Clinical reasoning cycle Assignment

Clinical reasoning cycle

TABLE OF CONTENT
ASSESSMENT 1.............................................................................................................................1
1. INDIVIDUAL CONSIDERATION ...........................................................................................1
2. CUE/INFORMATION COLLECTION .....................................................................................1
Cues collected during interview ..................................................................................................1
Gathering new information .........................................................................................................1
Describing cues ...........................................................................................................................2
3. PROCESSING INFOMRATION ...............................................................................................3
Interpretation ...............................................................................................................................3
Prioritising cues ..........................................................................................................................3
8. REFLECTION ............................................................................................................................7
REFERENCES ...............................................................................................................................8
APPENDIX : Health History...........................................................................................................9

ASSESSMENT 1
1. INDIVIDUAL CONSIDERATION AND HEALTH HISTORY
Mr. X is 60 year old man who frequently visit community health centre for the
monitoring of his glucose level and blood pressure. He lives alone and have a 24 hours health
care assistant which helps him in providing routine care. He has high blood pressure and medical
history of dyspnea and coronary heart issues. The detailed health history of Mr. X is provided in
the appendix.
2. CUE/INFORMATION COLLECTION
Cues collected during interview
Through the physical assessment it is observed that Mr. X is highly obese and pale skin.
He is suffering from type 2 diabetes and pressure ulcer. He also has medical history of coronary
heart disease and dyspnea. Due to age related factor and skin impairment he find it difficult to
perform routine his routine functions and thus for mobility related functions he require
assistance. On many occasion he also suffer from visionary issues which are triggered by age as
well as diabetes related complications. He does not follow have routine for physical exercise or
special diet for controlling weight and sugar level. Though he try to minimise the sugar intake
but there is no such proper diet plan.
The cardio and neurovascular assessment also shows that Mr. X often experience
breathing shortness and numbness in his arms and legs. The soreness in skin and limited physical
movement along with diabetes results in skin dis-integrity. When interviewed about past medical
history Mr. X also stated that he has history of hypertension. Since he leaves alone he used to
take his medication at his own (Ignatavicius & Workman, 2015). However many times he used
to forget the medication and due to visionary blurriness he is not able to distinguish in his
different medications. Currently he uses medications for managing his blood pressure, sugar
level and coronary heart diseases. The skin assessment through physical examination indicates
the pressure ulcers and unmanaged diabetes which requires immediate attention.
Gathering new information
In addition to the above assessment there is need to perform several other assessments so
that quality of care can be improved and nursing problems can be identified with more
effectiveness (Van Netten & et.al., 2016). Mr. X has skin integrity issues and thus it is necessary
to conduct a pain assessment which describes severity of skin issues. He stated that on scale of 1-
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10 he suffers from mild pain (6 rating) on his foot. The increase in swelling also enhances the
pain level for which he used to take pain management medications. The patient lives alone and
does not have any family members in contact. He has been a chain smoker and smokes 15
cigarettes daily. Due to loneliness he often feel depressed and thus his smoking habit is getting
worsen. The psychosocial assessment is important because due to emotional needs he smokes
heavily and it affects the respiratory and breathing patterns (Hansen & et.al., 2016). Due to
history of dyspnea and heart issues it is not good for patient to encourage smoking. Due to
obesity, age and skin issues there are high risk of fall for Mr. X. Thus fall risk assessment will
assist in eliminating such possibilities. Mr. X has vision impairment and thus he often miss the
stairs when he is walking without support from the assistance.
Describing cues
According to Szczerbińska & et.al., (2015) type 2 diabetes has strong association with the
cardiovascular and neurovascular complications. Thus it is very important that individuals must
emphasis on managing their weight and diabetes so that risk factors related to patient safety can
be managed. Mr. X does not have proper strategy to manage weight. In addition to this
hypertension and smoking habits have adverse impact upon physiology of the patient. Cardwell
& et.al., (2016) stated that among the patients of type 2 diabetes there are high possibilities of
visionary impairment making patients more complicated. Mr. X is 60 year old and thus thus
visionary issues are also accompanied by age factor. He also has safety issues related to
pharmacology.
