Reflective written Analysis of clinical incident

Answer

The Clinical Reasoning Cycle: Autonomic Hyperreflexia Medical Emergency

Introduction

            Clinical reasoning is a critical practice approach in the nursing setting, especially when a nurse practitioner operates in a medical emergency unit. It should be understood that the nurse’s role in this scenario goes beyond administering drugs as per the physician order. In this critical situation, practitioners are expected to collaborate with physicians in the delivery of care. The Levett-Jones clinical reasoning cycle offers a unique tool through which this critical reasoning process can be implemented. This theoretical framework urges healthcare practitioners to evaluate situations in eight steps including consideration of facts, information collection, information processing, problem identification, goal establishment, action implementation, evaluation, and reflection. This framework was crucial during my clinical placement as a nurse practitioner in a medical emergency team. The experience allowed me to understand the value of clinical reasoning in critical care scenario. I also had the chance to understand the pivotal role nurses assume in the emergency care setting.

Case Background

            My clinical placement period offered a unique opportunity for me to observe, learn, and apply effective clinical reasoning during the management of critical medical emergencies including Autonomic Hyperreflexia. A 34-year-old man was admitted to the emergency following a five-hour severe headache. The Medical Emergency Team made preliminary tests which concluded that the patient’s neck was not stiff, and there were no signs of rash and photophobia. Noteworthy is the fact that the highlighted signs are common causes of severe headaches. Further investigation of her medical history geared the team’s attention to a C5-6 vertebra spinal cord injury which he experienced as a gymnast at the age of 28. The incident left him paraplegic, and he was forced to use an indwelling urinary catheter. The patient’s vitals were checked, and they were quite interesting. He had zero signs of meningitis, and his respiratory and cardiovascular systems were intact. However, his supine blood pressure was 156/90mmHg and the pulse rate was at 100 beats per minute. Interestingly, his previous hospital notes showed that his blood pressure range shifted from 70/50 to 90/70 mmHg since he experienced the spinal code injury. His urine dipstick recorded positive for leucocytes (3+) and blood (4+): the full blood count was 12000x109/L while C - reactive protein (CRP) test showed an elevated value of 68mg/L. At that point, various factors indicated that the underlying condition was autonomic hyperreflexia. Some of these indicators included the history of spinal code injury, urinary tract issues, hypertension, and persistent headache. The emergency unit nursing team placed him on nitrate infusion to lower the blood pressure. Together with the administration of oral antibiotics, this intervention improved the symptoms, and his headache subsided. Meanwhile, the urinary catheter was replaced, then an antibiotic cover was placed on the new one to prevent infections. Such a commendable response to the medical emergency proved that effective application of a patient-centric clinical reasoning cycle enhances outcomes during practice. On this note, the primary aim of this paper is to offer a reflective account of the application of the clinical reasoning cycle during my clinical placement.

Consideration of Patient Situation

            Our patient was admitted on grounds of persistent pounding headache for at least five hours. This condition was quite critical, but it offered vague representation of the underlying issue. For this reason, preliminary tests were conducted to confirm whether the headache was caused by a problem in the visual and neural network. Turpin and Higgs (2017) urge nurse practitioners to apply experiential knowledge when dealing with such patients given the fact that symptoms can be quite misleading.

On the surface, autonomic hyperreflexia – also known as autonomic dysreflexia (AD) – is usually triggered by urinary tract infection in a patient who has experienced spinal cord injury. Other common triggers include distended bladder, urinary retention, blocked catheter, hemorrhoids, bowel impaction, pressure sores, skin irritations, bladder stones, and tight clothing. In their phenomenal piece, Sharif and Hou (2017) present a broad range of symptoms, including, nasal congestion, pounding headache, profuse sweating, confusion, dizziness, irregular heartbeat, anxiety, high blood pressure, and light-headedness. It appears fair to remark that since some of these triggers and symptoms were quite evident in the patient I encountered during my placement, the nursing team was on the lookout for any occurrence during the treatment process to avoid further complications.

Information/Cue Collection

            On that note, we had to collect relevant clinical and non-clinical information to gain further insight on the matter. This phase involved questioning the patient regarding his physical state: it is important to note that he described his career as a gymnast, and how a particular fall incident left him paraplegic. He also mentioned that the spinal cord injury also compelled him to live with an in-dwelling urinary catheter. Apart from the C5-6 vertebrae spinal cord injury, we checked his vitals to gain in-depth knowledge of the condition. The abnormal blood pressure, blood count, and CRP readings indicated an alarming case of hypertension and metabolic dysfunction at the cell level. This assessment increased the amount of data available for analysis prior to the decision-making phase.

