Clinical reasoning: Learning to think like a nurse

Nurses must employ approaches that attempt to increase the quality of health interventions and patient safety in order to improve patient outcomes. Because the majority of their work in health care environments includes making clinical judgments, it is critical that they have an organized approach of reasoning to assist them make effective choices. Nurses, according to Dougherty, Thompson, and Kudenchuk (2013), play a critical role in developing interventions to improve a patient's response to illness, ability to adapt to illness, and ability to live with a life-changing condition. For these reasons, they must be able to make appropriate decisions that result in excellent patient outcomes. The Clinical Reasoning Cycle (Levett-Jones, 2012) is one of the best ways for nurses to decide the intervention a patient’s needs. This essay aims to apply the clinical reasoning cycle to a clinical problem showing how a nurse made use of the process to improve a patient’s condition. It will also provide some recommendations that student and registered nurses can use to better their practice.

Patient Problem

The patient was a 35-year-old man suffering from tuberculosis. He arrived at the hospital complaining of a continuous cough, malaise and breathlessness. His partner stated that he had also lost his appetite for some time leading to weight loss. They had been on holiday in India about four weeks prior to the hospital visit.

Stage One: Patient Consideration

According to Levett-Jones (2013), the clinical reasoning cycle should start by taking into consideration all aspects related to a patient’s condition and note any intervention that the patient has received. As a result, the case under consideration in this essay begins with that approach. The patient was a 35-year-old man who presented a history of coughing and breathlessness after a visit to India. Moreover, he complained of a continuous feeling of fatigue. He had lost weight, and apart from a persistent cough, he showed no other physical problems.

Stage Two: Collecting Information

In this stage, the nurse gathers all the information that a patient can provide using different methods, such as clinical testing and questioning the patient. The primary reason for this assessments is to prevent adverse events and detect trends in the deterioration of a patient’s condition (Coyne & Needham, 2012). The patient had indicated the presence of a persistent cough raising suspicion of a TB infection. After interrogating the patient, the nurse gathered some cues concerning the patient’s condition. He never experienced night sweats. Clinical wisdom collected by the nurse has shown that tuberculosis can lead to night sweats, particularly among young adults (Mold, Holtzclaw & McCarthy, 2012). The nurse needed to remove this possibility hence the interrogation. Nevertheless, the additional information provided by the patient’s spouse, for instance the loss of appetite and weight, made the nurse pursue the potential of a tuberculosis infection further. This situation raised the need for more testing because he had mentioned that it was the first time he was seeking treatment.

The next step was a physical examination of the patient that involved drawing some blood. During the physical assessment, the student nurse noted a crepitation over his lung apices. The crepitation in the lungs was in the form of a rattling noise during inhalation. Literature reveals that crepitations are a common symptom among TB patients. An observation of 60 TB patients in one study revealed that 83.3% had crepitations (Vipin & Solanke, 2012). This information reaffirmed the nurse’s suspicions that the patient had tuberculosis despite the blood test showing normal levels of white blood cells and haemoglobin. The result led the student nurse to consult the lead nurse who recommended a sputum test, a chest X-ray and a Mantoux test.

After the chest X-ray, the nurses working with a nurse manager identified some shadowing in the upper and middle lobe although there was no enlargement of the hilar. The hilum on both sides showed a branching vascular look with the blood vessels leading from them tapering and diminishing. According to Sarkar et al. (2013), normal hilar appear this way. The X-ray showed a darkened upper and middle lobes a problem that has been associated with TB patients (Cadena et al., 2016).

The sputum analysis detected the presence of bacteria in the patient’s mucus. The analysis detected some Mycobacterium and acid-fast bacilli. Evidence-based practice demands that nurses gather all relevant information concerning a patient’s condition to enable them make informed decisions that enhance patients’ outcomes (Ellis, 2016). A Mantoux test was the final confirmatory test a. It gave positive results, and the patient was diagnosed with pulmonary tuberculosis. The nurse collected all the information together and passed it on to the lead nurse for confirmation before presenting it to a doctor for further analysis and for the patient to begin treatment.

