Nurses are the caregivers most directly involved

with patients 2417, responsible for monitoring and

assessing clinical changes in patients, intervening
when necessary, and communicating changes in status
to ensure appropriate intervention and coordination of
care. (Duffield et al., 2007)

INTRODUCTION
In this chapter, we begin to explore what it means to 'think like a nurse'.
We define and discuss the importance of clinical reasoning, outline the
clinical reasoning process and illustrate how clinical errors are linked
to poor reasoning skills. This chapter creates a foundation for the ones
.that follow and a backdrop to a series of authentic and clinically relevant
:clinical scenarios.
-Leaming to 'think like a nurse' is challenging and requires commitment,
':Practice and multiple opportunities for application of learning. However,
o~e benefits are significantforyou, as acurious, competent and intelligent
,nurse, and also for the people who will be the recipients of your care.
Si!liply stated, effective clinical reasoning skills improve ·the quality of
:plrtieiit care, prevent adverse patient outcomes and enhance nurses'
•:wtirk satisfaction.

opiedby • . :· . .
~harles Darw~:,nlversitJ.llqra~
Date· tZ£?P
CLINICAL REASONING: LEARNING TO THINK LIKE A NURSE

WHAT DOES IT MEAN TO 'THINK LIKE A NURSE'?

While there are a number of similarities in the way nurses and other health professionals think, t'lere
are also significant clifferences. Unlike many healt'l professionals who 'treat' and 'retreat', therapeutic
relationships between nurses and their patients can extend over hours, days or even longer. During this
time, nurses maintain constant vigilance and engage in multiple episodes of clinical reasoning for each
person in t'leir care, responding to the complex nature of the illness experience in ways that are authentic,
holistic and person-centred.
'Thinking like a nurse' is a form of engaged moral reasoning. Educational practices must help
students engage with patients with a deep concern for their well being. Clinical reasoning must
arise from this engaged, concerned stance, always in relation to a particular patient and situation
and informed by generalised know/edge and rational processes, but never as an objective,
detached exercise. (Tanner, 2006, p. 209)

WHY IS CLINICAL REASONING IMPORTANT?

Nurses are required to care for and make decisions about complex patients with diverse healt'l needs. As
they are responsible for a significant proportion of the clinical judgments in healthcare, their ability to
respond to challenging and dynamic situations requires not only psychomotor skills and knowledge, but
also sophisticated thinking abilities.
A body of evidence has identified that clinical reasoning skills have a positive impact on patient
outcomes while, conversely, nurses with poor clinical reasoning skills often fall to detect patient
deterioration, resulting in a fallure to rescue (Cooper et al., 2011). Clinical reasoning errors have been
implicated as a key factor in the majority of adverse patient outcomes (Institute of Medicine, 2010). The
reasons for t'lis are multidimensional and include the tendency to make errors in time-sensitive situations
where there is a large amount of complex data to process, and difficulties in distinguishing between a
clinical problem that needs immediate attention and one that is less acute (Hoffman, 2007).

WHAT IS CLINICAL REASONING?

Clinical reasoning is a systematic and cyclical process t'lat guides clinical decision making, particularly
in unpredictable, emergent and non-routine situations, and leads to accurate and informed clinical
judgments. Clinical reasoning is defined as 'the process by which nurses (and other clinicians) collect
cues, process the information, come to an understanding of a patient problem or situation, plan and
implement interventions, evaluate outcomes, and reflect on and learn from the process' (Levett-Jones
et al., 2010, p. 516). The clinical reasoning cycle (Figure 1.1) is informed by a body of research
undertal<en by Hoffman (2007) and Levett-Jones et al. (2010).

THE CLINICAL REASONING PROCESS

A diagram showing the clinical reasoning cycle and describing the nursing actions t'lat occur during
each stage is provided in Figure 1.2. The cycle begins at 1200 hours and moves in a clockwise direction
through eight stages: look, collect, process. diagnose, plan, act, evaluate and reflect. Alt'lough each
stage is presented as a separate and distinct element in this diagram, in reality clinical reasoning is a
dynamic process and nurses often combine one or more stages or move back and forth between them
before reaching a diagnosis, taking action and evaluating outcomes. Table 1.1 provides an example of a
nurse's clinical reasoning while caring for a man following surgery for an abdominal aortic aneurysm..

