so clinical reasoning is a systematic insightful process that guides clinical decision making but particularly in unpredictable emergent and non routine situations and leads to accurate and inform clinical judgment and that statement was produced by Hoffman 2007 and Levesque Jones and colleagues 2010 the definition that's been provided by the same authors is that clinical reason is defined as the process by which nurses and other clinicians collect cues process the information come to an understanding of the patient problem or situation plan and implement interventions evaluate outcomes and they react on and learn from the process so putting that into everyday language the reason we're looking at using clinical reasoning is we want our nurses to be thinkers we want future registered nurses to be able to look critically at the care that they're providing to their patients particularly in relation to preventing deterioration the new clinical reasoning model is made up of seven different steps and later in this video you're going to see a scenario involving a clinical tutor and two nursing students on the ward actually using the clinical reasoning process and actually going through each stage so that you as the student nurse will be able to view this scenario so that when your clinical tutors visit on subsequent visits you'll have a good idea about the format that they'll actually be using to run their clinical visit so what I want to do now is I want to show you the actual clinical reasoning cycle briefly explain the different parts of it so the first part that you can see in the cycle is considering the patient situation so that's where we actually look at describing the person what the situation is and the reasons why that person actually has been admitted to hospital or if he's seeing them within primary care why have they been admitted to the service following the patient situation we're then going to be moving on to look in how we collect the cues when you view the video involve in the scenario involving the student to student nurses you'll see quite clearly how the student nurse went about collecting all her information which she was then able to process and come up with a nursing diagnosis so that she could then actually plan set goals and ultimately evaluate the care so when we talk about collecting cues and informations we're talking about reviewing the current information gathering new information and recall in knowledge so when we talk about recall in knowledge we're talking about looking back on past clinical experiences and been able to link those to our current patients one of the largest sections is the processing of the information and that's actually made up of six subsections which we want you to try and consider when you're actually looking at putting your information together those different sections are interpreted so when we talk about interpreting where that's the question are the cues that we've collected are they normal for this person for the time and the place we move on them to discriminate the important thing about one we get to discriminate is that we actually distinguish the relevant from the irrelevant information and be able to identify those needs which are a priority for the patient then we move on and we look at relate and relate is when we look at basically joining up the dots putting two and two together and being able to try and actually identify what the main problems are with regards to the infer which is our next section and the process information we're talking here very much about being able to thinking about all the information that we've gathered up to now I've been able to come up with some conclusions and some opinions about what's actually happening with the patient when we move on to talking about matching the current situation the past situations we may be thinking about situations that we've experienced before and what this particular situation might be similar to and lastly to do with process and information is predict that's been able to predict an outcome what is likely to happen to my patient based on the information that I've gathered so far the next major section in the cycle is identifying the problem in the issue this has been able to pull all the information together that we've gathered under the section where we collected the cues and process the information so that we can actually come up with a nursing diagnosis and we need to remember as nurses that we are here to formulate nursing diagnosis and not medical diagnosis this in a way is very similar the nursing process so obviously following identifying the problem in the issue we're then gonna move on to looking establishing goals we want to be able to make sure that our goal goals are based on this smart theory which is specific measurable achievable realistic and timed so once we've established our goals they obviously we want to go on to take in action and this is where others nurses in conjunction with our colleagues we can actually sit down and we can clearly document all the interventions that are required to be able to try and prevent a deterioration in this patient's condition and their subsequent improvement once we've actually been able to carry out the nursing care with them want to be able to do our evaluation has their interventions been effective have they not been effective is the patient improving or are they deteriorating and lastly in the clinical cycle is the importance of reflecting we need to sit back and we need to say to ourselves what did we learn from that experience what do we take away from that experience that is going to have an impact on our future nursing career so those are all the stages involving in the clinical reasoning cycle what you're going to see now is the scenario which I outlined earlier involving the tutor and the nursing students we would encourage you to to watch the scenario be able to identify how the two students are using the various parts of the clinical reasoning cycle and to look at