Stage Three: Process Information

Levett-Jones (2012) gives the next stage in the clinical reasoning cycle as processing and analysis of information. Several techniques can be used in this stage to present a clearer understanding of a patient’s health condition: interpretation, discrimination, relation, inference and predicting. In the interpretation phase the nurse examined the information to understand the signs and symptoms that the patient presented. The patient complained of a constant feeling of fatigue for a young person. The feeling of being tired indicates an abnormality in the patient’s health.

The student nurse then moved on to discriminate the information given by the patient and his spouse. When questioned by the nurse, the couple said that he had not experienced night sweats. Although night sweats are a common occurrence among TB patients, some patients may not experience them as seen in the Vipin & Solanke (2012) study. The student nurse noted this but discriminated the information as it was not sufficient to rule out the presence of TB.

Relation of the information collected was another step in the clinical reasoning cycle. It involved making connections between the symptoms the patient displayed and symptoms associated with a particular illness, in this instance tuberculosis. The patient complained of three signs that normally present themselves in TB patients: persistent coughing, loss of appetite and a feeling of general tiredness. The three symptoms were a pointer to the possibility of TB. Furthermore, the crepitation in the lung also reinforced the suspicion.

After interpreting, discriminating and relating the information collected from the patient, the next step was to make some inferences from it. Sarkar et al. (2013) asserted that the hilum on both sides of the lung should have a branching vascular look and the blood vessels leading from them should narrow and diminish as they spread. The patient’s lungs in this case appeared normal. Nevertheless, the lungs had darkened lobes which have been associated to TB infection. This information was enough to make the nurse student recommend a sputum test to prove TB and a chest X-ray. The nursing student also recommended a Mantoux test that confirmed the student nurse initial thought.

Stage Four: Identify the Problem

The fourth stage of the clinical reasoning cycle involves the nurse finding facts concerning a patient’s condition (Levett-Jones, 2012). The sputum test, chest X-ray and Mantoux tests confirmed the nursing student’s feeling that the patient had TB. The TB was responsible for the overwhelming feeling of fatigue, loss of appetite and persistent coughing. It was likely that the patient has contracted the illness while on tour in India.

Stage 5: Create Goals

In this phase of the cycle, nurses should establish goals whose realization will lead to positive outcomes for a patient’s health. Working together with a registered nurse, the student nurse established the primary aim as treating the TB infection that would reinstate the patient’s health.

Stage Six: Action

This stage involves nurses taking action and creating a plan that will make it possible to realize the aim identified earlier. The registered nurse together with the nursing student spoke to the nurse in charge of the unit to determine the next course of action. After giving the information to the head nurse, the nurse called a doctor who examined the patient and confirmed the symptoms the nurse student had observed. The doctor also examined the sputum test results, chest X-ray and the Mantoux test before recommending treatment. Following the examination of the evidence and conclusion that the nursing student was dealing with a TB patient, the doctor recommended the antibiotics rifampicin and isoniazid for six months. The medications would be accompanied by pyrazinamide in the first two months of treatment.

Stage Seven: Evaluation

The seventh stage of the clinical reasoning cycle presented an opportunity for the nursing student to evaluate the process and deduct some recommendations on how to improve the application of the process in clinical practice. This phase was to involve an examination of the entire process from the moment the nursing student met the couple to their exit from the hospital after receiving the medication and instructions on how to use it.

Stage Eight: Reflect on the Process and Recommendations

The final stage of the clinical reasoning cycle allows nurses to reflect on their clinical decisions as well as make any suggestions on how to improve the process (Levett-Jones, 2012). Reflecting on the process that led to the TB diagnosis and recommended treatment, the nursing student has made several observations that could lead to improvements in clinical practice. First, the nursing student observed that the absence of an enlarged hilar is not an indication of the absence of TB. As mentioned in the case, the patient showed no signs of a larger hilar despite the TB diagnosis. Nurses should pay attention to this issue as overlooking it could lead to a misdiagnosis that leads to poor patient outcomes.

