Research proposal

essay will explore how nurses make judgments regarding

Introduction

This essay will explore how nurses make judgments regarding Mr. Singh’s clinical assessment, diagnosis and treatment. Clinical reasoning describes techniques nurses use to gather ideas, develop it, to help understand the patient’s health condition and execute interventions (Barker et al., 2016). This case study approach of Mr. Singh’s health conditions will focus on ‘bio-psychosocial perspective’ (biological, psychological, and sociological behaviours) to resolve his health problem (Patel and Morrissey 2011). In corroboration with ‘Tanner’s Model’ to appropriately investigate how nurses think in practice (Tanner 2013). As nurses shared decision making with other health professionals to help prevent further deterioration of Mr. Singh’s condition (Kraischsk, and Anthony 2007).

Tanner’s Model in clinical judgment are divided into four parts (Tanner 2013). These are; noticing, interpretation, responding and reflection. (Beth 2013). Tanner model would be more appropriate as it is straightforward and flexible compared to Lavella1997 - more strategic and carries more segments (Wooddruff 2015). Tanner Model will help student nurses to improve on the four strategic areas aforementioned (Tanner 2013). In addition, Mr. Singh’s ‘person-centred-care’ would help him to participate in his care, at the same time, help nurses to know more about his illness, concerns, needs and expectations etc.… (Slater, McCance and McCormack 2015). Giving nurses step by step approach to handling his health condition.

Noticing; Mr. Singh is an Asian descendant, 56-year-old on admission, diagnosed with; Acute Coronary Syndrome (ACS), smokes, divorcee, lives alone, stressed, diabetes type 2, hypertension, high Cholesterol, lost his job, appears distressed, eventually diagnosed with Bipolar. Noticing is what nurses used to list out all Mr. Singh’s health condition. Nurse will take his viewpoint into consideration and assess the impact of this sickness on his health (Patel and Morrissey 2011). As a formal protocol nurse would say: good-morning Mr. Singh. My name/number is 21321400 and would be the nurse looking after you today. Explaining his health condition, the procedures, treatment method to him. Asking Mr. Singh What name he would prefer to be called? Gain consent, and ask how are you today? To help nurse flow well with him and looking out for a current symptoms and concerns (Patel and Morrissey 2011). Furthermore, curtains drawn and covered him for privacy and dignity. Also, before any procedure, hands washed before and after, putting on gloves, and apron are advised by Patel and Morrissey. Showing him respect and to protect ourselves from bacteria.

In Mr. Singh ABCDE’s clinical assessment, the system goes beyond resuscitation, it is basis for diagnosis and urgent care establishing his level of consciousness and priority (Blows 2018).

The letter=A, represent his airway, B=breathing, C=circulation, D=disability, E=external. His Airway is patent since he engages in conversation (Peate and Dutton 2012). He has no need for resuscitation or to clear airway such as; head tilt, chin lift, place in recovery position and calling for assistance (Resuscitation Council UK 2015).

Breathing shows spontaneously on room air and Mr. Singh’s oxygen saturation (SPo2) shows normal with 100%. However, the British Thoracic Society 2017 recommend 94 to 98% while, for acute patients 88-92%, for oxygen saturation. Generally, Nurse should feel the warmness of exhaled air while observing his chest wall movement. Likewise, observe his colour, listening to breathing, ensuring his not using accessory muscles and positioning him on an upright position, showing Mr. Singh’s health is normal (Blows, 2018). It is good to note that, if Mr. Singh’s respiratory status is high, it may be due to changes in cardiac problems such as blocked blood vessels that leads to heart attack and chest pain. Going by the National Early Warning Score (NEWs), it shows Mr. Singh is getting better. (Royal College of Physician 2017)

