Clinical Reasoning Case Study for Geriatric Care Planning
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This case study focuses on geriatric care planning and implementation using the clinical reasoning cycle. It discusses the assessment, care planning, and care delivery for an 89-year-old woman with macular degeneration, rheumatoid and osteoarthritis, and hyperthyroidism. The nursing interventions for mobility and fall prevention are also discussed.
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Running head: CLINICAL REASONING CASE STUDY Clinical reasoning case study Name of the student: Name of the university: Author note:
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1CLINICAL REASONING CASE STUDY Table of Contents Introduction:....................................................................................................................................2 Part A:..............................................................................................................................................2 Part B...............................................................................................................................................5 Conclusion:......................................................................................................................................7 References........................................................................................................................................8
2CLINICAL REASONING CASE STUDY Introduction: Geriatric care is complex; there are various factors that have to be considered in case of the geriatric care planning and implementation. It has to be mentioned in this context that as people age, their needs and requirements also change or modify according to the changes in their perception and the decaying bodily functions. Hence the care planning and implementation of a geriatric patient will also have to consider certain sensitive factors and elements. However, there are various tools and devices in the reach of the nursing or other health care professionals nowadays, utilizing these tools, the care professionals can establish a patient centered care that will address each and every desire and requirement of the patient (Hunter, 2016). Clinical reasoning cycle, coined by Tracy Levett Jones, can be considered as one of the greatest nursing decision making tool which provides an excellent step by step framework for the nurses to follow and investigate care needs of the a patient effectively, by the means of collecting information,sortingtheinformation,processingtheinformation,identifyingcareneeds, deciphering care priorities, implementation care measures and reflecting on the process (Levett- Jones, 2013). This cycle provides not only a framework for holistic care delivery but also for the nurses to learn and implement evidence based practice and reasonable decision making, learning and reflecting upon their own mistakes and strengths. Part A: According to the functional consequences theory by the Miller, the health needs of the older adults are associated more intricately with their psychological, emotional and spiritual health needs, rather than only physical health needs (Hunter, 2016). Hence this theory guides the
3CLINICAL REASONING CASE STUDY nursing professionals to take into consideration the functional consequences, the holistic idea of mind, spirit and body inter-relatedness in every aspect of care when it comes of the geriatric or aged patients. Therefore, it can be mentioned that starting from assessment, care planning to care delivery. Each and every step associated will need to be interlinked with psychological, emotional and physical wellbeing for older patients. This case study represents the case of Amalie Jones, an 89 year old woman, who had migrated to Australia from Germany years ago and have been living in the country she was no born into; devoid of her husband with whom she stepped foot in this country for the first time. Hence, both aging and the demise of her husband must have had a significant impact on her psycho-social health and living away from her cultural background has a significant impact as well (Hur & Roh, 2013). The very first and second step of the clinical reasoning cycle is associated with patients situation analysis followed by collecting cues, where the nurse will get the initial assessment of the situation that the patient is in. in this case, Amalie lived alone in her house and ever since the demise of her husband her health conditions have been deteriorating. She has developed dry macular degeneration as well, and along with that she is suffering from mobility restrictions due to rheumatoid and osteoarthritis. Further assessment of the patient revealed that she had been suffering from hyperthyroidism as well. The data from her previous visits with her general physician discovered a few key issues that the patient had been suffering from like joint stiffness, swollen feet and enlarged painful joints, limited joint movement, constipation, vision deficit, and forgetting to take her medications. Her medications include Paracetamol, Ibuprofen, Thyroxine, and Hydroxychloroquine. The third step in the clinical reasoning cycle is processing the information that has been gathered in the previous two steps. This step helps the nurse to sort through the variety of
