Levett-Jones Clinical Reasoning Cycle: A Case Study on Nursing Prioritization

This case study discusses the application of Levett-Jones clinical reasoning cycle and Miller’s Functional Consequences Theory in identifying nursing prioritization for an 89-year-old woman with rheumatoid and osteoarthritis, macular degeneration, and hypothyroidism. The study covers the steps of identifying issues, establishing goals, taking action, and evaluating outcomes for pain, impaired physical mobility, and impaired vision. The care plan is considered valid for patients like Amalie.

Case Study
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Introduction:
Levett-Jones clinical reasoning is the important aspect of nursing which is useful for
identifying and prioritising nursing care issues. Levett-Jones clinical reasoning is a stepwise
approach consisting of different steps like considering patient, collecting information,
processing information and identifying problems for prioritising nursing problems. Miller’s
Functional Consequences Theory is applied in identifying these care prioritise. Remaining
four steps in the clinical reasoning cycle are establishing goals, taking action, evaluating
outcomes and reflecting on the case. These four steps can be useful in the planning care and
evaluating outcome of the provided care. In this paper, case of the Amalie is discussed. Using
Levett-Jones clinical reasoning cycle all the information related to Amalie is collected and
also based on the symptoms exhibited by the Amalie and referrals of GP, priority nursing
issues for Amalie are established. Appropriate care planned for the Amalie with respect to the
identified nursing prioritise (Hunter, 2016; Levett-Jones, 2013). Cultural background and
dignity of the Amalie is considered in identifying nursing prioritise and providing care to her.
Consider the patient:
This is case of Mrs Amalie Jones, who is 89 years old woman. She is living alone in a single-
story home. Her husband Henry passed away two years ago. Dominik is her son who lives in
Germany but has been visiting her frequently. Tracy is her daughter who regularly visits her
because she is residing in Australia. Other members of Henry also resided in Australia and
regularly visits her. She was active during her tenure as teacher and fundraising activist
during in local Catholic Church. In last two years her health gets deteriorated as a result she is
not participating in any activities. She has developed dry macular degeneration and also
associated with hypothyroidism, rheumatoid and osteoarthritis. She is not eating properly and
losing weight consistently.
Collect information:
She is experiencing mobility problem due to rheumatoid and osteoarthritis. As a result, she is
not visiting her friends and members of German association. Her doctor is concerned that she
is not eating properly and losing weight consistently. After assessment, her GP stated
symptoms like joint stiffness, swollen feet and enlarged joints, painful joints like knee, hip,
figures and back and limited joint movement. Along with these symptoms, GP also stated
symptoms like constipation, occasional dizziness, vision deficit, non-significant weight loss
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and occasional non-adherence to medication consumption due to pain. She is consuming
medications like paracetamol, ibuprofen, thyroxine and hydroxychloroquine.
Process information:
Her symptoms like stiffness, swelling and pain in the different joints are related to
rheumatoid and osteoarthritis. Both rheumatoid and osteoarthritis are chronic conditions.
Osteoarthritis is more degenerative as compared to the rheumatoid arthritis. Osteoarthritis
occurs due to wear and tear of the joints and rheumatoid arthritis occurs due to inflammation
of joints and autoimmunity also plays role in occurrence of rheumatoid arthritis
(Kourilovitch, Galarza-MaldonadoC and Ortiz-Prado, 2014). Wear and tear mainly occurs
due to degradation and loss of articular cartilage. In rheumatoid arthritis, stiffness, swelling
and pain occurs in multiple joints and in osteoarthritis it occurs in joints like hands, fingers or
knees (Kung and Bykerk, 2014; MacDonald, Sanmartin, Langlois and Marshall, 2014). Due
to both the types of arthritis, Amalie’s almost all the joints exhibiting stiffness, swelling and
pain. Age is the greater risk factor for osteoarthritis. Osteophytes are more common in older
people however radiographic evaluation cannot corelate radiographic severity and pain.
Degeneration of musculoskeletal system and age related anatomical changes are responsible
for osteoarthritis (Abhishek and Doherty, 2013). Her symptoms like constipation and
occasional dizziness might be due to less consumption of food. However, according to GPs
referral her body weight is not reduced despite less consumption of food. With the
development of the disease, patients with rheumatoid arthritis develop loss of weight loss and
appetite loss. However, patients with osteoarthritis doesn’t develop these types of symptoms.
Due to loss of appetite, she is not consuming proper food. Vision deficit is very common age-
related phenomenon due to macular degeneration. It can result, either blurred or no vision can
occur in patients due to damage to macula of retina. Amalie developed dry macular
degeneration which occurs in almost 90 % cases of macular degeneration (Mehta, 2015).
Although she is being consuming her medicines on regular basis, due to consistent pain there
can be emotional disturbance in her. It leads to the non-adherence to the consumption of
medications.
Identifying issues:
Rheumatoid arthritis affects lining of the joints hence it results in the painful swelling. It can
lead to bone erosion and joint deformity. In osteoarthritis, pain mainly occurs due to wear and
tear of joints. Amalie can experience pain during daily activities like pushing, pulling and
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twisting. Continuation of the activities despite pain can worsen the pain and it can worsen
joint deformity. Pain in the arthritis patients can produce fatigue and loss of appetite (Sarzi-
Puttini et al., 2014). Hence, Amalie is consuming less food. Moreover, due to pain she is not
following exact schedule for the consumption of her medications. Painful condition and joint
immobility can also produce impaired physical mobility. Impaired joint mobility can occur in
patients with rheumatoid and osteoarthritis mainly due to stiffness of joints, inflammation of
joints and degenerative joint disease. Both rheumatoid arthritis and osteoarthritis are
responsible for the impaired joint mobility because rheumatoid arthritis mainly occurs due to
inflammation and osteoarthritis occur due to degeneration of joints. Impaired joint mobility
can lead to inability to move body purposefully and inability to perform activities (Shin,
Julian and Katz, 2013; Meeus et al., 2012). Vision loss can occur in Amalie due to macular
degeneration, age related ocular changes and rheumatoid arthritis. It is evident that in patients
with rheumatoid arthritis there can be occurrence of dry eyes (Lim et al., 2012). Pain,
impaired physical mobility and vision loss are the three nursing prioritise selected for Amalie.
