Promoting Health in Extended Care

This article discusses the case of an 89-year-old woman named Amalie who is exhibiting impaired physical mobility due to rheumatoid and osteoarthritis, macular degeneration, hypothyroidism, and non-adherence to medication consumption due to pain. Levett-Jones clinical reasoning and Miller’s Functional Consequences Theory are used to identify nursing priorities, set goals, take action, and evaluate outcomes. The nursing priorities identified are pain, impaired physical mobility, and impaired vision. The article concludes that implementing these theories in nursing care for older patients can provide comprehensive care.

Promoting Health in Extended Care
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Introduction:
Levett-Jones clinical reasoning and Miller’s Functional Consequences Theory are important
in nursing because these give systematic method to provide nursing intervention to the
patient. Levett-Jones clinical reasoning comprises of phases such as consideration patient
situation, information collection, information processing and identification of nursing
problems in prioritising nursing care. All these steps are useful in identifying nursing care
prioritise. Other steps of Levett-Jones clinical reasoning include establishing goals, taking
action, evaluating outcomes and reflecting which can be helpful in providing care with
respect to the identified nursing prioritise. In this paper, case of old patient named Amalie is
being discussed. For identification of the nursing prioritise and providing care all the steps of
Levett-Jones clinical reasoning and Miller’s Functional Consequences Theory are followed
(Hunter, 2016; Levett-Jones, 2013; Berman et al., 2015). In older people, other than medical
treatment other aspects like psychological, cultural and social factors need to be considered.
Hence, cultural related factors are considered and self-esteem of the Amalie is maintained
during care.
Consider the patient:
Mrs Amalie Jones is 89 years old woman. She is living alone in a single-story home because
her husband Henry passed away. Dominik is her son and Tracy is her daughter. They
frequently visit her. She worked as teacher and also as fundraising activist for local Catholic
Church. However, since last two years she is not working due to her health issues like
macular degeneration, hypothyroidism, rheumatoid arthritis and osteoarthritis. She is losing
weight because she is not taking proper diet.
Collect information:
She is exhibiting impaired physical mobility due to rheumatoid and osteoarthritis. Her doctor
mentioned that she is losing weight because she is not taking proper diet. Her GP assessed
her and stated symptoms like constipation, occasional dizziness, vision deficit, non-
significant weight loss and occasional non-adherence to medication consumption due to pain.
She is on medicines like paracetamol, ibuprofen, thyroxine and hydroxychloroquine.
Process information:
She is exhibiting symptoms like stiffness, swelling and pain in joints. All these symptoms are
related to rheumatoid and osteoarthritis. These arthritic conditions are chronic conditions and
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mostly occur in the older age people (Miller, 2015). More degeneration of joints occurs in
rheumatoid arthritis as compared to the rheumatoid arthritis. More degeneration occurs in
osteoarthritis because wear and tear of joints. On the other hand, inflammation and
autoimmunity plays major role for the occurrence of rheumatoid arthritis (Kourilovitch,
Galarza-MaldonadoC and Ortiz-Prado, 2014). Wear and tear of joints mainly occurs due to
degradation and loss of cartilage. Majority of the joints are involved in rheumatoid arthritis,
while hands, fingers and knees are involved in the osteoarthritis (Kung and Bykerk, 2014).
As both rheumatoid and osteoarthritis exists in her, most of her joints get affected.
Osteophytes exists in older age and these are responsible for osteoarthritis in older people. In
addition to this, age related anatomical changes in joints and degeneration of musculoskeletal
system plays important role in osteoarthritis (Abhishek and Doherty, 2013).
Amalie is not consuming proper food; hence it can alter her nutritional status. It can lead to
constipation, fatigue and dizziness in Amalie. It is evident that rheumatoid arthritis patients
consume less amount of food with the progression of the disease. Hence, she might be
consuming less amount of food due to loss of appetite. Macular degeneration can occur in old
people like Amalie and it can lead to loss of vision. Blurred or no vision are the signs of
macular degeneration which occurs due to damage to the macula of retina. Macular
degeneration can occur in two forms like wet and dry degeneration. Dry macular
degeneration can occur in majority of the patients and in Amalie also dry macular
degeneration occurs (Mehta, 2015). She used to consume medications on regular basis,
however due to pain, there is change in her emotional status. Hence, she is not consuming
medications on regular basis.
Identifying issues:
Pain mainly occurs in Amalie due to inflammation of lining of joints in rheumatoid arthritis
patients. Inflammation of lining of joints can lead to bone erosion and joint deformity. Pain
occurs in osteoarthritis patients due to wear and tear of joints. It leads to insufficient activities
in Amalie like pushing, pulling and twisting. Moreover, continuous activity can produce
stress on joints and it can worsen joint pain and lead to joint deformity. Due to pain, there can
be loss of appetite in Amalie, hence she is consuming less amount of food (Sarzi-Puttini et
al., 2014).
Pain also resulted in non-adherence to medicine consumption in Amalie. Impaired physical
mobility can occur in Amalie due to stiffness of joints, inflammation of joints, pain in joints
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and degenerative joint disease. Hence, impaired physical mobility can occur in Amalie due to
rheumatoid arthritis and osteoarthritis (Shin, Julian and Katz, 2013). Vision loss in Amalie
occur due to macular degeneration, age related ocular changes and rheumatoid arthritis. It is
evident that rheumatoid arthritis can produce dryness of eye (Lim et al., 2012). After
following steps like collection of information, analysis and processing of information of
Levett-Jones clinical reasoning, three identified nursing priorities of Amalie are pain,
impaired physical mobility and vision loss.
