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1.0 INTRODUCTIONNursing field requires evidence based practice to make sure that the treatment given to patient does not harm them and is appropriate for different types of scenarios. This is done by implementing clinical reasoning and clinical decision making. The terms clinical reasoning in nursing is described as the deliberate nonlinear process of collecting, interpreting, analysing and drawing conclusions about information on the patient that is both factual and belief based (Christensen N, e., 2017). Clinical reasoning will influence a nurse during clinical decision making and conducting nursing process, which require high-quality thinking and action.
Nursing process is a series of organized steps designed for nurses to provide effective care which consists of five phases, including assessing, diagnosing, planning, implementing, and evaluating. It is considered the core function of nursing care because nurses provide care based on the findings in the nursing care plan. Assimilation of clinical reasoning in nursing process are significant as it will lead to the optimum nursing care for a patient.
Yildirim, B., & Ozkahraman, S. in 2011 said that Nursing process is congruent with the perspective of measuring outcomes by benchmarking and prototyping and is useful because it encourages uniformity in practice"(p. 258). The importance of integrating clinical reasoning in nursing process and the ways to incorporate it together will further be elaborated in this essay.2.0 IMPORTANCE OF INTEGRATING CLINICAL REASONING WITH NURSING PROCESS IN NURSING PRACTICEClinical reasoning is defined by Simmons (2010) as a complex cognitive process that uses formal and informal thinking strategies to gather and analyse patient information, evaluate the significance of this information and weigh alternative actions (p.
1155). Clinical reasoning is always considered one of the most important aspect of nurses' skills because it has the power to determine the outcome of patient care. Poor clinical reasoning skills may result in failure to deliver satisfactory and accurate health care. Sound clinical reasoning avoids unnecessary investigations which reduces cost for the patient, and ultimately improving the patient's health condition. Nurses with poor clinical reasoning causes a patient's health condition at risk of deterioration and death.The way nurses make judgements will have an impact when patients are examined systematically, ensures that patients receive the best quality care (Crampton, J., 2013). Integrating clinical reasoning in nursing process also ensures a systematic and smooth flow of work that will benefit patients as well as the nurses.Without clinical reasoning assimilation in nursing process, wrong types of treatment are given. This will take up cost and constraint time in return will end up longer admission period in hospitals. A nurse's approach to critical thinking and reasoning is found to affect the accuracy of the nursing diagnosis in nursing process. Thus, it is directly linked to influencing patient care and outcomes (Lambie, A., Schwend, K., & Scholl, A., 2015). 3.0 HOW TO INTEGRATE CLINICAL REASONING AND IMPLEMENTING NURSING PROCESS.Implementation of clinical reasoning in the nursing process provides nurses with a creative approach to obtain, categorize, and analyse client data and plan actions that will meet their needs. Nursing process is how you will approach your patient and it can provide save and efficient care to the patient. Nursing process consists of five steps which includes assessment, diagnosis, planning, implementation and evaluation often mention as ADPIE acronym. The nursing process is more than something that guides formal care planning and documentation, it's what must guide nurses thinking on a daily basis (Alfaro-LeFevre, R.,2012, p.3). The ADPIE process helps nurses recall the process and order of the steps they need to take to provide proper treatment for the individuals they are treating. Nurses can improve the efficiency of their work and develop to more accurate decisions in a timely manner by following the ADPIE process. In nursing, knowledge is applied systematically because helps nurses to know the steps and the order of the steps to take a holistic approach to provide care to a patient.3.0.1 ASSESSMENTThe first step in conducting nursing process is Assessment. It involves critical thinking skills, subjective and objective data collection. The difference between subjective and objective data is that subjective data involves verbal explanations from the patient or caregiver while objective data is measurable data. In obtaining subjective data process using the clinical reasoning, deciphering the characteristics of information provided need to be considered carefully and aligned with objective data to make proper decisions and recommendations (Toney-Butler, T., & Unison-Pace, W., 2019). This is because the information is generally descriptive or individualized and can vary depending on the patient's condition and health status. Every individual has different perceptions about sickness and the experience of health, and different expectations of the health system and people that work within the health system. Utilizing interview techniques suitable to