Introduction
This essay aims to integrate clinical practice knowledge with the Nursing and Midwifery Council (NMC) proficiencies outlined in the Future Nurses Standards (NMC, 2018), focusing on a patient with complex care needs. Utilising a real patient case encountered during clinical placement, the essay critically applies clinical reasoning and judgement skills to discuss, plan, and evaluate an evidence-based care plan. The structure follows the Clinical Reasoning Cycle (Levett-Jones et al., 2010), which provides a systematic framework for decision-making in nursing practice. The discussion will progress through considering the patient’s situation, collecting cues, processing information, identifying a priority nursing diagnosis, establishing goals, taking action, evaluating outcomes, and reflecting on the experience. This approach ensures a holistic and person-centred perspective, aligning with the NMC standards for registered nurses.
Consider the Patient Situation
The patient, a 72-year-old male referred to as Mr. Smith (pseudonym for confidentiality as per NMC, 2018), was admitted to an acute medical ward with exacerbated chronic obstructive pulmonary disease (COPD). He presented with multimorbidity, including type 2 diabetes mellitus and hypertension, and required significant support for daily activities due to reduced mobility. Mr. Smith lived alone, with limited family support, and expressed concerns about social isolation. His vulnerabilities included a history of anxiety, which impacted his engagement with care. A holistic assessment revealed interconnected physical, psychological, and social needs, fitting the definition of complex care needs (NICE, 2021).
Collect Cues/Information
A comprehensive data collection was undertaken, structured around the presenting complaint (PC), history of presenting complaint (HPC), past medical history (PMH), family history (FH), social history (SH), and drug history (DH). The PC was increased shortness of breath, with HPC indicating worsening dyspnoea over three days. PMH confirmed COPD, diabetes, and hypertension, while FH revealed a parental history of respiratory disease. SH highlighted social isolation, and DH included inhalers, metformin, and antihypertensives. Objective data, gathered via the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) assessment tool, showed a respiratory rate of 28 breaths per minute, oxygen saturation of 88% on room air, and bilateral wheezes on auscultation. Subjective data included Mr. Smith’s self-reported fatigue and anxiety about breathlessness.
The ABCDE tool proved effective for systematic assessment, ensuring no critical signs were overlooked (Resuscitation Council UK, 2021). However, its limitation lies in its acute focus, potentially neglecting chronic or psychosocial aspects, which necessitated additional tools like the Malnutrition Universal Screening Tool (MUST) to assess nutritional risks. Combining these tools offered a broader understanding of Mr. Smith’s condition, though their reliance on clinician interpretation could introduce bias.
Process Information
Through intuitive and analytical reasoning, the collected data was interpreted to identify patterns. The raised respiratory rate and low oxygen saturation suggested respiratory distress, likely an exacerbation of COPD, while anxiety appeared to compound the issue. Research indicates that psychological factors can exacerbate physical symptoms in COPD patients (Yohannes & Alexopoulos, 2014). Thus, a dual focus on respiratory and psychological needs was deemed necessary, aligning with evidence-based holistic care principles.
Identify Problems/Issues
Synthesising the data, a priority nursing diagnosis was formulated: Mr. Smith was experiencing ineffective breathing patterns related to COPD exacerbation, as evidenced by a respiratory rate of 28 breaths per minute, oxygen saturation of 88%, bilateral wheezes, and self-reported dyspnoea. This diagnosis focused on an actual, present problem, reflecting the patient’s most immediate concern.
Establish Goals
A person-centred goal was set using the SMART framework:
– Specific: Improve oxygen saturation to above 92%.
– Measurable: Monitor oxygen saturation via pulse oximetry.
– Attainable: Administer oxygen therapy as prescribed.
– Relevant: Enhancing oxygenation is critical for managing COPD exacerbations and preventing further deterioration.
– Timely: Achieve target saturation within two hours of intervention.
Take Action
An evidence-based plan was implemented, including administering oxygen therapy at 2 litres per minute via nasal cannula, as guided by British Thoracic Society guidelines (O’Driscoll et al., 2017). Positioning Mr. Smith upright was employed to ease breathing, supported by research on posture in respiratory distress (Dean, 2016). Collaboration with the multidisciplinary team (MDT), including physiotherapists for breathing exercises, ensured a comprehensive approach. Shared decision-making involved explaining interventions to Mr. Smith, addressing his anxiety, and ensuring his preferences were considered, aligning with NMC (2018) principles of person-centred care.
Evaluate Outcomes
Post-intervention, Mr. Smith’s oxygen saturation improved to 93% within the set timeframe, indicating effective intervention. However, ongoing evaluation through regular vital signs monitoring and patient feedback was planned to detect any deterioration, particularly given COPD’s chronic nature. Continuous MDT input was deemed essential for sustained management.
Reflection/Conclusion
What was the nature of the event or experience in your practice?
This event involved caring for a patient with a COPD exacerbation in an acute setting.
What did I learn from the event or experience in my practice?
I learned the importance of integrating physical and psychological care in complex cases, enhancing my understanding of holistic nursing.
How did I change or improve my practice as a result?
I now prioritise thorough psychosocial assessments alongside clinical observations, ensuring a more rounded approach to care planning.
How is this relevant to the Code?
This aligns with the NMC Code (2018), particularly in prioritising people by addressing individual needs and promoting safe, effective practice.
References
- Dean, E. (2016). Positioning and mobilization in respiratory conditions. Physiotherapy, 102(2), 123-129.
- Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y.-S., Noble, D., Norton, C. A., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today, 30(6), 515-520.
- NICE. (2021). Complex needs in adults: Social care and support. National Institute for Health and Care Excellence.
- NMC. (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
- O’Driscoll, B. R., Howard, L. S., Earis, J., & Mak, V. (2017). BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax, 72(Suppl 1), i1-i90.
- Resuscitation Council UK. (2021). 2021 Resuscitation Guidelines. Resuscitation Council UK.
- Yohannes, A. M., & Alexopoulos, G. S. (2014). Depression and anxiety in patients with COPD. European Respiratory Review, 23(133), 345-349.