Stages of the clinical reasoning cycle

1. Consider the patient situation
During the first stage of the clinical reasoning cycle, the nurse begins to gain an initial impression of the
patient and identifies salient features of the situation. This first impression, which Tanner (2006) refers to as
'noticing', is critical but can be negatively influenced by the nurse's preconceptions, assumptions and biases.
 CHAPTER 1: CLINICAL REASONING: WHAT IT IS AND WHY IT MATTERS

oumoaL
reasonmg
OYOLQ

Figure 1.1
The clinical reasoning cycle
Source: T. Levett~Jones, K. Hoffman, Y. Dempsey, S. Jeong, D. Noble, C. Norton, J, Roche &
N. Hie.key {201 0), The 'five rights' of clinical reasoning: An educatfonal model to enhance nursing
students' ability to ldentily and manage clinically 'at r!sk' patients. Nurse Education Today, 30(6),
5(5-20.

2. Collect cues/information
The importance of the cue collection stage of the clinical reasoning cycle cannot be underestimated,
as early subtle cues when missed can lead to adverse patient outcomes (Levett-Jones et al.. 2010).
During the second stage, the nurse begins to collect relevant information about the patient. He/she
reviews the information that is currently available, including the handover report. the patient's
medical and social history, clinical documentation, electronic medical records and other available
information.
The nurse then identifies additional information that is required, such as vital signs and/or a focused
health assessment. Importantly, the nurse focuses on collecting specific cues relevant to the person's
condition at this point in time. When appropriate, the nurse also seeks to elicit the patient's understanding
of the situation and the family's or carer's concerns.
Lastly, the nurse recalls knowledge related to the patient's panicular situation. A breath and depth of
knowledge is thereforeimperative for accurate clinical reasoning. Unless a nurse has a deep understanding
of the applied sciences,.especially pathophysiology, the ability to make sense of and correctly interpret
cues will be impacted.
3. Process information
In the third stage of the clinical reasoning cycle, the nurse interprets the cues that have been collected
and identifies significant aberrations from normal. Cues are grouped into meaningful clusters;
. clinical patterns arc identified, inferences are made and hypotheses are generat~d. During this stage,
experienced nurses call upon their wide repertoire of prcvlous clinical experiences matching the
features of patient's presentation with other similar situations. They are also able to 'think aheacr
anticipating potential outcomes and complications depending on the particular course of action (or
inaction).
6 CLIN:CAL REASONING: LEARNING TO THINK LIKE A NURSE

Cun1emp]a~whaty<1U
I·tmv.~~--n~i~tt,:s
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.dlffo,ryi1tlr,

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undorn;,1ndlngofl)&Mor,ymptom1,
cornpJrnnormalvs~n,;,muil.
Drsahl!rnm: dlsdnjU1sh ~ t from
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lncoiulst1mcl11S, ~rrow down tho
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~nd1'11C::.i:r.ls11gap,1neu..s.coll=cd..
F.eidte: d&m'ar MW n,~onshlpi; or
irnt'<rT1r.clusta.rcuru;toz<1thcirtc
ldffltlfyralatlonshl;,.i:betW<:cnthcm.
/nf«:m:akc<imluctlc:,r.s.or(cnncplnlons
&.:t follow loglally by lnt:1rpr~nz
subj~ctlvo ~nd obJl!(;t)vo cu"'; consider
altvftl:ltivi::;.tndconrncuone:i::s,
Ndldicurni<1ti1Wat1ontop;in
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,P~:t,10~{1m1a:Jyanwcpct,:
thQUghtproc;,m).