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4CLINICAL REASONING CASE STUDY different information gathered and then by interpreting, discriminating, relating, inferring and matching the data with the evidence, arrive at the most plausible outcomes regarding the care needs. From the above assessment, the key diseases that the patient has include rheumatoid osteoarthritis, and age related macular degeneration (Yau et al., 2015). It has to be mentioned that Amalie is 89 year old woman, and at her age, health concerns like macular degeneration and rheumatoic arthritis are very common. For instance, for aged members over the age of 65, the chances of age related macular degeneration are high, among which 85 to 90% are dry macular degenerations. There is significant deterioration of retina, due to the deposition of drusens, small yellow dots under the macula. This directly leads to drying of the macula and impairs its functions and causes retinal thinning, as a result there is peripheral vision loss and fluctuating vision which causes difficulty in reading (Wong et al., 2014). That is the reason behind the patient having partial vision loss and is her to quit driving. Rheumatoid arthritis is a chronic inflammatory autoimmune disorder where her own immune system is attacking her body tissues and joints. The swelling and pain in her joints were caused by the damage to the lining of her joints resulting in bone erosion and joint deformity. Along with that the contribution of the osteoarthritis along with the above mentioned pathophysiology contributed to her mobility restrictions and limited joint movement as well. This autoimmune condition also leads to fatigue and dizziness which can be the reason for her Occasional dizziness and her constipation can be due to decreased colonic transit time (Levi et al., 2016). The fourth step of clinical reasoning cycle is identification of the problems and issues based on synthesis of the information processed in the previous step. The three most significant issues for this patient include hervision deficit, which can be a significant safety risk and fall risk that can lead to her injury. The second care need is herlimited mobility and joint stiffness
5CLINICAL REASONING CASE STUDY along with pain which can lead to fall risk and risk for injury as well (Singh et al., 2016). The third safety risk of the patient is heroccasional dizzinesswhich can be an effect of her deteriorating arthritis and forgetting to take her medication, which can lead to her fall risk and injury risk as well. Along with that, it has to be mentioned that all three of the identified conditions can also lead to her inability to perform activities of daily living, hence these three have been pegged as the most pressing three care needs demanding prior attention (Cross et al., 2014). Part B Based on the above mentioned priorities, the top priority of care was found to be the limited mobility. It implies establishment of goals and nursing interventions appropriate to the patient’s situation.Considering the patient’s conditional and lifestyle the SMART goal for this case would be to reduce the risk of fall to the extent that Amalie can carry her activities of daily living without risk of fall. The outcome may be achieved within one month time. The next goal is to educate patient on the safety measures so that she can minimize the potential for injury. The outcome is expected to be achieved within three weeks. The nursing goals are set in nursing practice to be able to design nursing actions appropriate to fulfill the top nursing priority identified (Levett-Jones, 2013). The nursing interventions for Amalie include assisting the patients in muscle exercises and assist with resistance training exercises suing weight. The patient will assisted in executing the abdominal –tightening exercises, hop on foot, knee bends and standing on toes. The rationale includes gaining of enhanced sense of balance.It will help strengthen the compensatory body parts and reduce the risk of falls.The patient will be provided with safe environment such as
6CLINICAL REASONING CASE STUDY keeping items as much close as possible, low positioning of bed and use of bed rails. These measures promote safe environment to prevent falls and injury. To further reduce the risk of fall and injury, passive and active ROM exercises to all extremities will be initiated.The rationale for these interventions includes prevention of joint stiffness. It helps maintain the stamina and muscle strength (Gillespie et al., 2012). Further, Amalie will be demonstrated and educated about the use of mobility devices such as trapeze or walkers as they enhance the level of activity. It not only promotes safety but also prevents falls (Miake-Lye et al. 2013). Amalie will be educated about the principles of progressive exercise. She will be educated not to exercise to the extent where she will feel pain. The rationale is to prevent patient from further damage to the muscles and joints. Education will create awareness of inappropriate movements (Tzeng & Yin, 2014). The patient will be further