Establish goals:
Goals for pain: There will be improvement in pain scale in Amalie from 3 to 2 in two-month
period. There will be improvement in mood and coping ability as a result of pain in Amalie in
two months period.
Goals set for impaired mobility are:
Amalie will perform all her activities independently in two-month period. Amalie will
acquire skills to use supportive devices which are useful to walk and climb the stairs in two-
months period. Amalie will learn to use protecting devices to get protected from fall in two-
month period.
Goals for impaired vision: There will not be fall of risk in Amalie due to impaired vision in
two months period. Amalie will be able to use call light and verbalize her wish to seek
assistance in two weeks period (Gulanick and Myers, 2016).
Take action:
Assess severity of pain in Amalie. Pain severity assessment can useful in planning effective
intervention plan for her. Practice both medication and occupational therapy for Amalie
which can be helpful in reducing degree of pain on the pain scale. Pain scale is the valid
measure for differentiating severity of pain. Evaluate physical and psychological response of
Amalie to the pain severity. It is useful to provide appropriate nursing care to her. Emotional,
behavioural and mood related alterations can occur in Amalie due to pain. These signs can be
effectively managed by providing psychological counselling to Amalie (Walsh and
McWilliams, 2014; Durham et al., 2015). Through this counselling, there can be
improvement in the dignity of Amalie and her self-esteem can be maintained. Cultural
variations can influence psychological interventions like counselling. Hence, her cultural
aspects need to be considered while providing counselling to her (King and Hinds, 2012).
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Assess her ability to carry out activities of daily living. Through its assessment, effective plan
can be implemented for Amalie to improve her activity level and to support her in activities.
These assessments can also be helpful in identifying possible barriers and hurdles to perform
routine activities. Teach Amalie to use supportive devices like wheelchairs, canes and
transfer bars and monitor her for its usage. It can be helpful in reducing fall of risk and
improving her activities of daily living (da Silva et al., 2015). Teach Amalie to use call light
which can be useful in the management of vision impairment in Amalie. By using these call
lights, risk of fall in Amalie can be reduced (Elliott, McGwin, Kline and Owsley, 2015).
Evaluate outcomes:
There is improvement in the pain scale from 3 to 2 in Amalie after implementing both
medication and occupational therapy in Amalie. Synergistic effect of medication and
occupational therapy can be heightened as compared to the individual therapy. In case of
Amalie also, same results were obtained for the management of pain. There is improvement
in the psychological and behavioural aspects of Amalie. Her mood and coping ability for pain
are improved. Psychological aspects can impact pain sensitivity. Hence, it is necessary to
monitor psychological and behavioural alterations in Amalie to get valid results in the pain
management (Sarzi-Puttini et al., 2014).
Amalie acquired skills to use supportive devices, hence there is improvement in the activities
of daily living in Amalie. As a result, there is decline in the frequency of fall in Amalie. In
the literature, it is evident that fall frequency and risk of injury can be effectively reduced in
older people like Amalie by using assistance devices (Krist, Dimeo and Keil, 2013; Matzo
and Sherman, 2014). Amalie learned to use call light and she is using it accurately. By using
these call lights, she is eliminating vision impairment problem by calling nurse for assistance.
It is evident in the literature that fall frequency and injury risk gets lessened by use of call
light in vision impaired patients (Dev, Paudel, Joshi et al., 2014).
Reflection:
For the first time, I learned that arthritic conditions and impaired vision in people can
adversely affect their activities. Hence, I taught her to use these supportive devices and
monitored its use. I got confidence that by using these devices, stress due to routine activities
can be reduced in these patients. If I would have more knowledge about these disease
conditions in older people, I would have provided her these devices in the initial stage of the
intervention. It is evident from the literature that providing assistance devices in the earlier
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stage of intervention can improve signs and symptoms of arthritis and reduce fall of risk. I
learned that integrated intervention comprising of medical, physical and psychological
aspects for pain management can improve patient condition. I should have implemented
psychological counselling in Amalie in the initial period of nursing intervention (Carpenito,
2013).
Conclusion:
Levett-Jones clinical reasoning cycle and Miller’s Functional Consequences Theory are
implemented in Amalie’s case. All the steps in clinical reasoning are incorporated to collect
information related to the health issues of Amalie like rheumatoid arthritis, osteoarthritis,
macular degeneration and hypothyroidism. Based on the collected information and after
processing this information; three nursing prioritise identified like pain, impaired physical
mobility and impaired vision. Goals of care were decided based on the nursing prioritise.
Nursing actions were designed for each of the goals and actions were taken for the
assessment and intervention of Amalie. Evaluation outcomes were measured both
qualitatively and quantitatively. Pain is reduced in Amalie and as a result mood and coping
ability for pain augmented in Amalie. There is improvement in the performance of daily
activities and learning of assistance devices; resulted in reduction in fall frequency and risk of
injury. Amalie also learned to use call light and intimate nurse for assistance. Case of Amalie
clearly states that execution of Levett-Jones clinical reasoning cycle and Miller’s Functional
Consequences Theory in care of older patient like Amalie can provide comprehensive care.
Such type of care can be considered as the vital care for older people because all these steps
are scientifically validated in numerous studies.
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