ways that you can actually utilize the cycle with in your everyday nursing practice right it's nice nice to see you again okay so see also the wait could be hard nice to be back after a break yeah so dis remind me which which we can we on now has gone really quickly doesn't it so are you enjoying medical yeah I'm really enjoying that's what I really want to do so yeah are you finding that you were able to begin to sort of like usually knowledge that you learnt in school before you came onto placement ah yes I'm starting to relate I thanked my theory to practice well I suppose the main thing is just to try and us both if you have you got any any problems or any worries about your first couple of weeks yeah I'm feeling Road in my first week that's really good and you both you're smiling which is the really good thing and the feedback that I've got from the nurses when I got here a bit early it was really really good about the two of you which is which is really really pleasing I hope you don't mind that I asked to meet with the two of you together today I just thought it would be quite a good opportunity and you could share you could share experiences with each other so you remember last week when we met we introduced you to the new clinical reasoning cyclopean and I think you may have been given one of the little laminated cards that shows you exactly what the clinical reasoning cycle is and last week we spoke about you identifying one of your patients who you could present today using the clinical reasoning cycle and I thought what was really good was that you remember when I texted it you both joined the week you asked me if it would be possible if he could split your feedback regarding your patient and do half each was that something that you still wanted to do just before we start with that what's your what is your overall thoughts about this new clinical reasoning cycle it's gonna take a little while to to get too used to it because we're so used to just presenting a patient but I think it's a positive step forward I think it makes you think about what you're doing and why I'll see exactly what it is yes and I think it helps you plan for your day beautifully your shift meter should kind of like a clear plan of what to do so you kind of helps with your confidence that's what I'm finding what do you think the overall aim of the clinical reason in cyclists when it comes to patient's welfare making sure you've got the information available and you've researched it and you've got the steps in place to ensure patient safety yeah exactly right it's all about trying to prevent the patient's deteriorating mm-hmm and it's about you've been able to look at the much wider picture mm-hmm I've been able to be more critical thinkers rather than just carrying out nursing tasks without actually doing a lot of thinking about him so not monkey-see monkey-do yeah that's a good that's a good way of putting it yeah so who's gonna start okay so what I'll do is let you go through a bleep you're going to do the first half yeah then alex is gonna take over and do the second half and maybe what I'll do if it's okay is as we go along I'll maybe if I can think of a couple of little questions that'll help you reflect on your practice or maybe chip-in it's alright okay so my patient is called mr. Jones he's seen deform years old he was a medic to a day this morning at 5:30 is brought in by ambulance on the 16th of February he presented as being short of breath it's slightly confused because it had a fall at home he'd know skeletal injury no present victim on his buttocks and no loss of consciousness as we aware he got limited mobility Michael quiz he's got really a team two sleeves inflate and as edema comes up to his health that could be a real problem yeah especially in terms of increased dependency conduct yeah exactly and his age being seen before he actually lives alone he does that on a rocky way but he's got found out he's got family in Auckland okay um and I also able to say we shouldn't they did it he is for recess right I'm not so really that's a really valuable thing to pick up on his neck yeah why do you think that's so important that you know that we establish that sort of quite early so if he has a critical incident will he deteriorates then we know what we gonna do because only likes baby meat useful that's right and it's about taking the patient's wishes into account isn't it yeah so that was no that's really good that you managed to pick up on that thank you and Dean so since he's come on the ward I'm carrying with him with my preceptor my Erin and he admitted got a medical ward for day in about 10:30 so straightaway we did some vital signs and his blood pressure was 99 60 so it was a little bit low his respiration rate was 24 and he's come on two liters of oxygen we've got a nasal prongs on better set so that 95 percent his temperature was 37.2 and it's hot right Michael egg eight beats a minute good so he's actually scoring as a early warning school and AW is of sex this is quite high so we're aware of it he's got an indwelling catheter and they put that in an ad and he's had about 800 moves of your own past and small cities good that's good detail and that's the sort of thing that we're looking for when you doing handovers that you're actually been quite factual rather than for instance just saying is cut this draining all right because at the end of the day what does what does alright me so that's really good that's good detail okay we also did a 12-lead ECG because of this history he's got some failure but the house officer here to look at it that the couldn't see any changes from his previous admission so that's not bringing any alarm bells at the moment he stole it she a bit confused and anxious and I think he's confusing it just cause it's quite short of breath yeah exactly so what so what would we call that he's saying assured of breath he's a bit confused what would be sort of the medical term that we would refer to do you think it's my father yeah