educated about maintaining the atmosphere that is free of hazards and safe. It will prevent falls and associated injury. The patient will be able to maintain the functional independence to the desired level. It will help decrease the fatigue with activity. To achieve this patient will also be explained about the progressive activity. The patient may increase her self confidence by attaining small goals (Moorhead et al., 2014). Evaluating of the nursing interventions is important to ensure quality nursing care (Levett-Jones, 2013).The patient will be evaluated to perform the activities of daily living without falls using a scale of 0-4 where 0 indicates the complete functional independence and 4 indicates complete dependence. It ill help give information regarding recovery. The patient will be evaluated for knowledge on the assistive device and safety measures. It will indicate if the patients can correctly use the assistive devices. Success of the intervention will be evident from the patient performance of physical activity independently within the illness limitations. Further,
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7CLINICAL REASONING CASE STUDY the patient demonstrates the use of safety measures and methods to mobility enhancement (Yost et al. 2015). On reflecting on the care process it appears that there should also been a focus on the family engagement in the caring process. I should have educated the family members on measures to create safe home environment. It would have better help the client accomplish tasks at her own place (Miake-Lye et al., 2013). I should have also educated the client on energy saving techniques so that she can enough rest in between activities. I now understand its importance and plan to incorporate the same in next care plan. Conclusion: On a concluding note, it can be mentioned that the clinical reasoning cycle helps to assess the individual needs of the patients effectively and for the geriatric patients, there is a significant importance of the this step. Along with that it not only aids in discovering the most pressing care needs of a patient, it also helps in deciphering the most crucial care priority as well. This assignment had been a great opportunity to utilize the clinical reasoning cycle and apply it into clinical scenario and identify care needs and arrive at care priority. The case study helped me learn about the nursing interventionsappropriatefor fall prevention and required patient education on creating safe environment. Overall, clinical reasoning cycle have helped developed goal driven care plan using critical thinking and clinical knowledge. Hence, reflecting on the entire procedure, it can be hoped that this experience will be extremely beneficial in my practice.
8CLINICAL REASONING CASE STUDY References Cross, M., Smith, E., Hoy, D., Nolte, S., Ackerman, I., Fransen, M., ... & Laslett, L. L. (2014). The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study.Annals of the rheumatic diseases, annrheumdis-2013. Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community.Cochrane Database Syst Rev,9(11). Hunter, S. (Ed). (2016). Miller’s nursing for wellness in older adults (2 nd Australia and New Zealand ed.) North Ryde, NSW: Lippincott, Williams and Wilkins. Hur, H. K., & Roh, Y. S. (2013). Effects of a simulation based clinical reasoning practice programonclinicalcompetenceinnursingstudents.KoreanJournalofAdult Nursing,25(5), 574-584. Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Frenchs Forest, NSW: Pearson Levi, E. H., Watad, A., Whitby, A., Tiosano, S., Comaneshter, D., Cohen, A. D., & Amital, H. (2016). Coexistence of ischemic heart disease and rheumatoid arthritis patients—a case control study.Autoimmunity reviews,15(4), 393-396. Miake-Lye, I. M., Hempel, S., Ganz, D. A., & Shekelle, P. G. (2013). Inpatient fall prevention programsasapatientsafetystrategy:asystematicreview.Annalsofinternal medicine,158(5_Part_2), 390-396.
9CLINICAL REASONING CASE STUDY Moorhead,S.,Johnson,M.,Maas,M.L.,&Swanson,E.(2014).NursingOutcomes Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences. Singh, J. A., Saag, K. G., Bridges, S. L., Akl, E. A., Bannuru, R. R., Sullivan, M. C., ... & Curtis, J. R. (2016). 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis.Arthritis & rheumatology,68(1), 1-26. Tzeng, H. M., & Yin, C. Y. (2014). Most and least helpful aspects of fall prevention education to prevent injurious falls: a qualitative study on nurses' perspectives.Journal of clinical nursing,23(17-18), 2676-2680. Wong, W. L., Su, X., Li, X., Cheung, C. M. G., Klein, R., Cheng, C. Y., & Wong, T. Y. (2014). Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis.The Lancet Global Health,2(2), e106-e116. Yau,G.,Almeida,D.R.,Chin,E.K.,&Park,S.S.(2015).Age-relatedmacular degeneration.Handbook of Vitreoretinal Disorder Management: a Practical Guide. World Scientific Publishing Co. Pte. Ltd., Singapore, 33-42. Yost, J., Ganann, R., Thompson, D., Aloweni, F., Newman, K., Hazzan, A., ... & Ciliska, D. (2015). The effectiveness of knowledge translation interventions for promoting evidence- informed decision-making among nurses in tertiary care: a systematic review and meta- analysis.Implementation Science,10(1), 98.