His circulation, starting from his pulse rate of 80 beats per minute indicates normal. Reflection on his heart rate, capillary refilled held the nail of Mr. Singh’s fingers for 4-5 seconds above heart level and must return back pink colour in two minutes, showing normal (Royal College of Physician 2017(RCP)). Mr. Singh’s blood pressure (BP) shows 160/100, normal according to NEWs from the (RCN 2017) also, this is significant as it indicates hypertension, it will be control with medication (RCP 2017)). Nurse would monitor his food intake with reduced sodium(salt) intake and regular exercise. Central cyanosis inspecting his mouth and lips for blue colour, peripheral cyanosis- feeling his fingers and toes for coldness, as absent of peripheral failure would indicate poor blood circulation (Travis, 2010 pp.466-467). However, Mr. Singh is perfectly okay. Respiratory rate shows 16/minute and temperature at 36.4 which are normal, no sign of blood loss (Travis, 2010). Showing, Mr. Singh is perfectly okay

Disability Mr. Singh is alert, he can speak, he is not confusion, not in pain, and not unresponsive. This is according to ACVPU, a tool internationally used to describe, diagnoses and to ascertained his conscious level (Travis, 2010). In addition, Mr. Singh’s reaction to light and size of his pupil would be checked, due to high blood glucose (BG) with 12.4mmol/l, and needs urgent intervention with his medication (Blows 2018). Checked temperature and call for help appropriately plus manual pulse could be useful for skin moisture and ascertained weak pulse (Peate and Dutton 2012). Nurse to encourage ongoing checks; such as BP, BG, food intake and exercise.

Exposure; inspect his skin for rashes/erythema, check invasive lines for phlebitis, wound, and pressure sore. His skin might have appeared intake as there was no bruise or sore mentioned. Check deep vein thromboses, palpitate with thump for 5 seconds, feel legs for pitting oedema, and mean arterial pressure (MAP) as appropriate’ because it measures the pressure for perfusion of organs in Mr. Singh’s body such as his brain, coronary artery and his kidneys. Nurse to make sure it is not less than 60mmHg to provide enough blood for him. (Peate and Dutton 2012). The reason of this National Early Warning Score tools are to make sure that nurses cover all possible sections of his health. Its links changes in his observations and how not to miss changes that could affect his health progress (Royal College of Physicians 2017). Mr. Singh should be covered or maintained body temperature, privacy and dignity in place (Blows 2018).

The second stage of Tanners model is Interpretation. Troponin in Mr. Singh’s blood shows a Non ST Elevated Myocardial infarction (NSTEMI) which is medical name for heart attack (Juall and Carpenito Moyet, 2013). His goals are; checking his vital signs, 12 –lead ECG, catheter or urine bottle to check out-put monitor, IV cannula for fluid and prescribed medications. (Patel and Morrissey 2011) In the repeated troponin test, the result was – 5.63ng/ml indicating deteriorating condition, this could easily be controlled by his prescribed medications. (Juall, and Carpenito-Moyet 2013). Compared to the previous blood test of 0.67ng/ml, whereas, normal is 0.3 (Patel and Morrissey 2011). However, the main reason Mr. Singh chest pain was triggered by MI Myocardia infarct along with stress from family disintegration and job loss. This is a major problem in the society today, which in turn generate to poor dieting that is; eating food with high sugar content. Resulting to diabetes, obesity, smoking, hypertension, excessive intake of saturated fat from junk food (Hyperlipidemia are the common causes of heart problem also due to fat build up in the heart) (Shah, et al. 2013 pp.138-146). Family history. (Patel and Morrissey 2011) All Mr. Singh’s health conditions intertwined.

That said, stress is defined as the physical, psychological, social, or spiritual effect of ones (Mr. Singh’s) present pressure and event (Juall and Carpenito-Moyet, 2013). Hence, medications/referral to dietitian may not solve Mr. Singh’s problem. Stress of losing his family and job must have contributed to his health problems. This then triggers other health issues through a release of glucocorticoids, hormones release during stress. So referral to family counsellor, balance diet with his prescribed medication will help him better (Howastson-Jones, Standing and Robert, S. 2015). However, with nurses’ good communication skills and gaining understanding of his condition would explore ways to help him live normal life (Bach and Grant 2015).

