NRSG 259: Clinical Reasoning Cycle in Geriatric Care - Amalie Jones

This case study focuses on applying the clinical reasoning cycle to develop a comprehensive care plan for Amalie Jones, an 89-year-old woman with multiple health issues including macular degeneration, rheumatoid arthritis, and mobility restrictions. The assignment utilizes Miller's Functional Consequences Theory to prioritize her psychological, emotional, and spiritual needs alongside her physical health. The clinical reasoning cycle is employed to assess Amalie's situation, collect relevant cues, process information to identify key problems such as vision deficit, limited mobility, and dizziness, and then establish appropriate nursing interventions. These interventions include exercises to improve balance and strength, creating a safe environment to prevent falls, and educating Amalie on safety measures and energy-saving techniques. The care plan emphasizes maintaining Amalie's dignity and considering her cultural background throughout the assessment and care provision. The reflection on the care process highlights the importance of family engagement and energy conservation techniques for future care plans. Desklib offers a variety of similar case studies and resources for nursing students.

Running head: CLINICAL REASONING CASE STUDY
Clinical reasoning case study
Name of the student:
Name of the university:
Author note:

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Table of Contents
Introduction:....................................................................................................................................2
Part A:..............................................................................................................................................2
Part B...............................................................................................................................................5
Conclusion:......................................................................................................................................7
References........................................................................................................................................8

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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, sorting the information, processing the information, identifying care needs,
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

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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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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 her vision deficit, which can be a significant safety risk and fall
risk that can lead to her injury. The second care need is her limited mobility and joint stiffness

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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 her occasional dizziness which 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

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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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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 interventions appropriate for 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.

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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
program on clinical competence in nursing students. Korean Journal of Adult
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
programs as a patient safety strategy: a systematic review. Annals of internal
medicine, 158(5_Part_2), 390-396.

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Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2014). Nursing Outcomes
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-related macular
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.