During assessment it was identified that Mr. X lives alone and takes his medication
without any guidance. However when he is not well and has visionary issue then he often fails to
distinguish between his medications. Thus there are higher vulnerabilities of medication errors.
As per the view of Kuo & et.al., (2015) among elder patient emotional care and needs are critical
factor in enhancing the health outcomes. The same has been also identified in the case of Mr. X.
Since he does not have any family member to share emotional bond or care he suffers from
loneliness and depression. To deal with the psychological trauma he does not have any control
over his smoking habits. Among the patients of hypertension and heart diseases smoking
practices can lead to breathlessness and dyspnea (Munshi & et.al., 2016). The obesity also cause
several complications regarding breathing and circulatory issues. For improving the health and
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minimising risk factors it is vital that life style of Mr. X must be changed and more healthy
practices must be adopted by him.
3. PROCESSING INFOMRATION
Interpretation
Weight has been one of the important cue for the diabetic patients. Mr. X is 60 years old
and is in category of highly obese. The obesity not only complicate the sugar level but also affect
the mobility issues and skin integrity of the patient. The normal range of systolic blood pressure
is less than 120 while that of diastolic blood pressure is less than 80 mm Hg (He & et.al., 2017).
Mr. X is having hypertension and his blood pressure is recorded as 140/90 mm Hg which is very
high. The patients heart rate is 110 bpm which is slightly higher than normal value of 60-100
bpm. The irregular heart rate can be a symptom of heart failure or stroke. The healthy adults
must have blood sugar level of less than 110 mg/dl before meal or fasting and less than 140
mg/dl after two hours of having meal. From the assessment the fasting sugar level of Mr. X was
observed as 112 mg/dl which is higher and needs to be controlled. On physical assessment it has
been also interpreted that foots of Mr. X are swollen and pale skin also has some dis-integrity.
As compare to the past medical records swelling and pressure ulcers have shown more
progression due to diabetes and limited physical movement of the patient (Sapkota & et.al.,
2015).
Prioritising cues
The most important cue which must be managed on priority basis is the sugar level.
There is high need to manage the diabetes and hypertension because both of these aspects make
situation more critical (Dougados & et.al., 2015). The uncontrolled diabetes results in visionary
issues as well as higher risk factor for the neurovascular issues and heart failures. Another
significant cue which must be taken into consideration is that breathing shortness or dyspnea.
Mr. X must have control over smoking habits. Since the smoking practice can interfere with the
respiratory and circulation wellness this must be addressed at the priority. There must be regular
monitoring of respiratory rate, heart rate and skin integration so that vital symptoms of any
abnormality can be identified and managed. The medical history of heart disease and
hypertension can be worsen if these clinical manifestations are not managed effectively (Van
Netten & et.al., 2016). The breathlessness and dyspnea can also enhance the fall risk
vulnerabilities for the individual.
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4.) Problem
Identification
5.) Goals 6.) Actions 7.) Rationale for nursing
action
Nursing problem
1: The increased
blood sugar level is
priority issue as it
can trigger the
heart failure,
stroke, kidney and
visionary issues.
The nursing goal
is to manage the
weight of patient
so that blood
sugar level can be
maintained within
desirable limits.
Through appropriate
assistance Mr. X must be
encouraged to take
healthy diet and to initiate
physical exercises. With
these actions sugar level
must be checked regularly
so that progress can be
measured.
Obesity and unhealthy life
style has been one of the
key factor responsible for
abnormal sugar level. Thus
through recommended
actions Mr. X will lead to
healthy life. By
encouraging regular
monitoring of the blood
glucose level individual
and care service provider
also get better
understanding of the life
style management (Powers
& et.al., 2017). The actions
will also minimise the risk
factors of stroke,
hypertension and kidney
issues. The initiation of
physical exercise will also
make patient more active
along with the healthy
skin.