it's definitely sounds like it is a Nazi what do you think could be the reason for his anxiety because he's fallen he's in a foreign environment he doesn't know what's happening [Music] maybe because his oxygen saturation is Larry's not thinking as clearly as you know what they're very good answers maybe that's exactly right and we often find if we look at the literature to do with heart failure anxiety and this fear of really those two big things that sort of stand out so what we've also done with my nurse so I'm just learning how to do it the Falls risk assessment good aim we've done a pretty rocky assessment because um he can't move and because he's got so much fluid on the board so he trying to prep me in pressure areas developing did you want me to tell you something for the past medical not a big that would be great so he's actually got a history of hypertension and gout and he's got heart failure that we know about but he's also known to a medical outreach team he's on medications he's on beta blockers and normally it only takes through smiter the morning right he takes 80 milligrams it takes 40 milligrams an o'clock another 40 milligrams at midday and he's on a medication to lower his cholesterol and he's on medication to help us count I'm he's also on an ACE inhibitor so at her parole and he's on a Mac Prasad and he takes 20 milligrams BJ so what do you think what's the main purpose of an ACE inhibitor to keep it special oh that's right causes it to dilate the capillaries and arteries but Michael do you think it's a problem now that needs actually high protein so we've got the live by pre-show if he's still on it medication why do you think he's possibly hypotensive at the moment what could be a couple of things it's may be going on I wonder efforts they've put around IV on him and to get rid of the excess fluid and I got frozen Myers and what's the fruits might ultimately gonna happen if what's what effects they're gonna have on his blood pressure exactly yeah and the other thing is this month's come in with an exacerbation of heart failure what could have happened to his heart muscle in the meantime wait exactly his heart muscle has become a lot weaker which is ultimately what effect does that can happen it's blood pressure exactly traction and when you're doing your reading what you'll find is in the extreme situations if somebody comes in and they've got severe left ventricular failure is that you can end up with cardiogenic shock which you have read about which obviously will cause the blood pressure to drop quite significantly so no that's so that's a really good observation okay so we'll just keep exactly so I suppose now we kind of like recall what knowledge we know in terms of the pathophysiology for them and I know you've got the pulmonary edema it's got a bit of a cough and he's got some shortness of breath so he's got lots of fluid sitting in his lungs which is to do with this relief interface yeah Jordan trying to join up ago it may be trying to explain that to me that's what's happening with the pulmonary edema he's getting a buildup of fluid in his lungs because his heart's not pumping correctly and it's making his oxygen saturation control that's right so where's the fluid getting forced out of okay so what are those tiny tiny little air sacs at the end of your the main sort of like bronchus in your lungs that's right yeah so what's happening is it's that they're becoming so dilated the fluids getting forced out to them and the person's actually ended up with fluid in the lungs which is obviously causing this problem with the pulmonary edema which is obviously why this man who you describing to me is so short of breath and he's so anxious so ultimately were hoping that the Crucified will help actually get rid of some of that excess fluid so kind of two problems they don't we because trying to change it we haven't exactly so it's trying to sort of but it's trying to sort of balance something the two things really yeah [Music] would it be any other drugs the hood think of so this man's come in this morning he's really anxious he's really breathless suffering from dysentery is there any other acute type medications that we could maybe ask the doctor to prescribe that might help with his anxiety and with his overall shortness of breath could maybe think of something like Mike days are there yeah actually my won't actually reduce a shortness of breath will reduces anxiety let something like maybe something like that that's right and I I've seen while I've been on the ward here occasionally that they're now using intranasal midazolam for people with that sort of problem so that would be a really good one what about what it'd be happy are you seeing them using morphine as well you know I hear it's a good one I understand that it doesn't stop the shortness of breath but it blocks the message from their lungs to the brain say I can't breathe I can't breathe and takes it in so I feel like you're exactly right so morphine midazolam yeah I suppose the other one that I've seen you sometimes is that people will use rivotril drops the other name for its cleanliness bump which patients can use so that's really good that you've got that knowledge of those different types of medications okay I have to do some research and then I suppose of thinking and my planner care about identifying the problem and that issue or was it you gonna talk about it so that's really good so up to now you possibly given us a really good introduction to your to your patient and then you talked about how you actually managed to gather all your information together then obviously you went on the last part was how you actually process that information and to actually be able to come up with the nursing diagnosis which I think Alex you're going to talk to us about that's great I'm gonna identify the issues in the problems I'm at mr. John has encountered or was encountering so I'm one of the main ones I feel with shortness of breath and seek injury to the pulmonary