Nursing Assignment 366: Applying Clinical Reasoning to Patient Care

This report presents a comprehensive analysis of a nursing case study involving a 52-year-old male, Peter Mitchell, diagnosed with morbid obesity, type 2 diabetes, and associated comorbidities. The assignment focuses on applying the Levett-Jones clinical reasoning cycle to prioritize patient care needs. The report details each stage of the cycle, including assessment, cue collection, information processing, problem identification, goal setting, care planning, intervention implementation, and evaluation. The primary nursing priorities identified are weight reduction and glucose level control, with the report outlining both pharmacological and non-pharmacological interventions such as dietary modifications, exercise plans, smoking cessation strategies, and medication management. The analysis emphasizes the interconnectedness of obesity and diabetes and the importance of holistic, evidence-based nursing care to improve patient outcomes. The essay also includes a reflection on potential barriers to implementing the care plan, such as the patient's low self-esteem, and strategies to address these challenges, like cognitive behavioral therapy. The report concludes by highlighting the critical thinking skills developed through the clinical reasoning cycle and the effective design of nursing care plans.

Running head: NURSING ASSIGNMENT 366
Nursing assignment 366
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NURSING ASSIGNMENT 366
Case study 1
Nursing care delivered to the patients with chronic illness needs to address multiple
factors. Chronic illnesses like obesity and diabetes are known to be multifactorial disease and are
associated with various comorbidities. It thus greatly influences the patient health outcomes. It is
important for the primary care nurse to prioritise the care based on patient and the clinical needs.
It is the integral par of the daily nursing practice to prioritise the patient’s need of care. Nursing
interventions can be effectively delivered when collaborating and intergrading the various
aspects of the patient’s needs. It helps to maximise the care activities. This process requires
nurses to have clinical reasoning and decision making skills (Gee, Dalton & Levitt-Jones, 2015).
The essay deals with the case study of Peter Mitchell, 52 year old male with morbid obesity and
type 2 diabetes. In regards to the case study the essay presents the priorities of care while applying
the Levett-Jones clinical reasoning cycle.
Clinical reasoning cycle revered by Jones, is the tool to develop goal driven patient care
through a systematic process of considering many contributing and predisposing factors. There are 8
stages in this cycle. The first stage involves considering the patient’s situation (Gee, Dalton &
Levitt-Jones, 2015). In the given case study, Peter Mitchell is a 52 year old male was admitted to
hospital with morbid obesity and type 2 diabetes. The patient was noted with obesity ventilation
syndrome, sleeps apnoea and poorly controlled diabetes. He was referred by his GP after presenting
the symptoms of diaphoresis, increased hunger, and symptoms of shakiness, high BGL levels and
difficulty breathing whilst sleeping. The second stage of the clinical reasoning cycle is collecting
cues and information. It refers to reviewing the patient’s current medical history and collecting
specific information on the present activity treatment (Gee, Dalton & Levitt-Jones, 2015). The
history of the patient highlights Peter as smoker for past 30 years Peter was reviewed by

NURSING ASSIGNMENT 366
physiotherapist and recommended light exercises His dietician recommended for low energy and
high protein diet for weight loss. Medical history the patient includes depression diagnosed three
months, hypertension, obesity, sleep apnoea, gastro oesophageal reflux disease. Social history of the
patient reveals loss of job, significant weight gain and embarrassments due to weight gain. Social
isolation, poor performing activities of daily living, may be associated with his illness and weight
issue.
The third stage of the clinical reasoning cycle is processing information to recognise the
changes related to past health condition, predict outcomes recognise need of immediate
intervention (Gee, Dalton & Levitt-Jones, 2015). In case of Peter the fatigue may be associated
with his high weight. Reduced physical activity may be due to unemployment. It increases risk
for apnoea and other health conditions. Obesity and diabetes pose risk for cardiovascular disease
as the patient also has hypertension. His social isolation and health deterioration may have
increased the depression (Choi & DiNitto, 2014).
The fourth stage of the clinical reasoning cycle is the identification of problems and issues.
These processes require examining the fact and then establishing definitive goals ( Gee, Dalton &
Levitt-Jones, 2015). As per the case study Peter with height 170 cm and weight 145 kg indicate
obese. Obesity is confirmed or diagnosed in a person when the BMI is more than 30. In case of
patient the BMI is calculated to be 50.2 and is indicating very high obesity (Mark & Somers,
2016). The patient has presented in hospital with the ventilation syndrome and sleep apnoea.
Both the symptoms exist together in the patients diagnosed with obesity. The ventilation
syndrome is the breathing problem in obese patients resulting in low oxygen levels. It results in
obstructive sleep apnoea, where an individual stops breathing for short intervals when sleeping.

