today's topic on Keith RN is Keith RN and clinical reasoning key studies one of the essential paradigm shifts advocated by Patricia better and the co-authors of educating nurses in 2009 was the need for nursing education to emphasize clinical reasoning in order to really apply this concept of clinical reasoning to nursing education we first need to define it and Patricia Benner has done I think the most preeminent work on this topic I'd like to review the definition of clinical reasoning so we can therefore apply it in this active learning of three levels of clinical reasoning case studies and I have created in today's topic is fundamental reasoning as it relates to the topic of heart failure but first clinical reasoning is the ability of the nurse to first think in action reason as a situation changes over time by capturing and understanding the significance of clinical trajectories and grasping the essence of the current clinical situation it is also the nurse must be able to focus and filter clinical data in order to recognize what is most and least important so the nurse can identify have an actual problem he's present now as we look at the board I want to highlight just the bullet points of clinical reason it really lay this foundation so that we have a deep understanding of this most important concept in nursing education clinical reasoning is the ability to think in action recognize that patients don't change or don't stay the same they change the nurse must be able to think in action but then also reason and think as a situation changes the nurse specifically also understand the significance of clinical trends everything must be trended Vital Signs assessment data in the clinical context and the nurse must be able to filter the clinical data that is most and least important and right nice what is most relevant and the end result of clinical reasoning is to make the correct clinical judgment to determine if a problem is present and then identify the essence of what is my nursing priority and the case studies are not created on Keith I read they currently have 15 topics it will have many more posted in the weeks ahead but basically is to situate and contextualize clinical reasoning to a clinical scenario and I have three different levels fundamental reasoning is what we're going to discuss today in today's fundamental reason is the four might I see there's a synthesis for the first year first semester nursing student it emphasizes the applied sciences of pharmacology fluid and electrolytes as it relates to lab values and physiology in order to really strengthen those walls we also want to identify the basic clinical relationships of data so that the nurse can put the clinical puzzle together we then emphasize instead of the the focus is nursing nursing assessment as really extended identifying the nursing priority you assign nursing a process and so what I'd like to do is now go into an actual case study of fundamental reasoning on the topic of heart failure and let's go through this clinical scenario together Carlos bought geranium is a 68 year old male was a five year history of systolic heart failure secondary to ischemic cardiomyopathy with the current ejection fraction of only 15% he presents to the emergency department for shortness of breath over the past three days his shortness of breath has progressed from shortness of breath with activity to becoming short of breath at rest the last two nights into sleep in his recliner chair to rest comfortably with his head partially elevated he is able to speak only in partial sentences and has to take a breath when talking to the nurse he has known an increased swelling in his lower legs and his game six pounds in the last three days he's being transferred from the emergency department to the cardiac step-down unit where you are the nurse assigned to care for him and so as we look at the bar the first thing that we want our students to be able to do is to recognize looking at this scenario which they'll get in the emergency department or in the report what clinical data is most relevant that needs to be filtered there was a lot of information there but what aspects of that scenario are most important that must be recognized as relevant and significant to the nurse as we look at this scenario it's essential that the nurse recognizes the significance of the ischemic cardiomyopathy with an ejection fraction of only 15% that's really approaching end stage and therefore is at a much higher risk for having complications related to an exacerbation of heart failure the other piece of relevant data that must be recognized is that he's having shortness of breath for the last three days and it's progressed from shortness of breath with activity too short of breath at rest that kind of that trend you're looking at clinical reasoning understand the significance of clinical trends recognizing that tread is significant and it must be recognized by the nurse because it shows that the pulmonary edema is secondary to acute exacerbation of heart failure is clearly present and his worsening third piece of clinical data that must be recognized as the last two nights that his sleeping his recliner chair to rest comfortably with his head partially elevated he's able to speak only in partial sentences and then has to take a breath when talking to the nurse and again or that you know the inability to lie flat but the need to sit up is a clinical red flag because of the increasing fluid volume causing the exacerbation of pulmonary but the other piece that must be identified is that he's increased swelling his lower legs and has gained six pounds in the last three days is that significant absolutely as it relates the the the the correlation of not only left-sided heart failure with the respiratory involvement but now with the fluid gain were now transferring over to right by ventricular heart failure or right-sided failure in addition to the left-sided failure so labs are collected and let's look at our labs we have our basic metabolic panel it is sodium of 133 and a sum of 5.5 a