Clinical Reasoning Cycle: Improving Care for Geriatric Fall Risk

This essay critically reflects on a clinical decision-making case study involving a 70-year-old patient, Mrs. Mariam, admitted for a pelvic fracture after a fall. The essay employs the clinical reasoning cycle to analyze the situation, focusing on data collection, problem identification, goal setting, and intervention. It addresses the patient's history of hypertension, light-headedness, and anemia, alongside post-operative care and pain management. The analysis includes a comparison of HAAD and JCI guidelines, recommendations for minimizing fall risk, and reflections on the decision-making process, aiming to improve patient outcomes and prevent future complications. The student document is available on Desklib, a platform offering a range of study tools and resources for students.

Running head: CLINICAL REASONING
Clinical Reasoning
Name of Student
Name of University
Author Note

1CLINICAL REASONING
Introduction
The second highest causation of morbidity and mortality rate amongst the
general population is observed to be falling, succeeding road related
accidents. Major injuries and mortality rates are caused by severe cases of
falling and in other cases the patients become incapacitated, burdening their
family members and community members (Grivna, Eid& Abu-Zidan, 2014).
The Centres for Disease Control and Prevention (CDC), published
records that show head and bone injuries are now a major cause of
hospitalization caused by falling. Over 700,000 people annually get admitted
in the hospital due to falling with head and hip fractures. More than 95% of
hip fractures, additionally are caused due to falling, more often in women
than men (CDC, 2016). According to the estimation provided by world health
organization (WHO), 28-35% of falling occurs in geriatric patients, over 65
per year (WHO, 2016). It is estimated that the world’s geriatric population is
increasing faster than the young population, reaching 841 million in 2013.
This rate has quadrupled its value after 1950. Census estimation showed
that, by 2050, the geriatric population will multiply three times, increasing
the rate of falling amongst them and if preventive measures are not
undertaken in time. This will increase the burden of care in healthcare
facilities (United Nation, 2013).
The process of clinical decision making cycle is described as the
process by chich the nursing staff will deicide from options of planning which

2CLINICAL REASONING
is relevant to the patient. The individual decisions are different depending on
patient situation (Thompson, Aitken, Doran &Dowding, 2013). Component of
decision making is based on a model approach called DECIDE. The model
adheres to understanding of the problem, setting criteria, alternative
analysis, identification of the best suitable option, care plan development
and evaluation of the decided plan of care. It is important to focus on
decision making to establish as a nursing staff quickly affecting the care for
patient and receiving safe outcome for patient (Guo, 2008). The paper
discusses the risk related to falling association with fractures and injuries in
geriatric patients, comparing the HAAD and JCI guidelines of standard
practice relevant to the issue, demonstration of clinical reasoning cycle
understanding, application of the cycle relevant to the situation and
providing recommendation as well as interventional techniques to minimize
the risk of falling, followed by a conclusion.
Fall related fractures and risk factors
The definition of fall, given by WHO is “unintentional event where the
person will come to rest in the ground or the floor excluding the intentional
change of position to rest in the furniture” (WHO, WHO global report on falls
prevention in older age, 2007). Geriatric patients who live in care homes of
nursing facilities have more tendencies of falling than others living with a
community (WHO, WHO global report on falls prevention in older age, 2007).
There are four dimension of risk factors associated with falling which are

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related to biology, behaviour, socio-economy and environment. Factors
affecting biology are risk factors which cannot be improved in geriatric
patients over 65 years, cognition, physical ability as well as chronic diseases.
Influence of behaviour is dependent on external factors like substance abuse
of drugs and alcohol, sedentary lifestyle and footwear issues. The third
dimension is related to factors influencing environment, associated with
other factors like wet floors or staircases, dim lights, rough and bumpy roads
and footpaths et cetra. Lastly, the factors influenced by socio-economic
factors, like less income in family, illiteracy, health care inaccessibility, lack
of housing and interaction with other people (WHO, WHO global report on
falls prevention in older age, 2007). Hips fracture is commonly associated
with light-headedness complaint from the fall patients along with posture
instability and distress. It was observed in a sstudy in 2013, Brazil that light-
headedness was a common complaint among 45% of geriatric patients and
amongst them women were reported to be 71.6% (Suzana Albuquerque de
Moreas, Wuber Jefferson de Souza Soares, Eduardo Ferriolli & Monica
Rodrigues Perracini, 2013). The HAAD standards and Joint commission
international (JCI) regarding geriatric patients are discussed in the following
section
HAAD and JCI standards
The governing body of HAAD amongst the sectors of healthcare is present in
Abu Dhabi. The facility has the aim to provide excellent healthcare facility to