NURSING ASSIGNMENT 366
Sleep apnoea is caused by the obstruction to the upper airway that caused repetitive episode of
shallow breathing (Heymsfield & Wadden, 2017). These conditions occur as the adipose tissue
increase in excess amount in the obesity. It restricts the movement of the chest muscle and the
diaphragm. Therefore, respiratory muscles are easily fatigued. Excessive adipose tissue in the
neck and head area, inhalation and exhalation is slowed. Hypertension also occurs with increase
in heart rate due to increasing vascular resistance caused by excess fatty tissue (Mark & Somers,
2016). Observations on discharge highlighted an increase in respiratory rate and the blood
pressure. Hypertension in the patient is evident, and is known to contribute to diabetes.
Obesity increases the body’s ability to control glucose level by insulin production, and
consequently results in diabetes. Uncontrolled diabetes is associated with the increase in appetite,
diaphoresis, high blood glucose level and shakiness (Imamura et al., 2015). Unusual sweating is
known as diaphoresis and is common in overweight individuals. Diabetes patients are also prone
to excessive sweating and dehydration during low blood glucose level (Imamura et al., 2015).
Hypertension is influenced by both obesity and uncontrolled diabetes in Peter. Therefore, all the
symptoms observed in Peter has direct link with obesity and uncontrolled diabetes and thus are
major health issues. These symptoms share a common pathway in fact interrelated, which
justifies the clinical reasoning. The same is evident from the vital signs and symptoms presented
by Peter.
The fifth stage of the clinical reasoning cycle is the establishment of goals; this phase
includes making realistic and comprehensive nursing care plan within timeframe (Gee, Dalton &
Levitt-Jones, 2015). The first goal/priority is to reduce weight and control obesity symptoms.

NURSING ASSIGNMENT 366
The second goal/priority is to reduce glucose level and control diabetes. The care plan will
involve both pharmacological and non-pharmacological interventions.
In order to fulfil the nursing goals the plan of care will be carried out which, is the sixth
stage of the clinical reasoning cycle (Gee, Dalton & Levitt-Jones, 2015). In relation to
controlling weight, a diet plan will be formulated upon collaborating with dieticians. There is a
need of decreasing the fat consumption and increase protein uptake. Realistic weight loss plan
will be set for Peter on a weekly basis. Further, an appetite reduction plan will be developed to
track if signals of hunger are ignored or distorted (Sargent et al., 2012). There are several
benefits of weight reduction in obese patients. It will improve the overall quality of life. A
weight loss of 10 kg can reduce the cholesterol and hypertension. It will help achieve the
recommended target of blood pressure (Nanditha et al., 2016). The next strategy is the physical
activity. It is the modest method to reduce the weight by 1 kg each month. It is helpful in
increasing the metabolic rate and improves self esteem. Since the patient has type 2 diabetes, he
will be supported to participate in 30 minutes of moderate physical activity. It can be gradually
accumulated if participated for five days in a week. These lifestyle interventions will also help
reduce type 2 diabetes complications (Nanditha et al., 2016).
For the second goal, Peter will be educated to quit smoking and its adverse outcomes as it
worsens breathing problems. It results in upper airway obstructions and inflation. It is beneficial
in maintaing the blood glucose level. Hence, patient must be educated about its benefits. The
patient will be referred to motivational therapy and nicotine replacement therapy, for smoking
cessation (Pan et al., 2015). Motivational therapy will help adhere to physical activity and weight
loos goals. Education will help patient to adopt healthy behaviour and lead better lifestyle

NURSING ASSIGNMENT 366
modification (Nanditha et al., 2016). Peter will be educated about maintaining healthy diet and
nutrition so that he can sustain the weight loss intervention. Weight loss and smoking cessation
leads to several mental health concerns. Therefore, self monitoring and stress management
strategies are adopted from cognitive behavioural therapy. Self monitoring of glucose and blood
pressure will help control diabetes (Levich, 2011). Further, pharmacological interventions to
control glucose are use of anti-obesity medication as metformin, glycosidase inhibitors and
insulin uptake leads to weight gain. The patient can be administered with Orlistat on consulting
with physician as it prevents the absorption of dietary fat by 30%. It is an effective weight loss
aid for BMI >28kg/m2. Simultaneously, metaformin will be continued to control blood glucose
and Metoprolol will be administered to maintain blood pressure (Bedhiafi et al., 2018).
The seventh stage of the clinical reasoning cycle is the evaluation of patient outcomes,
and eighth stage is reflection to track the changes in the health status (Gee, Dalton & Levitt-
Jones, 2015). The weekly weight reduction plan and physical activity will be monitored for
compliance. Weight and vital signs will monitor regularly. The side effects of all the medications
will be monitored for its impact on vital signs. The patient is monitored to demonstrate change in
eating pattern and display weight loss. The patient will be evaluated for overall disease
awareness, adverse outcomes and benefits of the interventions (Eldredge et al., 2016). I will
reflect on the barriers in implementing the care plan such as low self esteem of patient and
address the challenges. In case of Peter the challenge is mainly with nutritional management. I
will help patient by making him ware of the daily allowance of calories. I will refer to cognitive
behavioural therapist for preventing binge eating (Brownell & Walsh, 2017).

NURSING ASSIGNMENT 366
In conclusion the essay enhanced personal critical thinking skills to identify and prioritise
the patient health issues. Clinical reasoning cycle helps in decision making by systematically
analysing the case study of Peter. Following each step correctly, leads to processing of health
information and design appropriate nursing care plan. Two health priorities identified for Peter
using the clinical reasoning cycle are control of weight and glucose level. The nursing strategies
used are evidenced based and will help patient control both obesity and diabetes symptoms.

NURSING ASSIGNMENT 366
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