glucose of 105 and the creatinine of 2.7 on our CBC our white rum is 4.8 there you go bonus 12.9 are platelets are 228 as we look at our cardiac labs our BNP or our be naturally peptide is 1855 and our INR is 2.5 and just like isn't practice these case studies mirror clinical realities where the nurse has to look at those lab values recognize which ones are abnormal but what's the significance or the relevance of that but it's essentially the nurse who recognizes the value that the potassium is 5.5 and the nurse muscular recognize this is an essential electrolyte that is essential for conduction of the heart muscle and as the potassium elevates were at risk for dysrhythmias including ventricular tachycardia and ventricular fibrillation but is there a relationship between the potassium of 5.5 and the creatinine of 2.7 our creatinine is worsening and therefore we are going to cute renal failure and so this context of heart failure decreasing perfusion to the kidneys causing the acute renal failure is also then going to cause the potassium to be elevated and want our students to this is a very common relationship they'll see in clinical practice that in acute renal failure of any type the potassium can't read critically elevated and must be anticipated and recognized by the nurse the other significant finding is the basic the BNP the B natural peptide is 1855 normal is less than a hundred but what does this elevated hormone recognise what's the significance of that well if the student has a deep understanding of heart failure they recognize this is a hormone that is secreted by the left ventricle when the stretch is increased due to the heart failure exacerbation and therefore it is elevated what the heart is overloaded and overworking it's a compensatory hormone that was created and designed to basically decrease blood pressure and even help form as a mild diuretic too in that context to help the body naturally resolve a fluid volume overloaded state but in the context of this severe elevation it must be recognized that something must be done the Ayyanar is also 2.5 now the patient is on coumadin and as we'll look at his history shortly does have a history of atrial fibrillation so recognizing that this is this is this is expected that a normal INR this is relevant but also a normal expected value is also significant and must be recognized by the nurse because even though it's normal the bottom line is is that it's in that normal range so he's not a too low or too high with his anticoagulation the chest x-ray shows bilateral diffuse pulmonary infiltrates consistent with pulmonary edema the chest x-ray again very relevant confirming all the data suggesting from his history that he is an acute heart failure exacerbation so now the nurse collects the vital signs in our set up idle Sciences are temp is 98 six-pulse is 82 and irregular our respiratory rate is 26 our blood pressure is 162 over 54 and our o2 SATs are 90 percent on six liters as we look at that data what do we want our students to recognize as far as what is the significance of relevance in those monocytes well most vital signs are always vinyl and as it relates to our pulse of 82 and irregularity he does have a history of atrial fibrillation but we want our students to recognize that the atrial fibrillation and heart failure is this a good rhythm or potentially exacerbating rhythm that can worsen underlying heart failure and what is lost when the heart is no longer able to contract in the atrium and have the atrial kick we lose that atrial kick and the increased cardiac our clinic levels 25 to 30 percent of stroke volume is lost in the context of atrial fib and swim want our students to recognize the relevance of atrial fib that he's currently in the exacerbation of heart failure and how this could be possibly contributing to this exacerbation of his underlying problem his respiratory rate of 26 it's too high remember normal is 12 to 20 so therefore with our no pulmonary edema the kidney on we know that this person is in distress and his blood pressure is 162 over 54 it's slightly elevated but is this okay is this relevant and if so why in the context of heart failure we know that increased after mode increases the workload of the heart and so therefore the higher that blood pressure is anything over 120 130 that heart and the left better has to squeeze that much harder in order to contract and open up the aorta Wow and therefore this person is working very hard the heart is working harder than it should in order to maintain cardiac output so one of our goals is you want to decrease the after load and decrease that systolic blood pressure and our O 2 sets of 90% on 6 liters again that's too low and beam on 6 liters we maximized our nasal cannula so we'd be thinking about other forms of oxygen delivery in the context of just even collecting our first set of vital signs as we look at our general assessment with our appearance he appears anxious and restless he has coarse crackles scattered throughout both lung fields he has labored respiratory effort in his sitting upright he's an atrial fib and he's pale and cool to the touch with pulses palpable throughout in three-plus pitting edema in his lower extremities from the knees down he's alert and oriented to person place and time and situation his abdomen is soft non-tender he's morning without difficulty in a skin integrity is intact as we look at what is relevant in this context of assessment that we've just collected in that data he's anxious what's the significance of that well it could be related to you know obviously he's hypoxic but what is that doing to his systolic blood pressure it's increasing his afterload and therefore increasing the workload off the heart so one of our goals and one of our nursing priorities we want our students to see is the importance of controlling that anxiety to decrease his afterload his skin is cool the nurse needs to ask why why would a skin be cool what sympathetic or is it parasympathetic nervous system activity is in is its priority here and in this context whenever the