Portfolio: Reasoning of care
Name
Internship period PLP 3, April 17 – July 8
Internship Dr Wahidin Sudiro Husodo Hospital &
UNHAS Hospital
Department Lontara 3, ICU, CVCU, woundcare &
UNHAS
Internship teacher
Internship supervisors
,Table of contents
INTRODUCTION............................................................................................................................................. 3
STEP 1: ORIENTATION TO THE SITUATION...................................................................................................... 5
1. SITUATION........................................................................................................................................................5
2. BACKGROUND....................................................................................................................................................5
3. ASSESSMENT.....................................................................................................................................................6
Measurements:................................................................................................................................................6
ABCDE- method...............................................................................................................................................6
Early Warning Score (EWS):............................................................................................................................9
Ecogram.........................................................................................................................................................12
Hetero anamnesis..........................................................................................................................................13
Patterns of Gordon...................................................................................................................................................14
4. RECOMMENDATION..........................................................................................................................................16
Differential diagnoses....................................................................................................................................17
STEP 2: CLINICAL PROBLEM STATEMENTS.................................................................................................... 21
CONCLUSION:...................................................................................................................................................... 25
STEP 3: ADDITIONAL CLINICAL EXAMINATION..............................................................................................26
WORKING DIAGNOSIS............................................................................................................................................31
STEP 4: CLINICAL MANAGEMENT.................................................................................................................. 32
MEDICAL MANAGEMENT........................................................................................................................................32
NURSING POLICIES................................................................................................................................................34
Nursing (risk) diagnoses................................................................................................................................35
Prioritizing care.............................................................................................................................................41
Results and interventions..............................................................................................................................45
Decreased activity tolerance....................................................................................................................................49
Ineffective breathing pattern...................................................................................................................................51
Impaired spontaneous ventilation...........................................................................................................................53
Risk for thrombosis..................................................................................................................................................54
INFORMATION AND COMMUNICATION TECHNOLOGY INTERVENTIONS..............................................................................55
Google translate............................................................................................................................................56
Video calling..................................................................................................................................................57
Alodokter.......................................................................................................................................................58
Prayer on phone............................................................................................................................................59
STEP 5: CLINICAL COURSE............................................................................................................................. 60
DESIRED COURSE:.................................................................................................................................................60
ADVERSE COURSE:................................................................................................................................................61
STEP 6: REVIEW............................................................................................................................................ 62
PRODUCT EVALUATION..........................................................................................................................................62
Results of the evaluation...............................................................................................................................62
Next of kin care..............................................................................................................................................63
PATIENT SAFETY...................................................................................................................................................65
Prevention of ventilator-associated pneumonia (VAP).................................................................................66
Decubitus prevention.....................................................................................................................................67
Phlebitis prevention.......................................................................................................................................68
ETHICAL DILEMMA................................................................................................................................................70
Experience of the SN......................................................................................................................................71
CASE DISCUSSION................................................................................................................................................. 73
What did SN learn?........................................................................................................................................74
PERSON CENTERED CARE........................................................................................................................................75
2
,BIBLIOGRAPHY............................................................................................................................................. 78
Introduction
Reasoning of Care is a comprehensive module that covers the entire nursing process from
assessment to discharge and evaluation. This module uses the six steps of clinical reasoning
developed by Marc Bakker (Bakker et al., 2017) and is additionally supported by the nursing
CanMEDS roles.
In this report, we examine Mr. X's situation through the lens of proActive Nursing. This
method, based on Bakker's six steps of clinical reasoning, ensures close observation and
analysis, with no aspect overlooked (Bakker et al., 2017). Clinical reasoning is of great
importance in nursing because it bridges the gap between our own observations and
interpretations and medical knowledge, including aspects of physiology, anatomy, pathology
and pharmacology. Through this crucial skill, nurses can effectively determine the most
appropriate nursing interventions for specific clinical scenarios or nursing problems, as well
as the necessary follow-up steps. By applying clinical reasoning, nurses establish a strong
foundation for making informed decisions regarding patient care and ensure that their
interventions are both relevant and effective in addressing the unique needs of each
individual (Berends, 2023).
It is noteworthy that by following Marc Bakker's six steps, all seven CanMEDS competency
areas are addressed. The CanMEDS roles serve as a comprehensive framework that
outlines the occupational profiles of healthcare providers, including nurses. These roles
define the essential competencies needed to fulfill various responsibilities within health care.
The seven distinct roles include caregiver, communicator, collaborative partner, reflective
evidence-based practice professional, health advocate, organizer and professional and
quality promoter. Each role highlights specific competencies that healthcare professionals
must possess to successfully carry out their responsibilities and provide comprehensive care
to patients (Enurse.nl, 2023b).
3
, The student nurse picked this case because she thought it was an interesting case. This is
because it involves (head) trauma and student is very interested in the brain and acute
emergency care. Because the patient was in an accident, it is a complex case. Because of
the force of the collision, there are many possible diagnoses. Is it an acute case and care will
have to be adjusted many times due to new insights and changes in the patient's image.
The learning outcomes of the module Reasoning of Care are:
1. The student demonstrates the ability to collect and combine information from
various sources in the different phases of the nursing process within an authentic,
highlly complex context.
2. Based on clinical reasoning, the student determines the nursing process within an
authentic highly complex context.
3. Using EBP, the student justifies the nursing process within an authentic highly
complex context.
4. The student performs the nursing process independently and evaluates the nursing
process within an authenthic highly complex context.
5. The student communicates in a person-oriented and professional manner with the
care recipient and his/her informal network, ensuring optimal information exchange.
6. The student applies information and communication technologies in addition to the
personal contact with the care recipient and his/her informal network.