Second, the nurse student recognized the need for greater testing when confronted with divergent symptoms. Although the nursing student’s initial suspicion was that the patient had TB, some of the symptoms that the patient presented contrasted this belief, such as the normal hilar in the patient’s chest X-ray. This problem shows that there is a risk that a nurse may misdiagnose a patient. Phillips (2015) states that misdiagnosis and failure to treat TB properly can lead to transmissions. The clinical reasoning cycle above provides proof that nurses should take all the possible actions needed to eliminate the presence of an illness. Such actions could help in improving the outcomes for a patient and protecting other people from infections.

Poor patient outcomes following a treatment can be attributed to incorrect misdiagnosis, failure to implement the right treatment and inappropriate management of complications that a patient presents (Sommers & Fannin, 2014). Therefore, nurses should take a holistic approach to the diagnosis and treatment of patients’ problems. Nurses must learn to look for all the information they can gather from their patients, collect their own data and communicate the information with other nurses, particularly those who have served in the profession for several years. A second opinion on a problem can help to gain better understanding of the symptoms patients present in their health problems, particularly where a patient does not exhibit the signs that are usually associated with a specific ailment.

In conclusion, the clinical reasoning cycle is an important tool for nurses to enhance their practice. It makes it possible for nurses to gain deeper understanding of a patient’s problem as well as the possible actions that they can take to improve patient outcomes. Through it, nurses can also learn to exercise greater caution in their work to prevent misdiagnosis and ensure they give patients the most effective treatment for their problems. Furthermore, the cycle provides nurses with a means to evaluate their actions in the diagnosis and treatment process which can help them to prevent such mistakes in future. The clinical reasoning cycle is a tool that should be recommended for practice among student and registered nurses for its efficacy in disease treatment.


Cadena, M. A., Klein, C. E., White, A. G., Tomko, A. J., Chedrick, C. L., Reed, S. D., Via, E. L., Lin, L. L. & Flynn, L. J. (2016). Very low doses of mycobacterium tuberculosis yield diverse host outcomes in common marmosets (Callithrix jacchus). Comparative Medicine, 66 (5), 412-419.

Coyne, E. & Needham, J. (2012), Undergraduate nursing students placement in specialty clinical areas: Understanding the concerns of the student and registered nurse. Contemporary Nurse, 42 (1), 97-104.

Dougherty, M. C., Thompson, E. A. & Kudenchuk, J. P. (2013). Development and testing of an intervention to improve outcomes for partners following receipt of an implantable cardioverter defibrillator. ANS Adverse in Nursing Science, 35 (4), 359-377.

Ellis, P. (2016). Evidence-based practice in nursing. London, Sage Publications.

Levett-Jones, T. (2013). Clinical reasoning: Learning to think like a nurse. Melbourne, Pearson Australia Group.

Levett-Jones, T. (2013). Clinical reasoning: Learning to think like a nurse. Melbourne, Pearson Australia Group.

Mold, J. W., Holtzclaw, J. B., McCarthy, L. (2012). Night sweats: A systematic review of the literature. Journal of the American Board of Family Medicine, 25 (6), 878-893.

Phillips, J. A. (2015). Global tuberculosis. Workplace Health & Safety, 63 (10), 476-476.

Sarkar, S., Jash, D., Maji, A. & Patra, A. (2013). Approach to unequal hilum on chest X-ray. The Journal of Association of Chest Physicians, 1 (2), 32-37.

Sommers, M. S. & Fannin, E. (2014). Diseases and disorders: A nursing therapeutics manual. Davis, CA: F.A. Davis.

Vipin, P. & Solanke, V. P. (2012). Prevalence of tuberculosis cases in Sree Mookambika Institute of Medical Science. International Journal of Contemporary Medicine, 4 (1), 7-10.

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