skin is cold or diaphoretic sympathetic nervous system activity is predominant and obviously the increasing tachycardia and heart rate increased respiratory rate increasing blood pressure is hurting this pain not helping him he also has course crackle scattered throughout both lung fields with a labored respiratory effort him again that course crackles are reflecting the increasing fluid that has collected in the lore and the basis working their way up that is increasing the workload of the heart as well as the respiratory effort and he has three plus pin edema in his lower extremities and again signifying the the relevance of a right-sided heart failure in addition to his left-sided heart failure so as we look at the context of a pharmacology one I kind of as we look at the fundamental it has an emphasis of having our students understand their labs deeply and so his home medications he's uncarpeted along hydralazine towards amide as well as potassium chloride as well as warfarin the ona students there are basic understand as far as what is not only the classification of these drugs but as well as the mechanism of action as well as the nursing consideration as the students work through these pharmacology as an open-ended case study insist that they do not just parent the drug block but that they put the mechanism of action in their own words because the mechanism of action must be deeply understood in order for them to critically think and under really understand what each of these medications are doing and the relationship then to the most important nursing assessments that the nurse must be vigilant formally we then will get the clinical relationships what I emphasize with fundamental reason is that there are a series of four to five clinical relationships that must be deeply understood and and fundamental reasoning gives students the opportunity to practice the identifying these relationships so they can then transfer this knowledge to the clinical setting where it really matters most and so the first example of a relationship I want each of my students understand is that what is the relationship of the past medical history and the current medications the patient is on that clinical data is related to one another and so therefore the medic the past medical history of atrial fibrillation the ischemic cardiomyopathy the myocardial infarction the high cholesterol as well as chronic renal insufficiency and the whole medications of carbonal all hydralazine tarsal and potassium chloride warfarin and Sebastin must be kind of connected and connect those dots and put that together the second question is there a relationship between any disease in the past medical history that may have contributed to the development of the current problem I went looking for is the domino effect and as we know in clinical practice as we understand deeply pathophysiology and our students begin to master that as they progress through our program they recognize that diseases like diabetes have influencing factors that not only cause diabetes but more importantly what's diabetes Falls we begin to see a combination of other dominoes that begin to fall clinically and so for example in this past medical history afib the Skinit myopathy myocardial infarction hyperlipidemia and chronic renal insufficiency the first problem that likely came was as high lipids and the high cholesterol and that likely then caused the development of his acute heart attack in his MI and then heart failure commonly develops secondary to ischemic cardiomyopathy as a result of ongoing ischemia and then the chronic renal insufficiency as the kidneys are hybl perfused the third relationship is that between the primary care providers orders in the primary problem what would the doctor order the things that he or she does as a primary care provider so for example in this context that the primary care provider orders Jim lasix nitro drip strict I know repeat the potassium and creatinine in four hours and as students understand the rationale for everything that is done clinically both in the pharmacology as well as nursing recognizing the significance of obviously the oxygen is going to improve the saturation and decrease the respiratory after the lasix having a deep understanding that lasix is not just any diuretic but it is a loop of Henle diuretic that is the most potent diuretic known to man that is going to promote the excretion of sodium and then promote the excretion of water and significant volumes of urine output should be expected but more importantly what electrolytes are lost typically potassium as the most common with some magnesium and sodium as secondary nitro drip why would the doctor order a nitroglycerin drip this is where the students must have a deep understanding of the pharmacology in the mechanism of action of nitroglycerin to recognize that nitroglycerin is not only a coronary artery base of dilator but actually dilates systemically the venous system which is then going to decrease preload or the filling pressures coming back to the right side of the heart and then it's going to decrease the workload of the heart as additional volume pools in the venous circulation therefore relieving what's coming back to the heart and in the acute phase of heart failure is a very effective strategy to decrease to do increase cardiac output by improving respiratory distress the and as we look at the the other aspect of relationships the nurse must understand priority setting one of the struggles that students have because of the professional development according to Benner is their ability to recognize what is most important or relevant relating the clinical data and then what is the priority and so as we look at clinical priorities and this kinase has been good the orders of titrant oxygen lasix nature listen and strict I you know in repeating the potassium creatinine as you know in practice we get numerous orders at the same time the question is which ones are you going to put first and do second and third and why we don't just want to start with the first order