Introduction To Clinical Reasoning
Clinical Reasoning can be considered as a central component towards effective management as well as bringing an overall improvement in overall quality of care that has been patient centered. There has been an increase in overall demand and a presence of highly complex nursing practices related to health care (Harasym, Tsai and Hemmati, 2008). Hence, the clinicians are required to make as well as justify the decisions which are to be based on large number of factors. These are in form of available evidence based, access to health care related resources, issues related to ethics, socio cultural norms and frameworks related to clinical governance as well as professional accountability (Croskerry, 2009).
The given report has tried to lay emphasis on exploration of different models that are related to clinical reasoning followed by understanding nature as well as context of clinical practice. There will further be an exploration on limitations of clinical reasoning so as to enhance the clinicians’ knowledge base. The areas of study has been made to link with a case study of 56 year old painter and decorator named Jim who was suffering from shoulder pain and wants a more accurate diagnosis that was has been given by the physiotherapist.
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The Case Study
The case study is based on a 43 year old police officer who was presented in a clinic with having a history of one week pain in his right shoulder. It was explained by him that pain started to him 7 days before when he woke up in the morning and also experienced a strange feeling in his middle two fingers. His pain increased more when he raised his arms above his head and eased as soon as he stopped the movement that was causing pain. Also, his pain becomes severe in night. After a time period of 3-4 days he experienced a stiffness in his shoulder and found the movement a little more difficult. He does not have a significant past medial history and does not have other health complaints also and was also a keen runner.
The aim of the subjective examination of the patient suffering from the pain is to find and know about the ethology and with this useful information will be provided to the physiotherapist providing information on the area and behavior of symptoms of the patient suffering from the pain. In other words, in can be said that during the subjective examination of the patient, physiotherapist extract the useful and relevant information about the individual related to history, symptoms so that exact information is known of the patient and all red flags are removed (Cooper, 2013).
The pain as described by the man in the case study took place only before a week and on that day he did a lot of physical work (Jones, 2004). The main symptoms of the pain in shoulder that the police officer was facing mainly included thickening, tightening and swelling of flexible tissue that surrounds the joint of shoulder. This leaves less scope of space in bone of upper arm in the shoulder joint and this eventually makes the movement painful and stiff. With this, it also becomes difficult to make the shoulder movement difficult as well as painful. After observing the symptoms of the patient, another aspect that is included in the subjective examination is the history of pain for the patient (Willcocks, 2012). The individual as per the case study is a 43 year old man and had started pain 7 days ago and was not associated with any kind of injury happened recently. But, the pain started out of the type of daily activities he performed owing to his occupation of police. The pain is more at night and during rising of hand.
The motor physical examination of shoulder pathology of the patient as in the case study examines and gives details about the glenohumeral joint which is the most mobile joint in the human body (Choi and et.al., 2012). But because the occupation of the police is such that it involves a lot of movement this is hampers the joint stability of the glenohumeral joint. As a result, the lack of stability makes the individual more susceptible to injuries especially those involved in sports and in occupation like that of police as in the case. Apart from this, examining of the posture of the patient was also found straight and there was no problem with it. This also includes palpation of the shoulder and provides valuable information on swelling and texture of the shoulder of the patient (Ahonen and Degner, 2012).
With the sensory examination of the patient in the case study having shoulder pain it was observed that there was stiffness in the neck and also a restricted movement in his first ribs. This in turn restricted the way in which nerves moved as they run from the neck and moves down the right arm. This was the main reason behind the strange feeling in his fingers. The muscular assessment of the police officer in the case study was also done and it was observed that all local shoulder muscles tested strong for him except that there was some tightness in the pectoralis minor muscle (Li, 2005). This is at the front of the chest and there was also pain in his scalene muscles which are on the side of neck and those on right were also tight. It was also assessed that there occurred some damage to supraspinatus muscle or tendon. The neurological assessment of the patient can reveal of any kind of numbness in the joint and may warrant of his condition. But this is not observed in the present case and there is only stiffness in his shoulder (Bayley and McKibbon, 2006).
After the subjective assessment next that need to be carried of the patient is the objective assessment which includes application of specific diagnostic tests. One of them is magnetic resonance imaging (MRI) which is one of the common tests for shoulder pain (Kassirer and et.al., 2009). This is useful for diagnosing rotator cuff tears as well as assessment of muscle and tendon tears. Also, the diagnosis of tear of rotator cuffs of the individual can be done on basis of physical examination and history and this can be confirmed with help of MRI also. Another diagnostic test that can be used for assessing the shoulder pain is X ray in which degenerative changes of the joint can be seen on the imaging (Jackson, 2014). This also assists in the diagnosis of glenohumeral osteoarthritis for the patient if the pain in shoulder has become severe and acute. But this was not the case for the police officer in the case and his pain in joint can be easily diagnosed with physical examination and history. With this, all red and yellow flags can be assessed and thus removed also (Moody and Pesut, 2006). Red flags like severe diseases of liver, heart, Gastric Perforation, peptic ulcer, pancreas and gall bladder as well as fractures do not exist for the patient being considered here. Apart from this, yellow flags like depression, pain syndrome, and lack of family or community support, concurrent psychological illness are all rejected in case of police officer as he is well mentally having full support of his family and having a good social life (Higgs, 2008).
