Intriguing Scenarios of Clinical Reasoning

Question: Discuss about the Intriguing Scenarios of Clinical Reasoning. Answer: Introduction Clinically, Mrs. Amaris case presents one of the most intriguing scenarios of clinical reasoning. The case exposes faulty approaches by the medical staff in the diagnoses and treatment of the patient. In diagnosing this case, there is the need to collect facts from the patient situation; this includes her age, her social life, her lifestyle, and medical conditions. The nurses also ought to have collected cues from Mrs. Amaris conditions, process the information, and analyze it, before identifying the problems, and taking actions. Arguably, the nurses in charge did not do comprehensive evaluation of available options when dealing with Mrs. Amaris case. Patient Situation Cognitive perception of nurses is a key determinant of patient outcome and the foundation to correct treatment. Usually, nurses allow their judgment to be clouded by attitudes and hasty conclusions creating a deficiency in critical thinking that results in failure to notice vital warning signs in patients' (Ericsson, Whyte Ward, (2007). Mrs. Amari, a 59-year-old woman, was admitted to a hospital and diagnosed with a minor stroke on physical assessment which later gained the status of the Transient Ischemic Attack (TIA) since a subsequent check-up told of the disappearance of the symptoms. A TAI is not a heart attack nor can it be defined as a cerebral vascular accident; a TAI is caused by an unusual disruption of the blood supply to the brain due to presence of a blood clot, plaque or damaged arteries as a result of hypertension. Collecting Cues A TIA is a form of stroke that is minor and subsides within a period of 24 hours a cerebral vascular accident, however, lasts longer and is riskier. When blood supply to the brain is disrupted, the blood components like oxygen and nutrients which are essential for the functioning of the brain are inhibited from reaching the brain. The brain cells, therefore, start to die, terminating the transmission of certain nerve impulses to parts of the body. This termination leads to paralysis and numbness of the affected areas which are usually on either the right or left part of the body depending on which part of the brain is affected by the blood disruption. Further blockage of the arteries serving the brain with blood may cause adverse effects or permanent stroke NSW Health (2006). For the TAI the blood supply usually resumes, and the symptoms subside. Mrs. Amari being an elderly woman inflicted an ascertainment bias among the nurses who immediately associated her symptoms with stroke since the condition gets common with advancing age; this prevented them from realizing the bigger picture. According to Darmani (2010), ascertainment bias is said to be the lack of clinical reasoning by nurses due to assumptions based on age, stigma and stereotyping. Due to the prior ascertainment, there were no background checks on the patient's history of medical assessment or analysis of previous patient charts. Instead, the nurses went ahead to gather new information basing their evaluation on the detection of signs associated with stroke. Their diagnosis followed the procedure of the stroke diagnosis that involves blood tests, computed tomography, MRI but failed to carry out a CAT scan which presents any bleeding in the brain. Coincidentally some of the signs and symptoms of a stroke were present and so once more there was a confirmation bias that led to a tilted processing and interpretation of patient information. According to Warren (2011), some of the signs and symptoms of a typical TAI that a patient should possess include: having a weak, numb and paralyzed experience of the face, limbs or arms, delayed speech, and poor comprehensive ability, dizziness, blurred vision, headache and difficulty in swallowing. Out of all these symptoms, the conclusion was that she was having a minor stroke due to the numbness of the right arm and the slurring speech. What the nurses failed to see was that there were other symptoms indicating signs of a more complicated complication which may have led to the damage of the arteries in the brain causing the minor stroke signs. All the other symptoms were overlooked. According to Lasater (2007), this is a conformational bias and is described as when a nurse looks for evidence to support prior conclusions without considering the opposing signs. (Ericsson, Whyte, and Ward, 2007) state the slurred speech and paralysis as the main misguiding factors in the diagnosis o f a patient that may lead to the conclusion that the patient is suffering from a stroke which may not be the case. Process Information In the current situation, it is clear that Mrs. Mari was a victim of biased