oedema the oxygen it's quite high protein so due to the IV frozen mine and maybe a bit of decreased cardiac output and this ventricular failure so that's one of the main problems also but of decreased level of dependency and due to the oedema and shortness of breath due to here the swelling up and up to us Hep C is not mobile at the moment so he's needed quite a bit of assistance with it and he's also quite anxious and confused it was my oxygen saturations but of fotox here the air and also because he is currently not able to give out a beard and mobilize and he's feeling about what else could he be potentially be at risk of you said that this man's come in and he's he's very mobile he's obviously got increased level of dependency he's got this huge amount of edema he's not moving much at all what potentially could he be at risk of exactly which would which could lead on to what one sowhat's Kleck so why would you why would you put somebody on that with a risk of developing a DVT good that would be a really good like prophylactic type mesh you know to stop that yeah no that's great so what else to be thought there and also maybe an increased risk of infection because he has got an ongoing catheter and he's also is also a risk of infection due to the swelling he made about pressure Ariana's League and if the buildup is bad enough to have leakage first and he's also could be at risk of developing maybe after you write us yet because obviously these days we are trying to promote the prevention of sepsis yeah which chip which you've done in school which is a which is a major issue the glob C lead to somebody died in so that was really good that you identified the increased risk of developing urine infection with a man a catheter in because ultimately if this man was to develop which we would refer to as urosepsis it was end up being very very ill indeed look at maybe doing a urine all of us confusion in crates little boy became a bit delirious good so bits about that for identifying the problems I think I'll go on so maybe establishing some goals now for my patient so I I think one of the main things is making sure he has a daily weight and sure he is losing weight each day and maybe I feel and put in the output fluid dance chat what would be what was quite the important factor when it comes to weigh-in somebody on award particularly with heart failure make sure you do it in the morning exactly and have you ever heard of the phrase a dry weight this wouldn't obviously apply to your man because he's got a catheter in yeah but a dry weight is when somebody who's not catheterized we would encourage them to pass urine before we weigh them because that would give you an even more but that was good how you identified about doing it at the same time where possible every day and that way you could a lot you can more objectively measure the urine output good also monitors confusion and maybe orientate come to the time so where he is and I'm sure he's got a school down nearby really so that's good that you're thinking about every day straightforward practical things that we can do as nurses to try and maintain somebody's safety and some of those things you've just clearly outlined for us there also maintaining has appreciate areas making sure there's water low I think we learned admit some that it had a water load um so making sure he does if he's not able to move boylee turns well what even trying to get him up in us cheer what - also half of his lungs that's right I know and that's we were talking before about the risk of developing a DVT that would be a great thing yeah that what you could actually get this person moving you significantly reduce the chances also looking at he is for recess we know there and also maintain use of certain situations above 95% you said before that you've given him oxygen at the moment I had nasal problems what would normally be the maximum amount of oxygen that would be prescribed to get somebody by a nasal prongs how many liters yeah exactly what's gonna happen if you give somebody much much higher flows through nasal problems you're right so people can end up with really nasty so inflamed mucosa inside the nose so that's that's dead right what you've said generally no more than four liters yep also look at maybe keeping his leaks elevation well he's and beard making sure that the fluid and keeping us Heath I was being it nice and sixty degree so very position to breathe with the extreme excess Lord and also just reassure him regularly and do hourly around then just to make sure that he knows we were available if he needs us we can keep no and those are really you know we want to obviously do our very best for our patients particularly particularly this man and it's a it's the matter of been really attentive to his needs isn't it yeah and you've clearly gone through quite a lot of different things both of you that you need to do for this month which hopefully is going to have an impact on his recovery report to my early warning score and and his vital signs oh it explains his blood pressure pulse respiration rate oxygen saturations one by one and the temperature with Avella normal or abnormal because my responsibility to leave my procedure loud because I am astute what could that could be a little situation say this man when he's at home normally has an oxygen saturations of say 90% or 89% yeah is there anything that nurses can discuss with the medical staff when it comes to the early warning and we're getting a good plan as normal reading because what we need to do when people come in is we need to look at the baseline solely and we need to like join in when went through gave us a background about this mom's history so that includes looking at things like his vital signs yeah and what are they normally yeah so we can as you quite rightly said we can have a discussion with a medical staff to look at actually adjusting as ews so that's that's a great point he brought up Pollux and also look at asfar and reporting to the my procedure