R., … & AMD‐Annals Study Group. (2017). Variability in HbA1c, blood pressure, lipid parameters and serum uric acid, and risk of development of chronic kidney disease in type 2 diabetes. Diabetes, Obesity and Metabolism, 19(11), 1570-1578. https://doi-org.ezproxy.scu.edu.au/10.1111/dom.12976
Cheung, B. M., & Li, C. (2012). Diabetes and hypertension: is there a common metabolic pathway?. Current atherosclerosis reports, 14(2), 160–166. https://doi.org/10.1007/s11883-012-0227-2
El-Sherif, N., & Turitto, G. (2011). Electrolyte disorders and arrhythmogenesis. Cardiology Journal, 18(3), 233-245. https://ezproxy.scu.edu.au/login?url=https://www-proquest-com.ezproxy.scu.edu.au/scholarly-journals/electrolyte-disorders-arrhythmogenesis/docview/2464202654/se-2?accountid=16926
Ferrari, E., Moceri, P., Crouzet, C., Doyen, D., & Cerboni, P. (2012). Timing of troponin I measurement in pulmonary embolism. Heart, 98(9), 732-735. https://doi.org/10.1136/heartjnl-2012-301724
Kazancioğlu, R. (2013). Risk factors for chronic kidney disease: an update. Kidney international supplements, 3(4), 368-371. https://doi.org/10.1038/kisup.2013.79
Lovegrove, J., Fulbrook, P., & Miles, S. (2018). Prescription of pressure injury preventative interventions following risk assessment: An exploratory, descriptive study. International wound journal, 15(6), 985-992. https://doi.org/10.1111/iwj.12965
Morrone, D., & Morrone, V. (2018). Acute Pulmonary Embolism: Focus on the Clinical Picture. Korean circulation journal, 48(5), 365–381. https://doi.org/10.4070/kcj.2017.0314
Mushiyakh, Y., Dangaria, H., Qavi, S., Ali, N., Pannone, J., & Tompkins, D. (2012). Treatment and pathogenesis of acute hyperkalemia. Journal of community hospital internal medicine perspectives, 1(4), 7372. https://doi.org/10.3402/jchimp.v1i4.7372
Viera, A. J., & Wouk, N. (2021). Potassium Disorders: Hypokalemia and Hyperkalemia. American Family Physician, 92(6), 487–495. https://www.aafp.org/afp/2015/0915/p487.html
Webster, J., Coleman, K., Mudge, A., Marquart, L., Gardner, G., Stankiewicz, M., … & McClymont, A. (2011). Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial). BMJ quality & safety, 20(4), 297-306. https://doi.org/ 10.1136/bmjqs.2010.043109
Zuo, Z., Yue, J., Dong, B. R., Wu, T., Liu, G. J., & Hao, Q. (2021). Thrombolytic therapy for pulmonary embolism. Cochrane Database of Systematic Reviews, (4). https://doi.org/10.1002/14651858.cd004437.pub6

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