Figure 1.2
The clinical reasoning process with descriptors
Source: Adapted frorn T. Levett~Jones, K. Hoffman, Y. Dempsey, S. Jeong, D. Noble, C. Norton, J. Roche & N. Hickey (2010). Toe 'five rlghts' of
cllnlcal reasonlng: An educational model to enhance nursing students' ebllity to identify and manage cllnlca!ly 'at risk' patients. Nurse Education
Today, 30(6), 515'-20.

Table 1.1 Phases of the clinical reasoning cycle with examples

Process Description Example of a nurse's thinking

Consider Describe person and context. Mr Smith is a 60-year-old man admitted to ICU
the patient yesterday following surgery for an abdominal aortic
situation aneurysm (AAA).

Collect cues/ Review current information Mr Smith has a history of hypertension and he takes
inforriiation (e.g. handover reports, patient beta-blockers. His BP was 140/80 mmHg an hour
history, patient cnarts, results of ago.
investigations and nursing/medical
assessments previously undertaken)

Gather new information (e.g. Mr Smith's vital signs are: T 37.6°C, PR 116, RR 20,
undertake patient assessment). BP 110/60 mmHg.
His urine output is averaging 20 mUhr. He has an
epidural running @ 10 mUhr.

Recall knowledge (e.g. physiology, BP and PR are influenced by fluid status.

pathophysiology, pharmacology, Epidurals can lower the BP because they can cause
epidemiology, therapeutics, culture, vasodilation.
context of care, ethics, law).
 CHAPTER 1: CLINIC/IL REAsm,ING· WHAT IT IS AND WI IY IT MATIERS

Table 1.1 Phases of the clinical reasoning cycle with examples (continued)

Process Interpret analyse cues to come to an Mr Smith's BP is low, especially for a person with
information understanding of signs or symptoms. a history of hypertension. He is tachycardic and
Compare normal vs abnormal. oliguric.

Discriminate: distinguish relevant Although Mr Smith is slightly febrile, i'm more

from irrelevant information; concerned about his hypotension, tachycardia and
recognise inconsistencies; narrow oliguria.
down information to what is most
important; recognise gaps in cues
collected.

Relate: discover new relationships Although Mr Smith's hypotension, tachycardia

or patterns; cluster cues together to and oliguria could be signs of impending shock,
identify relationships between them. his BP decreased soon after we increased his
epidural rate.

Infer: make deductions or form Mr Smith's BP is probably low because of his epidural
opinions that follow logically and b!ood loss during surgery.
by interpreting subjective
and objective cues; consider
alternatives and consequences.

Match current situation to past AAAs are often hypotensive post-op.

situations or current patient to
past patients (usually an expert
thought process).

Predict an outcome (usually an If we don't give Mr Smith a fluid challenge, he could

expert thought process). develop acute kidney injury or go into sfTock.

Identify the Synthesise facts and inferences Mr Smith has reduced cardiac output related to
problem/issue to make a definitive nursing decreased intravascular volume and vasodi!a:ion
diagnosis. evidenced by hypotension, tachycardia and o'.ig~ria. ·

Establish goals Describe what you want to To improve Mr Smith's cardiac outp·ct,
happen, a desired outcome and a haemodynamic status and urine outp:.it over :he next
time frame. 1-2 hours.

Take action Select a course of action between I wili phone the medical officer (using ,SBAR) to
the different alternatives available. request an order for a fluid challenge, increased IV
rate and aramine if needed.

Evaluate Evaluate the effectiveness of Mr Smith's BP has improved and his urine output is
outcomes and actions. Ask: 'Has now averaging> 30 mUhr. I'll continue to monitor
the situation improved now? 1 him as he may need another fluid challenge or
aramine later.

Reflect on Contemplate what you have learnt I now understand ...

process and from this process and what you I should have .. .
new learning could have done differently.
Next time I wi'.I .. .