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the population and revive their safety. The JCI on the other hand strives to
achieve improvement on the quality of care and sfety of the patient in
healthcare facilities. Their standards of guidelines number six state that to
minimize the risk of safety of patient goals are to be set to prevent falling
incidents. The JCI, 2015 published sentinels to alarm the risk factors
associated with falling in a health care settings. Credibility of such incidents
are to be taken by the authority (Zhani, 2015)
Clinical reasoning cycle
The definition of clinical reasoning is as follows, “process whereby nurses will
collect cues, process the information, identify the problem and patient
situation, plan and implement the interventions, evaluate the outcomes,
reflect on and learn from the process”. the importance of clinical reasoning is
relevant to nursing to improve the patient conditions and achieve better
outcomes. Early recognition of condition is facilitated by clinical reasoning
cycle application as well as minimizing the risk that can jeopardise patient
outcome. Combination of more than one standard is possible using this cycle
(Jones, 2013). The following paragraph describes the steps associated with
clinical reasoning cycle.
1. Consider the patient situation
The case study is about a patient named Mrs. S. Mariam, who is 70 year old.
She was admitted in the emergency unit in 2 May 2016. The cause of
admission was because she has slipped and fracture her pelvic on the left

5CLINICAL REASONING
while inside the house. The patient’s daughter informed that Mrs. Mariam
had been facing light-headedness for three months prior to the incident and
her admission. The patient has a previous history of hypertension but no
history of surgery. Mrs. Mariam is currently wedded, dwelling in Abu Dhabi
along with her husband and family whom she is very close with.
2. Collect cues / Information
This stage of clinical reasoning has three segments that is required to be
followed. The foremost segment is to review the information at hand. The
patient has a medical history of hypertension for the past 25 years. She
complained of having dizzy feeling but neglected it for the previous three
months along with cerumen impaction in both ears. Analysis of vital signs of
the patient showed that her blood pressure (BP) was 150/70 and pulse in the
periphery was 88 beats per minute (BPM), respiratory rate of 16 breaths per
minute and oxygen saturation (SpO2) of 99%. The patient is currently taking
5 mg of amlodipine to treat her hypertension, 16 mg of betahistine for
treatment of vertigo, for cerumen impaction treatment, she takes docusate,
40 mg enoxaparin for anticoagulation. 0.5mg alprazolam for sleeping and
nalbuphine 10 mg as needed. On the 1st of march 2016, the patient’s blood
test was taken which reflected that her red blood cell count was quite low;
3.14, haemoglobin was 81, hematocrit count was 0.250 mean corpuscle
volume- 79.6, mean Hb corpuscle- 25.8 and mean platelet vlloum was 12.3.
the x-ray scan was done for femur, spine lumboscaral, pelvis and hip on the

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right side on the 2 May 2016. Analysis of the report showed presence of
fracture in the intertrochantric femur and lumbar scoliosis on the right side.
Surgery was decided to be done on the 3 may 2016 on the left side femur
utilizing Intermedullary (IM) nailing method. Preceding the operation the
patient was observed to high BP and Hb count decreased from 8 to 7. The
patient was administered with two units of blood bag that same day. A
second round of blood test was done on the patient to understand the cause
of Hb declination that became 10g/L after blood transfusion. Physiotherapy
was recommended to the patient for managing ache, complication aversion
and exercise. The next step is to accumulate fresh data, after assessment
the patient signs of proper cognition and her Glasgow coma score were
15/15. Mephore dressing covered her right leg which underwent surgery and
she read 20 on Braden scale. The morse scale showed her risck of falling was
70 and her 20 canula gauge was placed in the right hand which is covered
with crepe bandage along with Foley’s catheter insertion. The Wong Baker
faces scale showed 4/10 pain score. The last segment is the recollection of
found data; Mrs. Mariam, risk high from falling with a Morse score of 70. She
showed anaemic symptoms due to lowering of components of blood. She had
high blood pressure postoperative condition along with normal pain
threshold, cooperative and stabilized vital signs.
3. Process Information
This stage with regard to the patient situation is considered to do
interpretation, discrimination, relation, inference, matching, prediction, and

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analysis. Interpretation; except the MPV, all other blood components like Hb,
RBC, Hct, MCH and MCV were found to decrease. This shows that the patient
was showing anaemic symptoms. The Morse fall score showed that it was
very risky for Mrs. Mariam to fall but Braden score was normal. Considering
that the patient underwent surgery, the pain score was plausible.
Discrimination; the immediate priority is to lower the Morse fall score, vertigo
and pain score. Relation; cerumen impact could be the result of vertigo and
light-headedness in the patient’s case. Pain can induce high BP. Inference; in
light of the recent events, it can be inferred that the patient is to be kept
under strict monitoring to avoid any postoperative complication or issues
related to prolonged bed rest. Reassessment is important to check for pain
threshold to ensure proper medicine efficacy. Physiotherapy rehabilitation
was recommended to her by the doctor. Matching; comparing with another
similar case of a female patient showed same postoperative symptoms but
did not undergo IM. Although the operation was successful, the showed
anemic symptoms and high BP along with a development of fall anxiety.
Prediction; it is essential to ensure effective pain management as to avoid
wound healing delay, immobilization repercussions like ulceration, deep vein
thrombosis. Blood transfusion is referred if other signs of blood loss are
noticed. A research conducted in 2014 by the World Journal of Orthopaedics
(WJO), shows that anaemic symptoms, loss of urine retention, pressure scars,
hospital acquired pneumonia, DVT, cardiac arrhythmia and postoperative
delirium along with gastrointestinal bleeding is common is cases of hip