Mr. Singh type 2 diabetes shows, his beta cells in pancreas releases insulin but not enough. Hence, his cell membrane shows resistance with varying degrees of insulin secretory defect. (Blows 2018). Mr. Singh blood glucose will be monitored before and after meals to avoid diabetic coma. This could cause hypoglycemia (with low blood glucose) as “Blows” stresses. All his health conditions are related, if well managed, he could go home sooner. While, he would need continuous follow up mostly, looking at the major risk factors listed above to help him live a normal life (Nice.org.uk. 2019 Overview type 2 diabetes in adults).

Responding; Mr. Singh would be engaged in diversional activity like; purposeful distract by thinking of something pleasant. Inhale through the nose for 4 seconds, refer to resources to learn relaxation techniques, yoga classes. All these could help Mr. Singh to be disconnected from stress cycle, decrease heart rate, respirations and strong feeling of anger (Juall, L. and Carpenito-Moyet, 2013). Similarly, diabetes revolves around chronic heart disease and stress. Hence, taking his medication and keeping the blood pressure to keep blood pressure within 120/80 as recommended by (RCN 2017) and blood-glucose level normal, before 4 to 7 mmol/l and under 9 mmol/L especially after food would be of great help to him (Hicks 2015). The normal glucose levels for those without diabetes are between 2.5% and 6.0%, while moderate diabetic control would be 6.1-8.00% (Howastson-Jones, Standing and Robert, 2015). The link between diabetes and heart disease are the major risk factor for early onset of coronary heart disease, including high blood pressure, and major causes of morbidity and mortality (INNE 2010). Therefore, urgent follow-up, early diagnose and taking medications would save lives. INNE further explained about need to see optician due to retinopathy, nephropathy, and peripheral neuropathy. His hypertension tablet is amlodipine 10mg daily to treat blood pressure from160/100 to 120/80, it is also, a calcium channel blocker that dilate blood vessel and improves blood flow. Further used for the treatment of Mr. Sing’s chest pain, it relaxes the blood vessels, (side effect –dizziness, lightheadedness). Whereas, for hyperlipidemia Simvastatin 20 mg to be taken at night to lower his bad cholesterol in blood. (side effect headache, difficulty sleeping). Anxiety and depression would be Sertraline 100 mg daily use for Mr. Singh’s side effects; (drowsiness, tremors or shaking, decrease sex drive, sweating) etc. control properly with medications. Also, Fluoxetine 20mg daily equally used for his anti-depressant, side effect; (light headedness, drowsiness) etc.… (British National Formulary 77 2018 (BNF)).

Mr. Singh’s medications are; dalterparin 300mg used for treatment of deep vein thrombosis prescribed by the physician (side effect hemorrhage). Including aspirin 300 mg to relief pain and blood thinner which prevent blood cells known as platelets from clumping to form clot, (side effect increased bleeding) would be use for heart treatment ((BNF 2018))., Metformin 1g three times daily, helps control blood sugar level (side effects; muscles pain and headache) etc. He would need glycemic control, owing to Mr. Singh test for glycohaemoglobin has been drastically raised to 12.4mmol/1. This test ‘measures the amount of glucose bound to hemoglobin and can be accurate measure of the average levels of blood glucose in the preceding three months and help control his glucose level (Patel and Morrissey 2011). All these medications and exercises would help normalised his health situation (Peate and Dutton 2012). Regarding smoking, nurse to respect his autonomy and encouraged him to stop smoking gradually (Patel and Morrissey 2011)/ (BNF 77 2018).

Mr. Singh’s physical assessment involves; precise resting situation, tolerable exposure (meaning only the areas to be checked are opened, ensuring all other areas are covered) and dignity maintained. Generally, inspecting him from head to toe, remarking on any important discoveries such as; pressure sore, wound or redness (Patel and Morrissey 2011). Taking his correct weight, waist circumference measuring it against the time of his admission. (Patel and Morrissey 2011). Oxygen in the blood and temperature shows normal (O’Driscoll et al., 2019). Showing great improvement to his health. Likewise, Point-of-care, ultra-scans and echocardiography could help clinicians to diagnose acute cardiogenic pulmonary oedema to prove Mr. Singh is perfectly well or need further medical intervention (Geersing et al. 2012). Furthermore, nurse to inform the doctor about referral to the psychiatrist.