clinical reasoning that led to wrong treatment and thus the worsened condition. The physical assessment shows she has progressed from stage one hypertension to stage two. Her respiratory rates are normal, and her GCS shows signs of moderate brain damage where she can only open her eyes to voices. She can respond to pain but has a clear vision, the blood glucose levels, and the temperature is stable and normal, it is essential to acquire the patient background knowledge on the history of assessments and health records (Malinina, Zema, Sander Serebruany, 2007). From the previous evaluation and which was correct, there is the presence of a carotid bruit which indicates signs of a narrowed artery. According to Cox (2008), a carotid bruit is a sound occurring in the neck area which is detected by a stethoscope and which indicates signs of narrow artery lumen. Then the next step will be the new diagnosis, the firs t alarming sign is hypertension, and so we need to perform ambulatory blood pressure check accompanied by a lipid test to determine if she has high cholesterol levels. There after we need to repeat the MRI and CT scan this time being objective and being on the lookout for any danger signs in the brain. From the findings, Mrs. Amari is suffering from the condition of high blood pressure which has originated from a condition known as hypercholesterolemia which is the presence of too much cholesterol build up (Tarner, 2006).This is a cause for alarm as the cholesterol build up exists in the arteries, and this has led to the narrowing down of the arteries transporting the blood from the heart. As a result, the cholesterol on the walls of the arteries have led to the hardening of the walls, and this is causing the heart to pump harder which may occur at her age cause heart failure or a heart attack (Groopman, 2008). According to Qureshi, Clarke Rudd (2012), the heart pumps harder and as the arteries narrow down the blood pressure goes up, and this is causing plaques in the brain that may lead to frequent TAIs due to disruption of blood supply, this explains the numbness and slurred speech. If the plaques continue to add, there may occur permanent brain damage or permanent stroke (Tarne r, 2006). Infer Medication; therefore, needs to start right away to reduce the cholesterol so as to reduce the risks associated with hypertension and cholesterol levels. To improve her condition, Mrs. Amari needs to improve her lifestyle regarding eating a balanced diet and exercising more, reducing her salt intake and living a stress-free life, Apart from that she will receive drugs to lower her blood pressure, reduce her cholesterol and eliminate the blood clots and plaques. However, it will be impossible to fully remove all the cholesterol in the arteries and also regain the shape of the lumens. The measures if implemented correctly will reduce the risk factors. The brain functioning of Mrs. Mari was altered, and this was assessed by the CAT scan and the MRI performed. Due to the change in the neurology of Mrs. Amari, it is important that she emphasizes on dietary change and management of stress. Her condition creates a risk of brain damage, and so it is necessary also to supplement her with pres criptions of supplements and vitamins to boost her brain activity. References Cox, Bev,B.Sc, R.G.N. 2008, "Stroke and transient ischaemic attack",Practice Nurse,vol. 36, no. 1, pp. 43-48. Darmani, N.A. 2010. "Cannabinoid-Induced Hyperemesis: A Conundrum From Clinical Recognition to Basic Science Mechanisms." Pharmaceuticals, vol.3. no.7.pp 2163-2177. Ericsson, K., Whyte, A. and Ward. J. 2007. "Expert performance in nursing: reviewing research on expertise in nursing within the framework of the expert-performance approach." Advances in Nursing Science. vol 30. no.1.pp 58-71. Groopman, J. (2008). How Doctors Think. Boston: Houghton Mifflin. Lasater, K. 2007. High-fidelity simulation and the development of clinical judgment: students' experiences. Journal of Nursing Education. vol.46.no. 6. pp 269-276. Malinina, D., Zema, C., Sander, S. Serebruany, V. 2007, "Cost-effectiveness of antiplatelet therapy for secondary stroke prevention",Expert Review of Pharmacoeconomics Outcomes Research,vol. 7, no. 4, pp. 357-63. NSW Health, 2006. Patient Safety and Clinical Quality Program: Third report on incident management in the NSW Public Health System 2005-2006. NSW Department of Health. Sydney. Qureshi, S., Clarke, A. Rudd, A. 2012, "Transient ischaemic attack",GP,, pp. 27-29. Tanner, C. 2006. "Thinking like a nurse: A research-based model of clinical judgment in nursing." Journal of Nursing Education, vol.45. no.6.pp 204-211 Warren, Ed,F.R.C.G.P., G.P. 2011, "A QOF perspective on... stroke and transient ischaemic attack",Practice Nurse,vol. 41, no. 1, pp. 19-22.