the individual and the situation are necessary and should include open ended questions and listening skills to understand the expectations and situation of the patient.Objective data is generally measured in numerical terms and compared to suggested variables in health determinants for specific groups of patients. This consists of neonates, infants, toddlers, children, adolescents and adults and also include males and females, or even variables for patients in certain categories such as cancer patients, spinal patients, renal patients and so on. Applying clinical reasoning can assist in deciding how sick or stable an individual might be or are there any rapid changes in condition that can identify a deteriorating patient and how and what interventions should occur to minimise poor outcomes for a patient. Objective data to be collected can be vital signs including Glasgow Coma Scale (GCS), blood pressure, temperature, heart rate, oxygen saturation, blood sugar and urine output. Wound assessment, circulatory assessment including skin colour and pallor or a physical assessment of appearance is also included in objective data collection (Toney-Butler, T., & Unison-Pace, W., 2019). The focus of the assessment is the patient and how they are experiencing their illness and ill health. Once all the information has been gained it can be documented and sorted (MelinJohansson, C., Palmqvist, R., & R¶nnberg, L.,2017). Excellent record keeping is vital, so that all the information gathered is recorded and presented in a way that is accessible to the whole healthcare team.3.0.2 DIAGNOSISNursing diagnoses differ from medical diagnoses. A medical diagnosis is made by a physician and will be a condition that only a doctor can treat while a nursing diagnosis describes a patient's spiritual, psychologic, sociocultural and physical response to a sickness or potential health problem. The medical diagnosis never changes when disease is present, but a nursing diagnosis evolves as the client's responses change. It also represents the nurse's clinical judgment about actual or potential health process occurring with the individual, family, group or community. Nursing diagnosis uses the information gained from the assessment to identify actual and potential problems, as well as strengths (Yildirim and Ozkahraman, 2011). Actual problems are those that come directly from the assessment, for example pain from a fracture. Potential problems are those that could arise from the problem, for example the risk of developing a pressure sore if confined to bed for prolonged time (Hogston, R., & Marjoram, B. (Eds.), 2011). Strengths are self-sustaining abilities, prior experience of the sickness. Nurses that are making the diagnosis must have the sufficient knowledge and experience to make sure that the plan for the patient are right on track. the nursing diagnoses chosen should always match the patient's condition. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and risk factors found within the patient's assessment. Multiple nursing diagnoses may be made for one patient.3.0.3 PLANNINGThe planning stage focuses on each of the problems found in the diagnosis. Each problem is given a precise outcome, and each outcome is given nursing interventions to help achieve the intended goal. Interventions are established in the planning stage to reduce, resolve or prevent the patient's problems while supporting the patient's strengths in an organised goal directed way (Kozier, B., 2008). There are two steps in the planning stage, setting goals and discovering actions. Short term and long term goals need to be set through SMART goals which is identified as Specific, Measurable, Achievable, Realistic and Timely (Hamilton and Price, 2013). These are done in cooperation with the patient. In action planning the actual care that is going to be implemented needs to be clearly stated using the REEPIG criteria to ensure that care is of the highest standards (Hogston, R., & Marjoram, B. (Eds.), 2011). Firstly, the care planned is Realistic given available resources. Secondly, the care planned is precisely stated exactly what needs to be done so there is no misinterpretation of instructions. Thirdly, Evidence based research that supports what is being initiated. Fourthly, the care being planned is Prioritised by dealing with the most urgent problems first. Any potential risks that may cause complications or harm to the individual should be placed in order with the highest risk that are life-threatening listed as the top priority and lower risks being addressed later. Fifth, is to Involve both the patient and members of the multidisciplinary team who are going to implementing the care. Lastly, Goal centred is the care planned will meet and achieve the goal set.3.0.4 IMPLEMENTATIONThe implementation phase of the process is where the individual and medical team implement the care plan and interventions so that the patient can achieve their goals and the process can be evaluated and measured. Implementation of the care occurs during the 24-hour period. As each new member of the nursing team comes on duty the care being delivered need to be re-assessed whether it is still appropriate or not. On-going assessment of the patient is vital and this is where good record keeping is important (Alfaro-LeFevre, 