Establish goals:
Goals for pain: Amalie will be able to demonstrate improvement in the pain scale from 5 to 3
in one-month period. Amalie will be able to exhibit improvement in mood and coping ability
form the pain in one-month period.
Goals set for impaired mobility are: Amalie will be able to perform activities like bathing,
clothing and cooking independently like other same age people in one-month period. Amalie
will learn to use adaptive and supporting devices to walk and climb the stairs within one-
month period. Amalie will be able to use protective devices to get protected from risk of
injury due to fall within one-month period.
Goals for impaired vision: Amalie will be free of injury due to risk of fall caused by impaired
vision for a period of one month. Amalie will be able to use call light and verbalize help
requirement in one-week period (Gulanick and Myers, 2016).
Take action:
Assess severity of pain in Amalie which can be helpful in the early intervention. Both
medical and occupational therapy can be provided to Amalie for improvement in pain scale
from 5 to 3 in the pain scale of 0 – 10. These scales are more reliable sources of pain which
can distinguish severity of Pain. Evaluate Amalie’s response to pain and plan suitable
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intervention for it. Pain relieving medications and physiotherapy need to be provided to
Amalie. In response to pain, there might be emotional disturbance and mood changes in
Amalie. Mood of Amalie can be improved and coping with pain can be taught by providing
counselling from the psychologist (Walsh and McWilliams, 2014; Durham et al., 2015). It
can be helpful in improvement of self-respect and dignity of Amalie. Her cultural background
considered while providing counselling to her. Assess level of activity in Amalie which can
be helpful in planning suitable intervention. It can also be helpful in identifying potential
barriers, hence suitable supportive devices can be provided to overcome these barriers.
Provide devices like wheelchairs, canes, transfer bars and other assistance devices. These
devices can be helpful in enhancing activity and reducing danger of fall (da Silva et al.,
2015). Demonstrate use of call light to patient. Call light can be useful in alerting nurse,
hence there are less chances of fall due to impaired vision and risk of injury (Elliott,
McGwin, Kline and Owsley, 2015).
Evaluate outcomes:
It has been observed that there is improvement in the pain scale in Amalie from 5 to 3 n pain
scale by integrated intervention of pain medications and physiotherapy. It is evident that as
compared to the individual intervention of pain medication or physiotherapy, integrated
intervention can exhibit more effect. Moreover, there is improvement in the mood of Amalie
and her coping ability for the pain. Pain is the subjective parameter and its sensitivity can be
effectively reduced by improving positive attitude and coping ability of the patient (Sarzi-
Puttini et al., 2014; Walsh and McWilliams, 2012). Amalie started performing all the
activities of daily living independently and acquired required skills for the utilization of all
the assistance devices. As a result, she is using all the devices comfortably and there is
reduction in the fall frequency of Amalie. Older people are at higher risk of fall injury;
however, with the use of assistance devices fall frequency and related injury can be
effectively reduced in the older people (Akese, Adejumo, Ilesanmi, and Obilor, 2014; Krist,
Dimeo and Keil, 2013). Amalie learned use of call light and she is using it effectively. Hence,
she can avoid vision problem and take assistance of nurse in performing her daily activities.
Use of call devices proved to be useful in reducing fall risk in patients with impaired vision
(Dev, Paudel, Joshi et al., 2014).
Reflection:
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I now understand that rheumatoid arthritis, osteoarthritis and macular degeneration can
adversely affect activities of daily living in patients. Hence, it is necessary to provide them
with support and train these patients to carry out their activities. I had more knowledge about
rheumatoid arthritis and osteoarthritis, I would have understood the impact these conditions
on activities of daily living in patents. It is well established that support for the daily activities
of these patients in the early stage can reduce burden disease on patient. I now understand
that pain can have both physical and emotional disturbance in the patient. I would have
initiated psychological counselling in patient in the early stage of care (Carpenito, 2013).
Conclusion:
Using Levett-Jones clinical reasoning cycle and Miller’s Functional Consequences Theory,
information related to Amalie’s condition like rheumatoid arthritis, osteoarthritis, macular
degeneration and hypothyroidism is collected. Based on the collection of information and
processing of information, three cares prioritise like pain, impaired physical mobility and
impaired vision are the three cares prioritise identified. For each of these cares prioritise,
goals were set. Based on the established goals, actions were taken for assessment and
provision of care. In pain management, severity of pain is reduced and mood of Amalie
improved due to reduction in pain. In impaired physical mobility management, Amalie
performing daily activities independently and using assistance devices effectively. In
impaired vision management, Amalie learned to use call light and reduced frequency of fall.
Hence, it proved that application of Using Levett-Jones clinical reasoning cycle and Miller’s
Functional Consequences Theory in older people like Amalie is useful in providing stepwise
approach for providing effective care to the patient. Since, all the steps taken in the
established framework, this care plan can be considered as valid plan for patients like Amalie.
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