on the chart we want to critically thinking one of the most effective filters that that we use in practice and is also on the NCLEX are the ABCs of airway breathing and circulation and so in this context we can situate the ABCs very naturally to practice saying our first priority here is to get what's going to benefit the airway or the breathing clearly oxygenation get that nasal canula increase your oxygen flow secondly the second priority is what's a sea priority that actually could be an indirect B and that's going to be get rid of extra volume urinary volume as it relates to lasix in the loop diuretic give that IV push and then the secondary one would also be the nitroglycerin the nitroglycerin drip another C priority but this is going to help your students translate this knowledge to practice again word matters most is we look at the next problem what is the priority problem that your patient currently presents what now as we looked at all this clinical data and we've talked through it it's evident and obvious and even without being a physician the nurse is able to recognize that our primary problem is heart failure left-sided heart from it has progressed to right-center heartfulness patient is in crisis and must be recognized as a pretty critical patient with a high risk of of a bad outcome the other question look at priorities what is the underlying pathophysiology of the primary problem one of the things that I see students struggle with is applying pathophysiology to nursing practice they had it as a prerequisite but it was decontextualized to Nursing Practice and that's something that as nurse educators you must bring back the concepts of cardiac output and stroke volume times heart rate as it relates to heart failure in the context of this great illustration of left-sided failure that is transferring over to writes and fire these concepts of the physiology must be deeply understood and we must expect our students to deeply understood and stand these concepts related to clinical practice then we look at what is the priority as you look at all this data we've collected we've filtered through it together in this case study but what nursing priority is not going to guide your plan of care identifying you know using the ABCs in some of the context relation would be the importance to decrease the work order of the heart improving oxygenation and all that goes with that I'm not going to take the time to go through the specifics of none of the nursing interventions with each of these but you can have a rich classroom discussion using Nanda or just simply stating the problem without Nanda and the nursing priority without Nanda to help our students really translate into things like a nurse in practice and then we look at the educational priorities what as you look at this patient down the road several days heart failure is an excellent example where when the patient is you taught well and educational priorities are reinforced we can prevent readmissions and help them manage their themselves more effectively in that context as an outpatient so discuss the educational priorities of diet daily ways using the resources that your institution has to promote the patient to stay outside the hospital and not be readmitted you know heart failure is primarily the one of the number one causes for readmissions with the elderly and it's something that heart failure must be deeply understood by each of our students especially if they're going to practice and even transitional or acute care settings I also discussed the importance of caring a nurse in these case studies all these questions are open-ended as you've noticed there's no multiple choice because as you know in practice you either know the content and are able to recognize relevance trend your data and determine what's my priority problem or you don't and therefore failure to rescue results with adverse outcomes and even death and so again this fundamental reasoning case study mirrors clinical practice in that context but I want my students to care because Carrie promotes that engagement that is going to increase the vigilance and promote better outcome so again those two simple questions what is the patient might be experiencing or feeling right now in the context of this exacerbation of heart failure we know that he's already very anxious and how can we comfort this person how can the nurse demonstrate not only excellence in caring for the immediate need but also demonstrate caring in the context of providing that care is an essential skill that we must guide our students to never forget that there is a patient behind the problem the other caring question is what can you do as a nurse to engage with donate yourself with the patient's experience and show that they matter to you as a person and these are rich questions that really are open-ended with numerous responses and so this provides rich dialogue in your classroom it's not only situate caring but to talk about it and discuss it so that your students can readily translate this to the bedside I have a free topic or a free download of heart failure or excuse me of sepsis this was hard on you but I have a free download of sepsis on my website so you can see fundamental reasoning and in the context of sepsis and compares to what you're doing to implement active learning best practices in your classroom and as we look at clinical reasoning and active learning exercises in your program remember that this is not just a trendy pedagogy and these to flip your classroom but they emphasize clinical reasoning which represents how nurses think and practice and is a transformational paradigm shift based on the research of the Carnegie Foundation identified in educating nurses and ultimately this case study in using these cases will not only promote the learning of your students but is going to promote better outcomes for the patients your students will soon be caring for thank you and be sure to check out my website and see for yourself thought how these resources can help promote the learning of your students today thank you