Nursing Care Provision: Prioritizing Issues and Using Clinical Reasoning Cycle

This essay identifies and prioritizes the most important nursing care issues for the patient(s) using Millers’ Functional Consequence Theory to identify the influence impacting on the older persons and their level of function, and Levitt-Jones’ Clinical Reasoning Cycle as the tool to drive the process of identifying and assessing, implementing and evaluating care.

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Name
Institution affiliation

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Introduction
Clinical reasoning has been used interchangeably with other terms including problem-
solving, clinical judgment, critical thinking, and decision making(Gee, Dalton & Levitt-Jones,
2015). This learning package term will be explained or defined as the process nurses and other
clinicians use in collecting cues, processing the information, coming to an understanding of
patient's problems or issues, planning and implementing interventions, evaluating the outcomes
while reflecting and learning from the process(Lin, Watson& Tsai, 2013). Clinical reasoning
skills with nurses are important because it helps them to have a positive impact on the outcomes
of the patients(Gee, Dalton & Levitt-Jones, 2015). Nurses with deficiencies of/poor clinical
reasoning skill fail to rescue patients from their impending deteriorating health(Lin, Watson &
Tsai, 2013). This essay will identify and prioritize the most important nursing care issues for the
patient(s) using Millers’ Functional Consequence Theory to identify the influence impacting on
the older persons and their level of function, and Levitt-Jones’ Clinical Reasoning Cycle as the
tool to drive the process of identifying and assessing, implementing and evaluating care(Gee,
Dalton& Levitt-Jones, 2015). It will contain part A involving identification of the nursing
priorities and part B will choose the top priority of care(Michaud et al., 2013).
Clinical reasoning cycle was introduced in 2012 by the School of Nursing and Midwifery
and was developed by Universities of Western Sydney and Newcastle through an ALTC grant.
Authors of clinical reasoning cycle describe it with five rights of clinical reasoning. They include
reason, time, right cues, patient, and action.
Stages of the Clinical Reasoning Cycle
Consider the patient

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This is Mr. Dinh Nguyen an 83-year-old widower. He was diagnosed with Multiple
Sclerosis (MS) six years ago and was also diagnosed with Osteoarthritis four years ago-now
controlled on medication.
He currently lives alone in his home after his wife passed away 12 months ago. He is currently
undergoing feelings of grief and isolation. He lives an independent life and has noticed a marked
decline in his health with ongoing worsening exacerbations of his MS(Gee, Dalton & Levitt-
Jones, 2015).
Mr. Dinh and his wife Ngoc did not have children and this makes him have no immediate
family. He, however, has a brother, Bao, and family living by but he doesn't want to bother his
family with his life.
Dinh manages superannuation earning him a small income and he is very careful with his money.
This has enabled him the financial independence that only caters to his expenses and goes
for a holiday once a year(Gee, Dalton & Levitt-Jones, 2015).
There are negative consequences associated with the problems facing Dinh and includes;
physical- intracranial bleeding, bruising, lacerations, pain, scratches and other superficial
wounds, fractures, and hematomas (Gee, Dalton & Levitt-Jones, 2015).
Falls sometimes instills fear of falling resulting in; self-imposed limitation to activities,
and commencing a cycle of decreasing functional ability. Dinh did not manage a holiday this
year due to his altered mobility.
He’s been experiencing blurred vision, numbness in his face and an electric shock when
he tries to move his head and neck(Gee, Dalton & Levitt-Jones, 2015). This shock travels his

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back down to the legs which impact his movement and gait severely. The major cause of
blindness experienced by elderly is Age-related macular degeneration (AMD)(Latimer-Cheung
et al., 2013).
He has difficulty in doing chores like cooking, showering, and dressing more particularly
bending to tie his shoelaces.
He has also started experiencing some urinary incontinence.
Dinh has an Immune System deterioration which is a chronic, systematic low-grade
inflammation as a result of influence by chronic anti-genetic stimulation (Gee, Dalton & Levitt-
Jones, 2015).
The risk factors of the age include altered mobility, isolation and falls and risk.
Collect cues/information
Dinh had a history of Multiple Sclerosis (MS) in 6 years and Osteoarthritis four years and
is undergoing feelings of grief and isolation in recent times(Latimer-Cheung et al., 2013). He is
having feelings of some electric shock go through his back to his legs and he is unable to do his
normal cooking, washing, and also dressing now. His disease seems to worsen and he is very
uncertain about his future (Latimer-Cheung et al., 2013). He also feels isolated and grieved over
staying alone since the wife died 12 months ago.
Process information
Isolation and grief are related to overstaying indoor and lack of focus group discussion.
Blurred vision caused by old age or problem with the brain and cognitive impairment