Source: K. Hoffman (2007). A comparison of decision-making by 'expert' and 'novice' nurses in the ciinicn! setting, monitoring patient ."!.88:-:-1=-dynarn'c s~atLS
post abdominal aortic aneurysm surgery. Unpublished PhD thesis, Unlversity of Technology, Sydney; and T. Levett-Jones, K. Hoffman, Y.
D. Noble, C. Norton, J. Roche & N. Hickey (2010). The 'five rlghts' of clinical reasoning: An educatio:12.. :node! to enhance nursing studecr:s·
and rnan<'.lgo clinicGlly 'at risk' patients, Nurse Education Torfi:.Jy, 30(6), 515· 20.
CLINICAL REASONING: LEARNING TO THINK LIKE A NURSE

4. Identify problems/issues
Improving the diagnostic process is not only possible, but it also represents a moral, professional,
and public health imperative. (Institute of Medicine, 2010)

The fourth stage of the cycle is where the nurse synthesises all of the information that has been collected
and processed in order to identify the most appropriate nursing diagnoses. A three-part 'actual' diagnosis
or a two-part 'risk' diagnosis may be formulated. The accuracy of this step is critical as the nursing
diagnosis is used to determine appropriate goals of care and subsequent nursing actions. The following
examples are adapted from Berman et al. (2017).
Nursing diagnosis
1. A nursing diagnosis is a problem that becomes apparent following a thorough and systematic
interpretation of subjective and objective data. An actual nursing diagnosis consists of the person's
problem, the related aetiology (cans al relationship between a problem and its related or risk factors),
and supporting evidence/cues.
For example: Dehydration related to post-operative nausea and vomiting evidenced by dry mucous
membranes? oliguria, poor sJ..'in turgor, hypotension and tachycardia.
2. A risk nursing diagnosis is a clinical judgment about a potential problem where the presence of
risk factors indicates that a problem may develop unless nurses intervene appropriately. A risk
diagnosis is written in two parts and does not include signs and symptoms.
For example: Risk of infection related to skin tear and type 2 diabetes.
5. Establish goals
The fifth stage of the cycle is where the nurse clarifies and prioritises the goals of care depending on
urgency. Goals must be SMART (Specific, Measureable, Achievable, Realistic and Timely) and
designed to address the nursing diagnoses previously identified. Without SMART goals, the nurse
cannot determine the efficacy of their actions.
6. Take action
In this stage the nurse selects the most appropriate course of action to achieve the goals of care and
address the nursing diagnoses. The nurse also decides who is best placed to undertake the interventions,
and who should be notified and when.
7. Evaluate outcomes
This stage requires the nurse to re-examine objective and subjective data (patient cues) in order to
evaluate how effective the nursing interventions have been. and whether the patient's problem has
improved. If the evaluation identifies that the patient's condition has not improved, the nurse reconsiders
the patient's situation and seeks to identify a more appropriate course of action. There may be a need to
engage in a new cycle of clinical reasoning at this stage.
8. Reflect on process and new learning
Effective clinical reasoning requires both cognitive and metacognitive (thinking about one's thinking) skills
in order to develop the ability to 'think nke a nurse' (Mezirow, 1990). Thus, the final step of the clinical
reasoning cycle involves reflection. This requires nurses to critically review their practice with a view to
refinement. improvement or change. Reflection is intrinsic to learning. It is a deh'berate, orderly and
structured intellectual activity that allows nurses to process their experience, and explore their understanding
of what they did, why they did it. and the impact it had on themselves and others (Baud, 2015).

Nurses reflect in and on practice by asking themselves questions such as:

What happened and why?
What was done well and what should be improved?
What should be done differently if presented with the same or similar situation?
What has been learnt that can be used when caring for other patients?
• What is needed to improve future practice, for example more knowledge about·a specific condition
or more practice in particular sldlls?
 CHAPTER 1: CLINICAL REASONING: WHAT IT IS AND WHY IT MATTERS 9