Models Of Clinical Reasoning And Their Relevance To Contemporary Practice
Clinical reasoning can be defined a process where nurses and other clinicians are there to collect cues, process information. This is followed by understanding the problem faced by patient so as to plan as well as implement interventions for evaluating outcomes for reflecting and learning from process (Elstein, 2009). The process is dependent on critical thinking so as to be influenced by attitude of person as well as philosophical Perspective and preconceptions. The process of clinical reasoning cannot be considered as a linear process but is required to be conceptualized as a series or spiral of linked as well as ongoing encounters of clinical origin (Koh and et.al., 2008).
It further entails for a multitude of cognitive processes so as to enable the physicians for combining scientific information with clinical skills as well as experiences faced with similar patients. This will help in making a proper sense of illness faced and to determine the best action that can be taken so as to cure it.
In this regard, there exist varied kinds of models related to clinical reasoning that can be applied so as to make decisions as well as judgment for supporting the process of clinical decision making (Kassirer, 2010).
Client centred model
According to this model, clinical reasoning is considered as a process that involves reflective inquiry in collaboration with the client itself. Through which there is development of in depth understanding of clinical problem by the patient also. This help in providing a sound basis for intervention as a solution to the medical condition (Kuiper and et.al., 2008). The process of reasoning is portrayed by an upward and outward spiral so as to demonstrate clinical reasoning. The model recognizes three core dimensions known as knowledge, cognition and meta - cognition. A sound knowledge base is required by the clinician for effective clinical reasoning and information need to be readily accessible and highly organized (Simmons et al., 2003). Cognition is the thinking ability such as analysis, synthesis and evaluation of data that is collected by the service provider for the patient. Likewise, for the given patient in the case being Jim it is important for the clinician to have proper knowledge on condition of patient and also thinking ability and skills. Meta cognition is the awareness and monitoring of cognitive processes which is an integrative element between knowledge and cognition. This ability is essential for the clinician of present patient Jim in order to accomplish effective problem solving for the client (Higgs and Jones, 2000).
Outcome Present State Test Model
Outcome Present State Test Model also known as OPT is of reflective clinical reasoning that provides for a structure to conceptualize the process of clinical reasoning. The model is further composed of 10 components (Lake and Hamdorf, 2004). These are inclusive of;
- Patient under study
- Clinical reasoning web
- Keystone issue
- Cue logic
- Present state
- Outcome state
- Decision making
It can further be considered as a blueprint so as to assist the students towards organizing the thinking that is involved in process of clinical reasoning. It is also there for providing framework to contrast relation between problem and outcomes and act as a guide for solving the issues (Bland and et.al., 2009). In present scenario, the issue faced by client Jim in terms of shoulder pain is such that its origin cannot be recognizes. Hence, requirement as per given model of clinical reasoning is to write the essential areas of client problems on OPT model worksheet (Bartlett and et.al., 2008). This would be inclusive of name and profession of patient, work profile, identified reasons towards origin of pain, medical diagnoses, assessing medical history of Jim, signs and symptoms, data generated by lab and other diagnostic as well as social/family history (Hendrick and et.al., 2009).
In the same way, clinical reasoning web can be regarded as a pictorial representation to identify functional relation among diagnostic hypotheses that is derived from synthetic thinking due to convergence in identifying the central issues that need urgent care (Kuiper and et.al., 2008). The web in case of Jim will assist in promoting clinical reasoning by having an overview of client's story so as to identify as well as represent issues and needs that have been revealed by patient.
These will act as a major guideline towards the process of clinical reasoning. The next step as per the model will be to map out as well as visualize the relation that exists among medical and nursing diagnosis (Hogarth, 2005). The model will thus assist in ensure towards making decisions/judgments followed by support clinical decision making. It will assist in providing reasoning about clinical situations faced by Jim so as to ensure for meeting up proper patient care needs. It will further provided a guideline for nursing staff towards carrying out a primary diagnosis in order to decide on nursing care needs on account of stipulated medical condition. The nursing staff will become more conscious so as to make s proper sense of situation faced by patients (Kuiper and Kurtz, 2009).
Dual-process theory: an emerging model
Dual-process theory can be defined as that model of reasoning which tries to integrates the processes that have been identified in the areas of clinical reasoning research since the time span of 1970s. It allows for making the doctors understand as to how they think as well as reason in every day practice (Dawes, Summerskill, Glaszious and et al., 2005). The theory has given a considerable amount of research to the phenomenon of intuition. It further plays a major role towards making decisions.
This theory has been stemmed out from the works done in mid-1990s in the area of cognitive psychology by Epstein and Hammond. Here, there is a presence of two separate systems which can be used for clinical reasoning (Adler and Rodman, 2003). The first has been described as intuitive’, ‘tacit’ and ‘experiential. It can further be considered as a reflex system where triggers have been found to occur in automated mode. It is there to produce intuitive response which is generated without putting in many efforts and is also below the prescribed threshold of perceptible consciousness (Arnold and Boggs, 2011).
This so called intuitive system has been found to be rapid where visual information that is available readily is made to operate on the principle of recognition. In case of Jim the clinical reasoning can be based on comparing the signs and symptoms with the ones that have been observed in situations similar to present ones. The generate responses in case of given case of Jim have been found to bear high dependence on contextual cues. This system has been negated by many researches on account of reliability of intuition (Albanese, 2006). Some of them have a view point that although the given system of intuition is very effective in terms of time but is found to be a lot more vulnerable towards error while undertaking the process of clinical reasoning (Crosske