            On this note, it should be established that observable aspects of AD usually occur due to the interruption of a patient’s autonomic nervous system (ANS), which is fundamentally segmented as sympathetic autonomic nervous system (SANS) and parasympathetic autonomic nervous system (PANS) (Sharif & Hou, 2017). Both the SANS and PANS are in charge of the involuntary functions of a human body. Usually, the first triggers actions based on scenarios while the latter counteracts the functions to bring stability (Sharif & Hou, 2017). For instance, the SANS compels a person to urinate or sweat when the body’s waste levels are excessively high then PANS regulates the extraction process when the levels have reduced. Unfortunately, a patient suffering from autonomic hyperreflexia has dysfunctional SANS and PANS. This patient’s system overreacts to various stimuli with regards to the bladder capacity, bowel movement, and digestion process, thus, causing some of the listed symptoms (Sharif & Hou, 2017). This kind of systemic failure can be quite hard to contemplate without intensely analyzing the information generated in the first two phases of this clinical reasoning cycle.

Information Processing

            This stage necessitates the evaluation of information collected through the first two phases, which involve observation and testing (Arthur, 2020). Once all relevant information was obtained, the medical emergency team engaged in a brainstorming session to determine the possible cause. The physiotherapist and our department nurse leader gave us an opportunity to voice our perspectives on the issue, while they applied experiential knowledge to guide the process. Since it was established that he was not photophobic, and that neither his respiratory nor cardiovascular systems were functioning properly, we confidently discarded meningitis as a possible cause. We agreed that the test results strongly indicated that our patient was experiencing autonomic dysreflexia.

Problem Identification

            Normally, this phase gives practitioners the chance to confirm their assumptions before moving further into the decision-making process. Decision-making in the clinical setting is often complex as it depends on a plethora of internal and external dynamics. Such a unique reality compels practitioners to leverage the power of formal decision-making tools such as the ‘Clinical Reasoning Cycle’ and the ‘Decision Tree’. Such tools are instrumental in cases that demand systematic decisions and solutions. According to Daly (2018), medical emergency teams should utilize a broad range of clinical and nonclinical factors/findings to facilitate accurate diagnoses and reasonable solutions. Sharif and Hou (2017) concur with the preceding sentiment by adding that these clinical reasoning tools apply sequential chaining procedures which allow analysts to apply logical considerations prior to the final decision.  As a team, we understood that this procedure had to be followed effectively to ensure that our patient received the best clinical diagnosis and intervention. Therefore, we listed the factors that made us believe that our patient was suffering from autonomic dysreflexia. Hunter and Arthur (2016) believe that a solid information processing stage gives sufficient ground for the problem specified at this phase.

Goal Establishment

            Autonomic dysreflexia is a manageable condition inasmuch as it lacks a specific cure. However, a clear grasp of a patient’s situation based on analytical exploration of findings enhances the outcomes of this stage (Grace, et al., 2016). Such is often the case as the spinal cord injury is almost completely irreversible. Given this reality, our goal as the treatment team was to regulate the blood pressure to mitigate detrimental outcomes such as intracranial hemorrhage, cardiac arrhythmia, seizures, or even death. In an attempt to attain such a progressive outcome, we decided to lower the blood pressure to at least 94/60 mmHg within 4-6 hours. Once the blood pressure was regulated, we were to stabilize his autonomic nervous system in the long-run. It suffices to assert that goal setting is a crucial step of any clinical decision making procedure as it prevents practitioners from engaging in futile efforts. When placed into perspective, this step gave us an opportunity to envision the desirable condition for our patient prior to the intervention; therefore, it is quite useful in decision-making (Daly, 2018).

Implementation

The first goal necessitated the infusion of nitrate into his cardiac system. This move was instrumental in lowering his blood pressure to the highlighted 94/60mmHg. After the blood pressure regulation, we replaced his urinary catheter with a sanitized model then attach an antibiotic cover. Oral antibiotics were also used to reduce the headaches as the blood pressure subsided. Such a time-sensitive procedure has been praised by Lee and Joo (2017), as they acknowledge the threat caused by autonomic dysreflexia in patients with spinal cord injury.

Outcome Evaluation

            This phase is always important in all clinical interventions since it allows providers to determine whether the implemented solutions have valuable impacts on the patients (Cook, Durning, Sherbino, & Gruppen, 2019). As a team, we used the blood pressure, patient feedback, and professional observation as the key performance indicators. We knew that the emergency treatment was a success as soon as the blood pressure levels reached 94/60 mmHg. The patient’s comments on how he felt after the intervention also demonstrated efficacy. Noteworthy is the fact that all recorded symptoms improved. Our leader, the physiotherapist applied observation and wise judgment to confirm the success of our treatment process.

Reflection

            Reflection is the final, and arguably, the most instrumental stage of this process since it guides practitioners in future circumstances. We held a discussion after the treatment to point out the strengths and weaknesses of our operation. This approach made it possible for each individual to acknowledge his/her flaws and focus on improvement. As a future practitioner, I gained useful knowledge on matters pertaining to autonomic hyperreflexia treatment and clinical judgment at large.