There must be regular Pressure ulcer causes
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movement and assessment
of the skin. Weight
management practices and
skin care measures must
be followed.
extreme pain to patient. It
also enhances the risk
factor for edema and other
skin injuries which are
worsen among diabetic
patients. In older age
diabetic patients find it
more challenging to
observe skin repairing and
healing (Sapkota & et.al.,
2015). Thus described
action will assist in
eliminating skin injuries
and associated infection
risks which may otherwise
hard to healed.
Nursing problem
2:
Hypertension and
breathing shortness
enhances the fall
risk for the patient
along with the
respiratory and
circulation issues.
The nursing goal
for this problem is
to control the
smoking habit and
to assure the heart
rate and blood
pressure within
normal range.
There must be regular
monitoring of the
breathing pattern and
number of cigarettes
smoked by Mr. X.
The long term
breathlessness and
excessive smoking is
harmful for the respiratory
outcomes (Holland, 2017).
Thus proposed action will
minimise the damage
caused to blood vessels
and lungs as a result of
smoking. Regular
monitoring of heart rate
and breathing pattern will
help to control the dyspnea
and chronic heart injuries.
The breathing irregularities
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are also associated with the
hypertension. Thus regular
monitoring is also crucial
in stabilising the blood
pressure of the individual.
The management of blood
pressure can prevent the
damage to blood vessel to
a great extent.
Mr. X must be
encouraged to participate
in social activities so that
he can cope up with
loneliness as well as
medication errors and fall
risks associated with his
loneliness.
It is very necessary that
emotional needs of Mr. X
are also addressed. In the
old age the people with
chronic diseases may need
strong support, care and
love. Thus loneliness may
trigger new complexities
such as dementia and other
psychological disorders
(Yusuf & et.al., 2016) .
Further due to higher age,
skin and mobility issues
and obesity Mr. X is often
prone to fall risks as well
as medication errors. Thus
increased social
involvement of Mr. X
with other community
members and health care
service providers can be
significant in preventing
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any kind of health
deterioration in Mr. X.
8. REFLECTION
The interview has provided me an excellent opportunity to understand the various
assessment tools which can help in diagnosis and treatment of the issue. During the entire
assessment I also came to know that in order to provide holistic and person centred care to my
patients I must not only emphasis on physical assessment but instead a cultural, psychosocial and
psychological assessment is also necessary. It was very challenging for me to prioritise the
various identified problem and to develop suitable nursing interventions and goals for the issues.
However I tried to assure that the actions chosen by me are effective enough to provide complete
care to the individual.
Another important learning which I gained from this experience is that the elderly care
requires additional efforts. For instance during the interaction with Mr. X I realised that there is
huge gap between old patients and other individuals. I tried to maintain proper communication
with him so that he does not feel uncomfortable in interacting with me. There were many
occasions when I was not sure that which nursing issue must be prioritised for the patient.
However when I performed a wide range of nursing assessment I understood that apart from the
safety of individual their own preferences and individual needs are also essential in categorising
nursing problem. One of the important professional learning which I received from the process is
that it is very essential to collect cues in systematic manner so that information can be processed
accurately and in correct direction.
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REFERENCES
Books and Journals
Cardwell, J. & et.al., (2016). Assessment of diabetes knowledge in trained and untrained ward
nurses before and after intensive specialist support. J. Diabetes Nurs. 20. pp.60-64.
Dougados, M. & et.al., (2015). Impact of a nurse-led programme on comorbidity management
and impact of a patient self-assessment of disease activity on the management of
rheumatoid arthritis: results of a prospective, multicentre, randomised, controlled trial
(COMEDRA). Annals of the rheumatic diseases. 74(9). pp.1725-1733.
Hansen, A.B. & et.al., (2016). Long-term exposure to fine particulate matter and incidence of
diabetes in the Danish Nurse Cohort. Environment international. 91. pp.243-250.