CLINICAL REASONING AND CRITICAL THINKING

As a client's status changes, the nurse must recognise, interpret, and integrate new information
and make decisions about the course of aation to follow. For satisfacto,y client outcomes clinical
reasoning goes hand in hand with critical thinking. (Martin, 2002, p. 245)
Clinical reasoning is dependent on a critical thinking 'disposition' (Scheffer & Rubenfeld, 2000).
Critical thinking is a complex collection of cognitive skills and affective habits of the mind and has been
described as the process of analysing and assessing thinking with a view to improving it (Panl & Elder,
2007). To think like a nurse requires you to learn the knowledge, ideas, skills, concepts and theories of
nursing, and develop your intellectual capacities to become a disciplined, self-directed, critical thinker
capable of clinical reasoning (Paul & Elder. 2007).
Nurses who are critical thinkers strive to be clear, accurate, precise, logical and fair when they listen,
speak, read and write (Paul & Elder, 2007). Critical thinkers think deeply and broadly, eliminating
irrelevant, inconsistent and illogical thoughts as they reason about patient care. The quality of their
thinking improves over time and through reflection (Norris & Ennis, 1989). Below is a list of attnl>utes
nurses need to develop their critical thinking and clinical reasoning skills (Scheffer & Rubenfeld, 2000,
p. 358; Rubenfeld & Scheffer, 2006, pp. 16-24):
A holistic and contextual perspective-consideration of the whole person, taking into account the
entire simation, including relationships, background and environment
Creativity-the ability aud desire to generate, discover or restructure ideas; and the ability to
imagine alternatives
Inqmsitiveness-a thoughtful, questioning and curious approach; and au eagerness to explore
possibilities and alternatives
Perseverance-a dedication to the pursuit of knowledge despite any obstacles that are encountered
Intuition-insightful patterns ofknowiug brought about by previous experiences and pattern recognition
Flexibility-the capacity to adapt, modify or change thoughts, ideas and behaviours
Academic integrity-seeking the truth through sincere, honest processes, even if the results. are
contrary to one's assumptions or beliefs
Reflexivity-contemplation of assumptions, thinking and behaviours for the pwpose of deeper
understanding and self-evaluation
Confidence-a firm belief in one's reasoning abilities
Open-mindedness--receptiveness to diiferent views and sensitivity to one's biases, prejudices,
preconceptions and assumptions.

QUESTIONING ASSUMPTIONS AND

UNDERSTANDING ERRORS
Nurses are human and we make the same kinds of thinking errors in our practice as we do in our day-
to-day lives. Sometimes we overlook or misinterpret the significauce of an importaut cue, or we jump to
conclusions or fail to take into accouut alternative possibilities or options. Additionally, preconceptions,
assumptions, biases, stereotypes and stigmatism can negatively influence our clinical reasoning and in
some cases even prevent clinical reasoning from occurring. We may be unaware of the assumptions aud
prejudices that we hold as they are often long-standing and deeply embedded. For this reason nurses
must develop insight and self-awareness by deliberately reflecting on their biases and preconceptions.
Failure to do so can undermine the accuracy of clinical reasoning aud consequently patient safety.
Nurses can help avoid clinical reasoning errors by being mindful and reflective, and by usiug the
multirode of decision support resources available to help them make a decision. They can also maintain
a healthy skepticism and make it a habit to ask: 'What is influencing my thinking about this patient?',
'Could my interpretation be flawed?' and 'What other nursing diagnosis is possible in this situation?'.
Table 1.2 provides a list of clinical reasoning errors, many of which arise because of flawed
assumptions and beliefs. Some of these errors are then illustrated in the narratives that follow.
10 CLINICAL REASONING: LEARNING TO THINK LIKE A NURSE

Table 1.2 Clinical reasoning errors

Error Definition

Anchoring The tendency to lock onto salient features in the patient's presentation too early in the
clinical reasoning process, and failing to adjust this initial impression in the light of later
information. This error is compounded by confirmation bias.

Ascertainment bias When a nurse's thinking is shaped by prior assumptions and preconceptions, for
example ageism, stigmatism and stereotyping.