            When reflecting on this stage, I cannot help but notice the subtle application of Gibbs Reflective Cycle. In 1988, Graham Gibbs defined reflection as a six-phase process which aims at improving performance in subsequent challenges. The first step of Gibbs’ framework involves description of the problem (Kanofsky, 2019). Here, each member of the team shared his/her opinion of the treatment process: emphasis was placed on why we dealt with the issue in that manner. The second step involves the sharing of feelings. At this sentimental phase, each member gave an open-ended response to the emotions evoked by this process (Kanofsky, 2019). It appears wise to highlight that most members of the emergency team stated that they found the procedure noble and humane since we basically saved the life of a critically ill patient. In his framework, Gibbs proposes the evaluation of the experience as a third phase (Kanofsky, 2019). This point was crucial since is unearthed the positive and negative aspects of the treatment process. We then proceeded to the analysis phase of Gibbs Reflective Cycle when our team leaders used their experience to share alternative ways in which we could have approached the problem. With this knowledge, we concluded that we did the right thing. Fairly stating, our implementation of the final stage of Gibbs Reflective Cycle was quite vague as we did not come up with a precise action plan in case a similar incident occurred.

Registered Nurse Standards for Practice

            The Nursing and Midwifery Board of Australia (NMBA) expects healthcare practitioners in its jurisdiction to meet seven predetermined standards of practice. The first standard holds that a nurse ought to think critically and analytically (NMBA, 2020). Critical and analytical thinking is vital in healthcare practice since things are not always as they seem (Young, et al., 2020). Our patient’s case appears quite illustrious: inasmuch as he had a persistent headache, the underlying problem was not meningitis or other straightforward triggers of headaches such as neck stiffness. The second one argues that he/she should engage in professional and therapeutic relationships during practice (NMBA, 2020). This standard is useful in the healthcare field since practitioners and patients collaborate as a team to find solutions to a common problem. The fact that we engaged in open communication throughout the process shows how we utilized such a principle to enhance outcomes. The third standard mandates practitioners to maintain the capacity to deliver effective services through constant academic and experiential learning (NMBA, 2020). When placed into perspective, the whole process equipped each member with experiential knowledge which would improve his/her performance in case similar situations emerge in future.

Conclusion

            Autonomic hyperreflexia is an emergency medical condition that demands teamwork, goal-driven, and patient centric professional care. For such a clinical problem to be solved effectively, the practitioners must embrace a systematic decision-making model such as the clinical reasoning cycle. A thorough exploration of the experience we had with our 34-year-old patient sheds some light on why formality is recommended when resolving clinical matters. Failure to apply a systematic decision-making process is highly likely to prove fatal.

References

Cook, D. A., Durning, S. J., Sherbino, J., & Gruppen, L. D. (2019). Management reasoning: implications for health professions educators and a research agenda. Academic Medicine, 94(9), 1310-1316. Retrieved from https://journals.lww.com/academicmedicine/Fulltext/2019/09000/Management_Reasoning__Implications_for_Health.19.aspx

Daly, P. (2018). A concise guide to clinical reasoning. Journal of evaluation in clinical practice, 24(5), 966-972. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/jep.12940

Grace, S., Orrock, P., Vaughan, B., Blaich, R., & Coutts, R. (2016). Understanding clinical reasoning in osteopathy: a qualitative research approach. Chiropractic & manual therapies, 24(1), 1-10. Retrieved from https://chiromt.biomedcentral.com/articles/10.1186/s12998-016-0087-x

Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement: Clinical educators' perceptions. Nurse education in practice, 18, 73-79. Retrieved from https://www.sciencedirect.com/science/article/pii/S147159531630004X

Kanofsky, S. (2019). Reflective Practice for Physician Assistants. Intrinsic Skills for Physician Assistants an Issue of Physician Assistant Clinics, E-Book, 5(1), 27. Retrieved from https://books.google.com/books?hl=en&lr=&id=QFvBDwAAQBAJ&oi=fnd&pg=PA27&dq=Gibbs+reflective+cycle&ots=J1pgeXhIw1&sig=ssvtCSWWm1X-TFF2lcUPasybeR4

Lee, E. S., & Joo, M. C. (2017). Prevalence of autonomic dysreflexia in patients with spinal cord injury above T6. BioMed research international, 2017. Retrieved from https://www.hindawi.com/journals/bmri/2017/2027594/abs/

Nursing and Midwifery Board Australia (NMBA). (2020). Registered Nurse Standards for Practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx

Sharif, H., & Hou, S. (2017). Autonomic dysreflexia: a cardiovascular disorder following spinal cord injury. Neural Regeneration Research, 12(9), 1390. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649450/

Turpin, M., & Higgs, J. (2017). Clinical reasoning and evidence-based practice. Evidence-based practice: Across the health professions, 364-383.

Young, M. E., Thomas, A., Lubarsky, S., Gordon, D., Gruppen, L. D., Rencic, J., & Schuwirth, L. (2020). Mapping clinical reasoning literature across the health professions: a scoping review. BMC medical education, 20, 1-11. Retrieved from https://link.springer.com/content/pdf/10.1186/s12909-020-02012-9.pdf

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