DEVELOPING CLINICAL REASONING IN CRITICAL CARE PRACTICE A Comprehensive ...

59 Pages·2013·0.27 MB·English

by  Annie Hor

DEVELOPING CLINICAL REASONING IN
CRITICAL CARE PRACTICE

A Comprehensive Examination Presented to the Faculty
of
California State University, Stanislaus

In Partial Fulfillment
of the Requirements for the Degree
of Master of Science in Nursing
By
Marcelina Gracia-Lewis
May 2013
CERTIFICATION OF APPROVAL

DEVELOPING CLINICAL REASONING IN
CRITICAL CARE PRACTICE
By
Marcelina Gracia-Lewis

Signed Certification of Approval Page is
on file with the University Library

Dr. Carolyn Martin Date
Associate Professor of Nursing

Dr. Paula Le Veck Date
Professor of Nursing
© 2013

Marcelina Gracia-Lewis
ALL RIGHTS RESERVED
DEDICATION

This comprehensive is dedicated to my husband Myke and my children
Melyka, Colizel, Anesia & Philomen. Without their encouragement and love; none of
this would be possible.

iv
ACKNOWLEDGEMENTS

Drs. Carolyn Martin and Paula LeVeck are acknowledged for inspiring me to
seek my masters and their patience, guidance, and encouragement through the process
of completion.
My husband Myke Lewis-Tyson is acknowledged for the unwavering support,
understanding, and encouragement that he has given me through the duration of my
academic career.

v
TABLE OF CONTENTS
PAGE

Dedication ............................................................................................................... iv

Acknowledgements ................................................................................................. v

Abstract ................................................................................................................... vii

CHAPTER

I. Clinical Reasoning in Critical Care Nursing ........................................ 1

II. Teaching and Learning Strategies ......................................................... 11

III. Building Proficiency ............................................................................. 21

IV. Critical Care Orientation Model ........................................................... 31

V. Discussion ............................................................................................. 41

References ............................................................................................................... 44

vi
ABSTRACT

In critical care, nursing knowledge and clinical skills are advancing and grow more complex
in practice. It requires registered nurses to understand complex interventions in a highly
technical environment with advanced problem solving, decision making, and clinical
reasoning. With these advancements and the growing complexity of critical care, traditional
orientation programs that continue to separate theory from practice do not promote clinical
reasoning and inadequately prepare registered nurses to practice independently. To develop
clinical reasoning and become proficient in practice, orientation programs must emphasize
and promote experiential learning in the class and clinical settings. When clinical reasoning
and proficiency are developed, registered nurses understand the global picture of individual
situations and have the ability to provide appropriate care by managing rapidly changing
situations through judgment, thinking, and action. How clinical reasoning and proficiency are
developed and nurtured will be explored through specific teaching/learning strategies, nursing
competencies, and an experiential orientation model.
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CHAPTER I
DEVELOPING CLINICAL REASONING
The critical care environment is fast paced. A patient's condition may improve
or quickly deteriorate. Professional registered nurses (RNs) in an intensive care unit
(ICU) are faced with unpredictable situations and need to use evidence-based
knowledge to make quick decisions regarding patient care. They must be prepared to
anticipate and understand events that may threaten patient safety while preparing to
take action. Essentially, they must develop the ability to clinically reason. Clinical
reasoning is vital in critical care practice. It allows RNs to interpret new data and
changes in a patient's condition; to understand initial assessments and diagnostic
results. It allows RNs to identify a patient's changing condition and actions needed, in
order to provide safe care and to improve patient outcomes in an ICU (critical care)
environment.
Introduction
A critical care RN receives a patient from the emergency department (ED) that is
intubated, has two vasopressors infusing, normal saline (NS) at 200 milliliters (mls) per hour
and a NS bolus at 500 ml per hour. The patient’s systolic blood pressures remains low in the
80’s with the two vasopressors infusing at the maximum dose and the heart rate is accelerated
at 120-130 beats per minute. The oxygen (O2) demand and respiratory rate continues to
increase. The RN performs a complex assessment, with the primary focus on the cardiac and
respiratory status of the patient. The monitors are reassessed for accuracy and zeroed where
appropriate, medications are recalculated for accuracy and proper dosing, the ventilator is
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assessed for any discrepancies and for possible adjustments that may be made to improve the
respiratory status and decrease the O2 demand. Adjustments on treatments are made per
ordered protocol and a further assessment is performed after treatments are adjusted but there
is no improvement. At this moment, the RN must dig deeper to resolve the current crisis that
the patient is in. What could cause the current treatments to fail? What tests and procedures
should now be taken to solve this puzzle? The RN pulls information about the unresolved
hypotension with treatment and the respiratory status together and decides to obtain an
emergent arterial blood gas (ABG) because he/she knows if the patient is in acidosis,
vasopressors may be ineffective and the respiratory status will continue to deteriorate. The
ABG results indicate that the patient has a Ph of 7.19 and a bicarbonate level of 8.0. The RN
immediately notifies the physician of the ABG results, explains the patient’s hemodynamic
status with current treatments, and requests a bicarbonate drip for treatment. A 50 milliliter
syringe of bicarbonate is given by intravenous push and a bicarbonate drip is started per
obtained orders. As the night progresses the acidosis is corrected, the vasopressors become
effective, and the respiratory status and O2 demand improves due to correcting the
bicarbonate level. To care for this critically ill patient, the RN had to grasp the clinical
situation and dig deeper than the obvious to understand and resolve the patient’s critical
status. The RN had to apply knowledge and practical skills simultaneously to solve the
problem and stabilize the patient; they had to clinically reason.
In critical care nursing, clinical reasoning goes beyond knowing and thinking;
it also involves the process of taking action and applying knowledge in clinical
practice. According to Benner (1984), nursing knowledge and clinical reasoning
consist of extending practical knowledge through scientifically based investigation
that is developed through clinical experience and practice. Without clinical reasoning,
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RNs that transition into ICU can be dangerous. They may be a walking/talking
encyclopedia but may not have the ability to apply this knowledge in practice.
Clinical reasoning is practice-based and requires scientific and technical knowledge.
It requires the practical ability to apply knowledge in order to make clinical decisions
for each individual patient. It is the processes of thinking while taking an action and
performing skills (Himmerick, 2011; Jensen & Givens, 1999; Mattingly, 1991).
During the clinical orientation in the ICU, clinical reasoning is developed and
enhanced, preparing RNs to provide quality care to critically ill patients (Dunn,
Lawson, Robertson, Underwood, Clark, Valentine, 2000; Aari, Tarja & Helena, 2008;
Murphy & Nolan, 2006). If clinical reasoning is not further developed during the ICU
orientation, RNs can unknowingly be a danger to the patient and to self. The
development of clinical reasoning during orientation in the ICU is not a choice; it is
mandatory.
Clinical Reasoning Defined
Clinical reasoning is more than a simple application of theory; it is RNs
developing a treatment plan that addresses the medical and personal needs of each
patient. Clinical reasoning occurs when RNs move through available facts and
inferences to make a decision on the patient's plan of care (Simmons, 2009; May,
Greasley, Reeve, & Withers, 2008; Kaldjian, Weir, & Duffy, 2005). This chain
process involves the cognitive activities: judgments, decisions, and actions made
when caring for a patient.
Over time the understanding of critical thinking as it pertains to the clinical