Confirmation bias The tendency to look for confirming evidence to support a nursing diagnosis rather
than look for disconfirming evidence to refute it, despite the latter often being more
persuasive and definitive.

Diagnostic Once labels are attached to patients, they tend to become stickier and stickier. What
momentum started as a possibility gathers increasing momentum until it becomes definite and
other possibilities are excluded.

Fundamental The tendency to be judgmental and to blame patients for their illnesses (dispositional
attribution error causes) rather than examine the circumstances (situational factors) that may have been
responsible. Patients with a mental illness and from minority or marginalised groups are
at particular risk ofthis error.

Overconfidence bias A tendency to believe we know more than we do. Overconfidence bias reflects a tendency
to act on incomplete information, intuition or hunches. Too much faith is placed on opinion
instead of carefully collected cues. This error may be augmented by anchoring.

Premature closure The tendency to accept a nursing diagnosis without sufficient evidence and before
it has been fully verified. This error accounts for a high proportion of inaccurate or
incomplete nursing diagnoses.

Psych-out error People with a mental illness are particularly vulnerable to clinical reasoning errors, and
co-morbid conditions may be overlooked or minimalised. A variant of this error occurs
when medical conditions (such as hypoxia, delirium, electrolyte imbalance and head
injuries) are misdiagnosed as psychiatric conditions.

Unpacking principle Failure to collect and unpack all of the relevant cues, and consider differential diagnoses
may result in significant possibilities being missed.

Source: Adapted from P. Croskeny (2003), The importance of cogn!t!ve errors in diagnosis and strategies to minimize them. Academic Medlcine, 78(8), 1-6.

Examples of clinical reasoning errors

Some of the clinical reasoning errors listed in Table 1.2 are illustrated here with authentic clinical
experiences. As you read these narratives, it will become evident that even experienced, committed and
well-intentioned health professionals can make errors if they allow their thi.nldng process to be clouded
by assumptions, preconceptions and stereotypes. Environmental and situational factors such as noise,
fatigue, stress, multitasking and interruptions can also impede thinking processes. As you read these
examples, it is important to reflect on your own biases and prejudices, and any personal or contextual
factors that negatively influence your thinking, as this will enhance your self-awareness. emotional
intelligence and clinical reasoning ability.
 CHAPTER 1: CLINICAL REASONING: WHAT IT IS AND WHY IT MATIERS 11

Fundamental attribution error

This incident occurred when I was a newly registered nurse working on a medical ward.
The pationt was an elderly man (70+ years) who was admitted for a stroke. During his
admission the man had some degree of hemiparesis from his stroke; however, this
subsided to a large degree. The man appeared to be extremely resistive to our efforts
to make him as independent as possible. He wanted a great deal of assistance with his
activities o'f daily living and more than required for his level of disability. He required
constant encouragement to participate in any sort of physical activity, no matter how
minimal. The man was eventually transferred to a rehabilitation unit. Some weeks later
he returned to our ward as he would 'not participate' in his rehabilitation program. The
handover reported that he had 'failed rehab'. I judged him on his previous behaviour
and I assumed he was just lazy (based on the information from the rehab staff). On his
return to my ward he continued to constantly want assistance and seemed to be
determined to become dependent. I insisted (often strenuously and on reflection
harshly) that he walk and participate in his own care. Around this time he also started
to mention pain which hadn't really featured till then. He was investigated and was
found to have widespread bony metastasis from an unknown primary cancer. He died
three weeks later. I was astounded and felt very guilty as I had judged this man, mak;ng
assumptions that were proven to be erroneous. I did, however, .ensure that this man
received the very best care for the last three weeks of his life.