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Identify problems/issues
Dinhs’ problems include;
 Falls and risks
 Altered mobility and
 Isolation.
Part B: Establishing goals
Maintaining the dignity of older people
Falls and risk
Falls are common problems with the elderly with Multiple Sclerosis (MS). Research
demonstrating falls and risks shows that falls rate are more than 50% in every 6 months
period(Lin, Watson & Tsai, 2013). People with MS factors are more risk of fracture than those
who are not MS than those in the same age brackets. They also have an increased risk of fragile
fractures especially hip fracture hazard ratio of 4.08 which is 95% confidence interval [95%
CI]=2.21–7.56)(Kogan, Wilber &Mosqueda, 2016).
Falls increase loss of confidence and it becomes difficult for a person to sustain his or her
usual life roles. However, it should be noted that that, there is limited research done on people
with falls among people with MS. Fear of falls among adults are associated with loss of
independence(Kogan, Wilber &Mosqueda, 2016). To identify those people at greater risk among
people with MS, a therapist working with them should evaluate the key risk factors associated
with falls so as to allow appropriate use of interventions and resources required to minimize
falls(Kogan, Wilber &Mosqueda, 2016). Due to the nature of MS it is important to note that

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environmental, psychological, and physiological factors may lead to falls(Lin, Watson & Tsai,
2013). Research on the risk factors of MS have been given different approaches with some
researchers focusing on investigating factors affecting postural stability, others between 9-12
evaluating specific risks factors for falling(Wong et al., 2014). All these evaluated the risks
associated with falling among people with MS.
Take action
As said earlier falls is are common problems facing elderly with Multiple Sclerosis (MS).
Referring the patients to the physical and/or occupational therapy may actually improve function
and decrease disability(Papastavrou, Andreou&Efstathiou, 2014). Providing the patients with the
time of discussing their feelings and experiences through the use of support groups while
ensuring appropriate and proper use of mobility equipment may be helpful in adjusting to the
changes of life and measuring the disease progression(Tadd, 2017).
Physical exercise reduces falls and should be used to prevent falls(Latimer-Cheung et al.,
2013). According to the National Institute for Clinical Excellence (NICE), older people
healthcare providers should routinely ask whether there are recent falls so that so that those who
report falls may be observed for balance and deficit in gait(Hind et al., 2014). This will help in
improving strength and balance (Gorman, 2017). Older individuals who appear to be at greater
risks of falls should be offered an individualized, multifactorial intervention such as balance
training, vision assessment, home hazard assessment intervention, and medication review among
others(Kogan, Wilber &Mosqueda, 2016).
Dignity refers to the individual ability to maintain self-respect and be valued by other
people(Dewar & Nolan, 2013). Autonomy, on the other hand, is the individual control of

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decision making and other activities concerning their lives(Dewar & Nolan, 2013). In most
cases, the health care settings do not value the autonomy of the elderly.
Evaluate outcomes
Monitoring the total ambulatory walks(Coote, Hogan & Franklin, 2013). This is the total
distance covered in a given time period in patients living environment and is a gold standard for
measuring activities in walking(Bherer, Erickson & Liu-Ambrose, 2013). This is however
limited as it cannot be routinely applied in clinical practices.Dihn is able to walk for a half a
kilometer in one day and he has experienced reduced electric shock in is back and legs.
Dinh is able to share his feeling with people and family members since he was provided
with time to discuss his feelings and experience through support groups and feels no lonely
anymore(Dewar & Nolan, 2013). Measuring the maximum distance walked by a patient by the
virtual of their use of walking aid(Asano & Finlayson, 2014). However, environmental factors
may affect the maximum distance walked hence the wrong characterization of disability levels
progression of the disease(Bherer, Erickson & Liu-Ambrose, 2013). Dinh has been walking
around his home which is a small area, therefore, pausing challenge to measure his progress
when he remains at home(Papastavrou, Andreou&Efstathiou, 2014). The progress in the Dinh
walking abilities and ability to do his normal activities is a significant measure of
outcomes(Bherer, Erickson & Liu-Ambrose, 2013).
Reflect on the process and new learning
Next time I will make sure that the old who are living indoors are encouraged and avoid
the feeling of being isolated and grieved(Asano & Finlayson, 2014). Those whose partners die

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should be encouraged to find friends to talk to avoid feelings of being tired, lonely, isolated and
fearful. I should have given more time to the patient to share their life experiences and find the
friends who can understand and be interested to stay with them(Strauss, 2017). I also know that
physical and mental exercises are important to old people (Bherer, Erickson & Liu-Ambrose,
2013), (Coote, Hogan & Franklin, 2013).
I now understand that people who live lonely life and old are growing with fear and
diseases continue worsening due to their state of mind(Geerligs, Renken, Saliasi,
Maurits&Lorist, 2014). I also know that walking can be a way of measuring the ability of the
body of old people to function well and also to determine the progress in fighting their
disability(Geerligs, Renken, Saliasi, Maurits&Lorist, 2014). If I had enough knowledge of how
many people are going through grieve and is feeling isolated to help them improve their
situations (Heart,&Kalderon, 2013). I now understand long time loneliness and loss of loved
ones has negative effects even to the old.
Conclusion
To maintain the dignity of the older people patients and need to be given adequate
information as well as their caregivers to make informed decisions about care at every stage of
treatment to the end life treatment. Training also for the care providers is paramount to change
their attitude. The fundamental principles of quality health care have been recognized as the
effective communication and information provision to the patient and their caregivers.Older
people are likely to have some issues that affect them in terms of emotions, body movements,
psychological and physical well-being. More especially they are most likely to have difficulty in
walking, dressing, reasoning, etc. They require to be treated By healthcare providers with dignity

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when hospitalized and at home. Proper education to the healthcare providers will be important in
ensuring that they take older people with health issues as not a homogenous group but a special
group of human beings.

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