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fracture surgery (Carpintero, Caeiro, Carpintero, Morales, Silva & Mesa,
2014).
4. Identify Problem
It is essential to bring about all the clinical data to formulate a summary of
the patient condition. The three primary diagnosis of nursing was carried out
keeping the patient’s age, gender and family support. Diagnosis for pain
management is the first priority with respect to the condition of the surgery
and pain score report along with motor skill assessment, nutrition, sleep
assessment and administration of analgesics repeatedly. The next diagnosis
is to provide physiotherapy to improve the patient’s mobility post surgery
and check for ache manifestations along with motor skill assessment. The
third diagnosis is to avoid falling risk post surgery, light-headedness which is
common for people her age.
5. Establish goals
It is necessary to make sure that the patient suffers no lingering post
surgical ache, immobilisation issues, complications, wound healing delay,
health restoration and dependency issue, activity assessment, cognition
assessment and to make sure patient is aware of the repercussion of old age
falling to avoid further complications.
6. Take an Action
My preceptor and I thought through interventional method that could be
undertaken which would help the patient safety. The PQRST technique was

9CLINICAL REASONING
applied to assess the pain which was also the foremost intervention to
improve the patient’s health. Risk factors that would enhance the pain were
assessed; sharp aching sensation radiating in the entire right limb (4/10) was
initiated when the patient’s position was shifted. Additionally, preventive
measure to avoid falling was implemented with regards to the
recommendation of HAAD policy. The measures were; lowered position of the
bed, elevated side rails, personal items and calling bell kept within hands
distance to the patient, night lights provided and the bed-wheels were
locked. Constant monitoring of vital signs was maintained as per the norms
of the hospital. Administration of analgesics to manage pain, enoxaparin for
anti-coagulation to avoid DVT, amlodipine for BP regulation was provided.
Physiotherapist was able to mobilize her using wheel chair and prevent
complication.
7. Evaluation
The nursing goals were partially fulfilled before completed before discharge
planning was commenced. The patient’s pain level was null at resting phase
but reached with 2 when mobilised. She was discharged with consent and
referred to a care facility. Patient and her family were engaged throughout
the care plan and were taught about the condition during discharge to
ensure no medication or patient safety occurred post discharge. They were
also informed about the common physiological malfunctions that elderly
people go through to help care for her more precisely.

10CLINICAL REASONING
8. Reflection
I will be using the Rolfe reflective model to express my thought regarding the
case study and answer three main questions: What?, So what? and Now
what?. Answering to the first query; Mrs. S. Mariam is a married elderly 77
year old woman living in Abu Dhabi with her family who fell own at home anf
got a fractured pelvis. She has admitted to the facility and diagnosed with
extracapsular hip fracture on the right side and a medical history of
hypertension which persisted for more than 25 years. My preceptor and I
were the designated nurses given to take care of her. I tried to maintain her
safety and applied preventive measures against falling along with nursing
support o reduce her distress. I tried the application of massage in the
affected area and spoke through her care to reduce pain and distress non-
pharmacologically. The act was appreciated by my preceptor as according
to her emotional support helps patients overcome their recovery faster. I was
empathising for her situation and provided pain medication along with
emotional support. Answering to the question So what?; If I had let the
patient carry on suffering with her pain, she would have been unable to
receive slumber, move properly and intake less food. All this would have
affected her condition and the healing span would have been lengthened.
Thirdly, Now what?; I received praising from my preceptor who pointed out
that my care plan for her was successful as we were regarded the norms of
the HAAD guidelines for patient safety and helped her calm her aching
sensation that lead to her proper motor functionality like using the toilet,

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eating and getting used to the wheel chair et cetra. The only dispute worth
mentioning was the inefficiency of the nursing team. The workload could
have been reduced if the fellow staffs cooperated to reduce pressure. Good
team work would have helped the patient improve faster in a safer manner.
Recommendations
Keeping a goal to achieve patient safety ensures better health concern and
minimizes the risk of hospital readmissions amongst the old aged people.
Patient safety should be the focus of the care plan along with including the
family ensures improvement of patient’s quality of life. Patient as well as
family education is important to ensure no disparity in the support system.
Encouragement should be provided to care givers to note down the
implication of adverse threats, which would help the care facility opportunity
to provide proper assessment and improve acre management in times of
error. Contemplation, foreseeing and double checking is importance before
any decision is made so as to reduce patient safety risk.
Conclusion
Summation of the discussion, provide insight that the primary reason for
hospital admission is falling. Women are commonly observed to be admitted
in the hospital than men, when it comes to hip or bone fractures. Geriatric
show a common reasoning for hospital admission that is light-headedness
along with other risk factors as a resultant of falling anf other bone injury.