Doctor Jennifer Dempsey

University of Newcastle

Ascertainment bias
While employed as a mental health nurse in a GP practice I assessed a 65-year-old
woman, Alice, 1 who was referred by her GP as he was concerned about her mental
state. Upon assessment I found Alice had been diagnosed three years pdor with the
degenerative neurological condition, amyotrophic lateral sclerosis (ALS). She was
divorced, lived alone in a council flat in a small seaside village and had limited contact
with her daughter and grandchildren who lived six hours drive away, She had a prior
history that included childhood sexual abuse, a previous suicide attempt (in the context
of domestic violence) and two episodes of major depression which had responded well
to psychotropic medication and supportive psychotherapy.
Although Alice had significant physical symp~oms that affected her mobility at
times, she described having managed well until four months ago when her relationship
with her daughter had deteriorated severely. The abandonment had increased her
sense of isolation and this estrangement appeared to have been a trigger for a relapse
into major depression, with severe depressive symptoms, including increased loss of
motivation, tearfulness, disordered sleep, loss of appetite and a heightened sense of
hopelessness and suicidal ideation. Further discussion revealed that her GP had
initiated a neurological review, which revealed minimal deterioration in physica:
functioning, and an aged care assessment (ACAT), with a view to increasing the level of
support services available to Alice.
After consultation with Alice's GP, it was agreed that a psychiatrist review was
warranted and I prepared a comprehensive referral to the mental health services. At
the time I was working part-time with the Community Mental Health Team and thus
was present at the intake meeting where all referrals were reviewed as part· of a

· ',·' T. Pseudonym
12 CLINICAL REASONING: LEARNING TO THINK LIKE A NURSE

multi-disciplinary team process. The nurse from the Acute Care Service responsible
for presenting the referrals to the team commenced reading the referral. Before he
had finished, he commented, 'This is a waste of time; of course the woman's
depressed, who wouldn't be with a degenerative illness; besides, she's old.' Another
team member responded, 'Tell the GP to refer her to palliative care.'
Sadly for Alice, the mental health service declined a psychiatrist review; the Mental
Health Service for Older Persons likewise declined a review and recommended instead
that the application process for placement in an aged care facility be started. Alice's
'real' issues were not addressed because of the ageism and preconceptions of the
mental health team.

Associate Professor Rachel Rossiter

Charles Sturt University

Anchoring
Working as a nurse educator, I had been paged to come to recovery. Two RNs were
seeking advice about the management of a patient (Mrs L) who had had a left hip
replacement and was in severe pain, very distressed and calling out loudly and
incoherently. The anaesthetist had been notified but was in theatre with another patient.
Mrs L had been given morphine by the anaesthetist before being transferred to recovery.
As ordered, she was given three further bolus doses of morphine at 3-minute intervals
but with minimal effect. The nurses were encouraging her to use her PCA button but she
was not coherent enough to comply. I tried to do a thorough pain assessment but was
hampered in my attempts as the patient was unable to reply to my questions. I did an
assessment of the wound ... the dressing was dry and intact and the bellovac draining
a small amount. There was a small amount of urine in the catheter bag. I examined the
area surrounding the wound convinced that there must be a surgical problem. It
appeared normal and I could see no obvious reason for the pain.
Time was passing without any impro.vernent and we were all becoming anxious and
concerned about Mrs L's distress and pain. I was about to phone the anaesthetist again
but decided to check her wound one more time. In the process I briefly noticed that
Mrs L's catheter had not been taped to her leg and was actually lying under her thigh.
Lifting it over her leg I saw that it had also been kinked. As I untwisted it, urine began
to quickly flow. Within minutes there was close to 1600 ml in the catheter bag and Mrs
L had drifted off into a morphine-induced state. Her resps were now 6 and oxygen sats
85 per cent. We increased the oxygen to 10 L per minute with little effect and phoned
the anaesthetist for an order of naloxone as she had become narcotised. Had I not
anchored onto the belief that Mrs L's pain must be coming from the surgical site I
would have done a more comprehensive assessment, identified the cause of her pain,
not administered as much morphine, and prevented respiratory depression from
occurring. Checking that catheters are draining properly and not kinked or blocked
became part of my routine post-operative patient assessment following this experience.

Professor Tracy Levett-Jones

University of Technology, Sydney
 CHAPTER 1: CLINICAL REASONING: WHAT IT IS AND WHY IT MATTERS 13

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