4
Name
Internship period PLP 3, April 17 – July 8
Internship Dr Wahidin Sudiro Husodo Hospital &
UNHAS Hospital
Department Lontara 3, ICU, CVCU, woundcare &
UNHAS
Internship teacher
Internship supervisors
,Table of contents
INTRODUCTION............................................................................................................................................. 3
STEP 1: ORIENTATION TO THE SITUATION...................................................................................................... 5
1. SITUATION........................................................................................................................................................5
2. BACKGROUND....................................................................................................................................................5
3. ASSESSMENT.....................................................................................................................................................6
Measurements:................................................................................................................................................6
ABCDE- method...............................................................................................................................................6
Early Warning Score (EWS):............................................................................................................................9
Ecogram.........................................................................................................................................................12
Hetero anamnesis..........................................................................................................................................13
Patterns of Gordon...................................................................................................................................................14
4. RECOMMENDATION..........................................................................................................................................16
Differential diagnoses....................................................................................................................................17
STEP 2: CLINICAL PROBLEM STATEMENTS.................................................................................................... 21
CONCLUSION:...................................................................................................................................................... 25
STEP 3: ADDITIONAL CLINICAL EXAMINATION..............................................................................................26
WORKING DIAGNOSIS............................................................................................................................................31
STEP 4: CLINICAL MANAGEMENT.................................................................................................................. 32
MEDICAL MANAGEMENT........................................................................................................................................32
NURSING POLICIES................................................................................................................................................34
Nursing (risk) diagnoses................................................................................................................................35
Prioritizing care.............................................................................................................................................41
Results and interventions..............................................................................................................................45
Decreased activity tolerance....................................................................................................................................49
Ineffective breathing pattern...................................................................................................................................51
Impaired spontaneous ventilation...........................................................................................................................53
Risk for thrombosis..................................................................................................................................................54
INFORMATION AND COMMUNICATION TECHNOLOGY INTERVENTIONS..............................................................................55
Google translate............................................................................................................................................56
Video calling..................................................................................................................................................57
Alodokter.......................................................................................................................................................58
Prayer on phone............................................................................................................................................59
STEP 5: CLINICAL COURSE............................................................................................................................. 60
DESIRED COURSE:.................................................................................................................................................60
ADVERSE COURSE:................................................................................................................................................61
STEP 6: REVIEW............................................................................................................................................ 62
PRODUCT EVALUATION..........................................................................................................................................62
Results of the evaluation...............................................................................................................................62
Next of kin care..............................................................................................................................................63
PATIENT SAFETY...................................................................................................................................................65
Prevention of ventilator-associated pneumonia (VAP).................................................................................66
Decubitus prevention.....................................................................................................................................67
Phlebitis prevention.......................................................................................................................................68
ETHICAL DILEMMA................................................................................................................................................70
Experience of the SN......................................................................................................................................71
CASE DISCUSSION................................................................................................................................................. 73
What did SN learn?........................................................................................................................................74
PERSON CENTERED CARE........................................................................................................................................75
2
,BIBLIOGRAPHY............................................................................................................................................. 78
Introduction
Reasoning of Care is a comprehensive module that covers the entire nursing process from
assessment to discharge and evaluation. This module uses the six steps of clinical reasoning
developed by Marc Bakker (Bakker et al., 2017) and is additionally supported by the nursing
CanMEDS roles.
In this report, we examine Mr. X's situation through the lens of proActive Nursing. This
method, based on Bakker's six steps of clinical reasoning, ensures close observation and
analysis, with no aspect overlooked (Bakker et al., 2017). Clinical reasoning is of great
importance in nursing because it bridges the gap between our own observations and
interpretations and medical knowledge, including aspects of physiology, anatomy, pathology
and pharmacology. Through this crucial skill, nurses can effectively determine the most
appropriate nursing interventions for specific clinical scenarios or nursing problems, as well
as the necessary follow-up steps. By applying clinical reasoning, nurses establish a strong
foundation for making informed decisions regarding patient care and ensure that their
interventions are both relevant and effective in addressing the unique needs of each
individual (Berends, 2023).
It is noteworthy that by following Marc Bakker's six steps, all seven CanMEDS competency
areas are addressed. The CanMEDS roles serve as a comprehensive framework that
outlines the occupational profiles of healthcare providers, including nurses. These roles
define the essential competencies needed to fulfill various responsibilities within health care.
The seven distinct roles include caregiver, communicator, collaborative partner, reflective
evidence-based practice professional, health advocate, organizer and professional and
quality promoter. Each role highlights specific competencies that healthcare professionals
must possess to successfully carry out their responsibilities and provide comprehensive care
to patients (Enurse.nl, 2023b).
3
, The student nurse picked this case because she thought it was an interesting case. This is
because it involves (head) trauma and student is very interested in the brain and acute
emergency care. Because the patient was in an accident, it is a complex case. Because of
the force of the collision, there are many possible diagnoses. Is it an acute case and care will
have to be adjusted many times due to new insights and changes in the patient's image.
The learning outcomes of the module Reasoning of Care are:
1. The student demonstrates the ability to collect and combine information from
various sources in the different phases of the nursing process within an authentic,
highlly complex context.
2. Based on clinical reasoning, the student determines the nursing process within an
authentic highly complex context.
3. Using EBP, the student justifies the nursing process within an authentic highly
complex context.
4. The student performs the nursing process independently and evaluates the nursing
process within an authenthic highly complex context.
5. The student communicates in a person-oriented and professional manner with the
care recipient and his/her informal network, ensuring optimal information exchange.
6. The student applies information and communication technologies in addition to the
personal contact with the care recipient and his/her informal network.
4