Mr. Singh’s evaluation on health is handled by the multidisciplinary team once a week. Here, all those involved in his health condition such as doctors, occupational therapist, speech and language therapist, physio therapist, social worker, nurses and student nurses meet to discourse his improvement and discharged or may benefit from further medical intervention (Shah, et al. 2013). Mr. Singh might be improving hence, may not need further hospital intervention but community and his GP to continue from where the hospital stopped. Nurses are closer to the patient than doctors, therefore, nurses to check terminology doctors languages and make it easier for patient. Doctor for example, could use medical language to inform Mr. Singh that he has hypoglycemia which nurse would called ‘low blood glucose level’. Nurses always clarify medical jargons to patient such as Mr. Singh for better understanding about his ailment (Howastson-Jones, Standing and Robert, 2015). However, nursing diagnoses has both advantages (clearly define the problems), focusing more on Mr. Singh for example, other than all patients. Nurse consider problems from other scientific viewpoints such as social sciences, they direct specific nursing action and evaluation of action providing the bases on which care would be planned (Hinchliff, Norman and Schober 2008). Experience nurses could acquire further critical thinking disposition twice as much to novice or student nurses. Experience nurse for example, could look at medications taken by the student nurse and know that they are correct medications or another medication has been added to it, or by looking at a patient they know his/her condition has deteriorated. (Tanner, 2013). Disadvantages of nurses diagnoses are; patients such as, Mr. Singh do not understand nursing diagnose but needed integration in the discussion when nurses diagnose is being drawn. (Carpenito, 2013).

Preparing for discharge; named nurse thoroughly explained each medication to Mr. Singh; dosages, therapy and importance of compliance. Warning Mr. Singh about drug adverse effects and to watch for signs of toxicity (anorexia, nausea, vomiting, yellow vision, if on digoxin) (Williams Lippincott and Wilkins 2007). Therefore, dietary restriction advise to him such as; low cholesterol diet, low fat, low sodium diet and other food to avoid by asking help from dietician should be helpful. Mr. Singh must be informed about the need to stop smoking, encourage with ‘cardiac rehabilitation program’ in the community and resume sexual activity progressively as stressed by (Williams Lippincott and Wilkins 2007). This is where Mr. Singh will be helped by the physio therapist, occupational therapist, speech and language therapist, nurses, health care assistance and doctors back to his baseline. At times, it takes months mostly if other organs are affected. All his information transferred to appropriate services aforementioned to help with his continued care on time. Discharged plans would be as agreed by multidisciplinary team such as; (community nurse, dietician, liaison across health, social, third sector organization, specialist respiratory nurse in community clinic). His General Practitioner (GP) informed and encouraged on lifestyle changes. All these services should be introduced into Mr. Singh’s care package to ensure continuity of care on time (Blackwell and May 2015).

Nurse following up his care episode using acronym-‘SMART’ (specific, measureable, achievable realistic and timely tools for him); to weigh his improved condition to see whether it will deteriorate or stablise (Blackwell and May 2015). Expert Patient Program (EPP) explains the training Mr. Singh required to manage his health at home (‘United Kingdom Chronic Disease Management Tool’)/ (Roger et al., 2008). This would help him avoid further complications. Additionally, before Mr. Singh’s lives the unit, it would be nice to listen to the way he was treated, was it appropriate, did he enjoy his stay and his feedback could help with nursing improvement. Nurses weaknesses addressed going forward. Naturally nurses are honest and open when addressing patient’s health issues (Jone, Standing and Roberts 2015).

In conclusion, the bio-psychosocial perspective, Tanner model and Mr. Singh’s centred care helped nurses to followed the laid down procedural techniques to help him to recover properly. This in turn, provide Mr. Singh with safe and proficient patient care he deserve. Tanner model has helped nurses to prioritized what should be done first to save him. The model enlightened on step by step treatment, behavioral responses to his ailment, and his full recovery. Nurses perfectly managed his conditions along with other health professionals that aids his quick recovery.

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