and the into the house there was a house office of my concerns regarding has aw ease and just putting some a plan in place for that I would also count contact the medical outreach because I understand mr. Jones is currently and medical outreach in the community and it's good to contact them while they're in hospital and they can visit them and we can put a plan in place and actually know what is normal is and what has been happening for him in the past I'm not certainly Foster's really good relationships as well because obviously we don't want these the team going out to see him not realizing that he's in here but also what you were saying before is we want to try and make this man's care as seamless as possible so we all been well as a team heading to a level where he's able to go home we would like him then to be visited quite promptly by the outreach team to be able to continue that care something that's a really good point that you brought up there and I also contact the social worker just to review his own social situation he has been living independently but his family's in Oakland so and because of this recent episode of heart failure or an exacerbation I think it's good that we look at maybe putting some support somebody's a thief hippie a little bit that's great yeah well I was even thinking at the depending how he is on discharge we the hinnies primary options and looking at a few days and the rest time just to get him back on myspace they're really good initiatives that you suggested because it's not just about doing the care for this person while he's in here it's trying to and this is going this is looking at the clinical reasoning model it's looking at the much wider picture isn't it and you is the two of you becoming critical thinkers and being able to look at all the things that you've just described about how you want to plan for when he goes home so that what hopefully he'll be able to go home without there being any unnecessary deterioration and also looking at maybe the wider MDT worries and here looking and occupational therapist whether he needs extra equipment at home and even getting the tip on them just in case he needs someone to talk to that's really nice that you brought that up because again I think sometimes we can think of all their health practical type things that sometimes the spiritual side of care and tend to get neglected yeah would you both agree with that suggestion like you just said about asking him if he has belief yeah I've been able to bring the minister in I think that's a really nice suggestion and it just it just shows him that we're dressing this whole person and not just the physical side of things I mean for my evaluation I think the main thing would be this to make sure us BP is made both pressures maintains and that it's stable I mean if it was going to be at 90 over 60 make sure the doctors happy with it and effort though and having it aw s-parameters altered and making sure his urine output is maintained about 30 miles an hour so making sure he's not becoming dehydrated as well because of the frozen one a good point I'm also maintaining as fluid balance chart and has comfort in ensuring is oriented that's very good so I'm really pleased with all the information that the toribio presented I think what's maybe important to do before we sort of finish about this patient it's to allow you to give overview the opportunity to be able to briefly reflect on this patient so maybe we could start with you toiling just just a just a few sentences if you if you can think of how you what you actually got out of looking after this patient and what sort of impact do you feel providing this care will have on your nursing career I suppose for me as a student nurse I was thinking that by having the time to gather some information maybe thought about you know quit when I knew what had happened to him at home then he had a fall all had that let us past medical history any less alone and Hallie Wallace and eg and by taking bonus lives near iconic gave me a plane to know what I should be looking for some nurse and what what I should be focusing on and it helped me communicate with my Irene being my preceptor better so just I suppose that just gave me the more knowledge I get at the more confident I felt and certainly when I listen to all the information that you presented about the mums history all about his presentation when he came into hospital it certainly put you in a very good position to be able to then proceed to plumb the care for this mum in a real holistic manner and that was that was really evident when you were talking about how your goals would have been very difficult indeed for you may be something we can prevent maybe it's not maybe it's just because he had that oedema and it's it's fluid and that's why you try but you know I'm just thinking about how we can make it safer for him to be use was nothing you'd like to comment on before we before we finish Alex about I think you'd like to reflect on I think it's really helped me to see how much information you do anything about your patient and happy health appeared you need to be it's not just about writing down Lynn the shower or what medications are on it's about looking at the big picture and what's actually happening with your passion and be prepared as the patient does that area right well I'm really pleased how the trivia because we only introduced you to the cycle last week I've been really pleased how you how you've actually taken it on board and how the two of you have actually hit this patient during the week and actually broken it down into the different steps yes to present to me today so I think you're both doing really well I'm really really pleased with you so good each week when I come if we could maybe continue using this same model and I'm sure that it will help increase your confidence as you go through this placement so thank you for meeting with me today I look forward to seeing the two of you again next week all right thank you