2010). Implementation is also the step when nurses intervene to help by physically giving drugs, educate, monitor, etc. While implementing the care plan it is important for the medical professional to use clinical reasoning and question procedures in the care plan in order to ensure that they appropriately meet the goal of the individuals receiving the care. Steps or procedures that appear to be inappropriate should be reevaluated with the medical staff and the individual receiving the care plan in order to ensure it is safe and aligns with the medical goals.3.0.5 EVALUATIONThe most important part of the nursing process after implementation is done is evaluating whether has the care achieved intended result. This should occur constantly as care is being implemented. Evaluation at the end of a course of treatment involves reassessment of all the plan of care to determine if the expected outcomes have been achieved (Yildirim and Ozkahraman, 2011). In evaluation it is necessary to always include the name of the patient and the date of documentation in each note and making sure that the writings are as legible as possible so others can read it. It is also noted that writing the staff signature name at the end of each nursing note is a must. If the process is not working it should be reassessed and determined whether it needs modifying If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly. By performing regular evaluations nurses can determine the appropriate course of action, identify potential flaws and ensure that the nursing process is working as smoothly as possible.4.0 EXAMPLE OF NURSING PROCESS WITH ASSIMILATED CLINICAL REASONING.Mr A visits his general physician on day because he was feeling sick over the past few days. When he is called from the waiting room, the nurse takes his vital signs. She then asks Mr A a series of questions about how he's been feeling lately. The nurse records his responses when he says he is having difficulty breathing and has been feeling very tired. Mr A's medical history shows that he had problems with his cholesterol levels and blood pressure before. Mr A also has a blood sample taken during his doctor's visit. After the assessment, the nurse looks over Mr A's symptoms and found his pulse is higher than average and his blood pressure is elevated. The nurse considers that he's experienced fatigue and shortness of breath before when his cholesterol levels were high. The nurse determines that Mr A is experiencing Hyperlipidaemia, which is known as having high levels of fat within the blood. Mr A's blood tests result confirms the hypothesis. The nurse is concerned that Mr A is at risk for heart disease. The nurse sits down with him in a closed room and explains his cholesterol levels and high blood pressure and suggests him to start on medication to help lower the cholesterol and blood pressure. She also recommends him to exercise at least twice a week. The nurse also tells Mr A that he should taper down salt intake and eat less red meat. Mr A agrees and they setup a follow-up appointment two weeks later. The nurse reminds Mr A to come to the hospital if he starts to feel worse. Mr A's medication is prescribed and he takes it as recommended. One week later, he feels sick and calls the doctor's office. The nurse explains that the medication could cause nausea as a side-effect and advises Mr A to avoid any foods that generally upset his stomach. Mr A continues taking the medication and goes to the gym four times during the two-week period. Once the two weeks has passed, he returns to the doctor's office for his follow-up appointment. When Mr A returns, the nurse asks him a series of questions about how he's been feeling. He replies that he has been having an easier time breathing and feels significantly less tired since exercising and taking the medication. The nurse notes "Patient's Condition Improved" on his medical records and congratulates Mr A on his improvements and then advises him to remain on the medication for one more month and to continue his exercise. This example shows that the nursing process will be effectively accurate when clinical reasoning is implemented correctly. SMART goals are also considered in this scenario so that plans and advice given to patients are compliance.6.0 CONCLUSIONClinical reasoning is a process when nurses collect and process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate and reflect on outcomes, and learn from the process (Levett-Jones et. al, 2010). Integrating clinical reasoning in nursing process ensures that the nursing care plans are able to provide maximum care efficiency and greatly reduce the risk of negligence in nursing care. ADPIE is an acronym that helps nurses to organize the nursing care plan while working and thinking in a systematic point of view. It allows the process to be evaluated and improved continually as well as developing nurses' skills involving clinical reasoning and critical thinking. By giving proper care towards the patients, the morbidity and mortality rate in an area will be reduced thus, increasing the productivity of a country in whole. A good nursing care is a result of an efficient nursing process that is integrated with proper clinical reasoning skills.
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