He, X. & et.al., (2017). Diabetes self-management education reduces risk of all-cause mortality
in type 2 diabetes patients: a systematic review and meta-analysis.
Holland, K., (2017). Cultural awareness in nursing and health care: an introductory text.
Routledge.
Ignatavicius, D.D. & Workman, M.L., (2015). Medical-Surgical Nursing-E-Book: Patient-
Centered Collaborative Care, Single Volume. Elsevier health sciences.
Kuo, Y.F. & et.al., (2015). Potentially preventable hospitalizations in Medicare patients with
diabetes: a comparison of primary care provided by nurse practitioners versus
physicians. Medical care. 53(9). p.776.
Munshi, M.N. & et.al., (2016). Management of diabetes in long-term care and skilled nursing
facilities: a position statement of the American Diabetes Association. Diabetes
care. 39(2). pp.308-318.
Powers, M.A. & et.al., (2017). Diabetes self-management education and support in type 2
diabetes: a joint position statement of the American Diabetes Association, the American
Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The
Diabetes Educator. 43(1). pp.40-53.
Sapkota, S. & et.al., (2015). A systematic review of interventions addressing adherence to anti-
diabetic medications in patients with type 2 diabetes—components of
interventions. PLoS One. 10(6). p.e0128581.
Sapkota, S. & et.al., (2015). A systematic review of interventions addressing adherence to anti-
diabetic medications in patients with type 2 diabetes—impact on adherence. PloS
one. 10(2). p.e0118296.
Szczerbińska, K. & et.al., (2015). The characteristics of diabetic residents in European nursing
homes: results from the SHELTER study. Journal of the American Medical Directors
Association. 16(4). pp.334-340.
Van Netten, J.J. & et.al., (2016). Prevention of foot ulcers in the at‐risk patient with diabetes: a
systematic review. Diabetes/metabolism research and reviews. 32. pp.84-98.
Yusuf, S. & et.al., (2016). Prevalence and risk factor of diabetic foot ulcers in a regional hospital,
eastern Indonesia. Open Journal of Nursing. 6(01). p.1.
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APPENDIX : Health History
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Name Mr. X
Gender Male
Age 60
Current Medical History Hypertension, Type 2 diabetes, Pressure ulcers
Past Medical/Surgical History Coronary heart failure (3 years ago) and dyspnea
Medications Thiazide type diuretics, ACEI, insulin dosage
Do you live alone/with someone? Alone
Are you able to care for yourself? No
Do you need help with showering? No
Do you need help with toileting? No
Do you need help with dressing? No
Do you have a vision impairment? Yes
Do you wear glasses: No
What type of glasses are they? --
Do you have a hearing impairment? No
Do you wear a hearing aid? No
Which ear do you wear them in? No
Do you wear denture: No
Are they upper/bottom dentures? No
Do you drink alcohol? No
How often do you drink? --
How many drinks do you have each day? --
Do you smoke? Yes
How many cigarettes do you smoke a day? 15 cigarettes
Do you follow a special diet? No
What is the special diet? --
What is your height? 68.3 inch
What is your weight? 260 lb
Do you have any mobility issues? Yes
Do you use a mobility aid? Yes
What mobility aid do you use? Walking stick, walker
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Do you do any exercise’? No
Do you have any wounds? Yes
Where are they? On foots, arms and legs
1) Nursing assessment tool used Pain assessment tool
Result – The skin dis-integrity and pressure ulcer is severe and has 6 rating on visual analogue
pain scale
2) Nursing assessment tool used Diabetes risk assessment tool
Result – Poorly controlled blood glucose level along with hypertension
3) Any other nursing assessment tools used - Physical assessment tools and complete
focused assessment
Result: Irregularities in heart rate, blood pressure and blood circulation
Any other information you wish to add in relation to the person you interviewed.
Due to loneliness often depression is felt. In addition to this due to visionary issues
occasionally there is difficulty in distinguishing medications so there are high risk factors
related to medication errors and fall risk.
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