Clinical Reasoning Cycle In Nursing: A Case Study

Collecting Cues, Processing, and Presenting Related Health Information

Discuss about the Clinical Reasoning Cycle In Nursing.

Clinical reasoning cycle is one of the most effective tools that are used by the nursing professionals to provide a comprehensive care to the patients. This procedure contains eight important steps which is carried on properly will help the professionals to give the best care to the patient in a sequential manner which will address all her symptoms effectively (Dalton, Gee & Levett-Jones, 2015). Dementia and Alzheimer’s disease affect the lives of many old men and women in Australia. There are more than 413106 patients living in the nation with dementia and the 228238 (55%) are female and 184161(45%). This number would increase to 536164 by 2025. are male In this case study, the nurse will also follow the tool to address each of the nursing issues of the patients and with the sequential steps, he will effectively develop a care plan that will be beneficial for the patients recovery fork her present situation.

Clinical reason cycle is often used by a large number of healthcare professionals as it acts as a tool which helps them to sequentially collect cues about the patients’ condition, process the information and also come to an understanding of the patient problems (Hunter & Arthur, 2016). This toll then helps the nurse to plan and develop interventions which ultimately help in the evaluation of the outcome followed by the reflection o the nurse form this entire episode. Form the case study, it is seen that the patient is a widow who has been residing in an aged care facility and has returned from hospitals after a hip replacement after fall in the rehabilitation center. She is in the preliminary stage of the Alzheimer’s disorder and vascular dementia. She is also not used to walking with wheelie walker and has been bruised due to bumping on the walker. Previously, she used to be strong independent minded person and therefore she cannot accept the fact that she is dependent now on carers for her daily activities. Therefore she is being rude to the carers and are not helping them in her care. She is also intermittently incontinent due to her failure in reaching toilet on time. Mostly old people of Australia are found to suffer from dementia and Alzheimer’s and the patient had been no exception. Her will to walk alone makes her more risky towards fall as he is yet not habituated with the fact that her mobility is reduced and she needs assistance in walking. The occurrence of the disorder has affected the patient who has therefore developed shuffling, leaning patterns, unsteady balance and also decreased coordination as well as physical strength as they are the common symptoms of dementia. The unsteady balance may also be due to the medical as well as physical reason of Alzheimer’s which cause occurrence of plaques in the brain of the individuals and tangles as well (Koivisto et al., 2016). The cause of the incontinence may be due to the presence of Alzheimer’s diseases which results in development of overactive bladders those results in leakage of urine involuntarily before reaching restrooms. The falls are mainly due to unsteady balance and inability to be practiced with restricted movement. She also has a tear in her lower right leg and therefore it is also causing her huge pain which also needs to be addressed.

Identification and Prioritization of Three Nursing Issues

Three important areas need to be addressed by the nurses who will be in charge of the patient. While identifying the domains, where the patient will require care, it is also important for the nurse to keep in mind that she is in the first stages of dementia and Alzheimer’s diseases and therefore a patient centred care with compassion and empathy is important in the case (Kuiper, Pesut & Arms, 2016). Firstly, the patient is yet not accustomed with the fact that she is having restricted mobility and therefore she is not careful in her movement and was not able to conduct her activities independently and therefore it is important for the nurse to conduct a fall risk assessment and take precautionary measures accordingly. Secondly, the patient is having a large tear in her lower right leg and therefore the nurse should undertake proper dressing procedure for the healing of the bruises. It should be taken care that she is quite aged and her healing should require more time and therefore proper planning and care should be taken by the nurse wile caring for her wound. Thirdly, the patient has intermittent incontinence and therefore it very much important for the nurse to undertake proper interventions so that the issue can be handled properly and the patient does not have leaked urine before reaching the restroom.

The nurse should first conduct FRAT which is a fall risk assessment tool that was actually developed by Peninsula Health Falls Prevention service in the year 1999. It mainly contains three parts which are assessing falls risk status, risk factor checklist and also developing action plan. This will help the nurse to develop an idea about the severity of the issue and following this the interventions to prevent fall will be developed (Palvelen et al., 2014). The nurse should ask herself self assessment question regarding the patients risk of fall, communicate with the patient, and also take undertake environmental changes such as adequate lighting, developing visual contrast, keeping pathways clear and others. Secondly the nurse should follow a proper wound dressing procedure which will help the patient to overcome the pain from her tear and also help it to get dry soon. She will also be assessed on the pain management scale from 1 to 10 and depending upon her score, interventions need to be taken for both of her wound management. Moreover she had gone hip arthroplasty and therefore she may also face pain in the surgical sites which also needs to be checked. Hence, pain management should be done accordingly so that both the factor can be addresses (Joshi et al., 2014). The third intervention would be to take proper care for the patients’ issue in urination as she is suffering from incontinence. The goal should be that the patient has reduced episode of such independence, receive assistance in such time; can overcome environmental barriers, allocation of proper adaptive equipment and others (Teunisen et al., 2015). The main goal of the nurse should however be an overall comprehensive care to the patient by attending all her symptoms of the Alzheimer and dementia so that the patient can age well with a better quality life in the aged care.

Establishment of Goals of Nursing Care

After assessing the fall risk assessment, the nurse should accordingly take actions. Besides advising the patients with proper precautions (the patient is in preliminary stage so her cognitive ability is not completely lost), the nurse should make the environment risk free as much as possible (Vlayen et al., 2015). She should ensure adequate lighting, reduction of glare and also limit the shadows. She should also provide the patient with visual; contrast by using obvious contrast in colour to define objects form the background, using of solid colours with in pattern to decrease confusion and also avoiding black surfaces which the patient might misinterpret as black hole as her cognitive ability is declining. Her pathways should be kept clear by keeping the surface level dry and non slippery. The floors, furniture and the outdoors would be modified accordingly. The nurse should also enhance accessibility by keeping important things in visible, easy to reach places, using a firm mattress, using adaptive equipment and also lowering the bed light. The bathroom should have increase safety by sing bath chairs, proper bathroom rails, properly placed bards, using right footwear (Miake et al., 2013)

For management of the pain after hip replacement surgery, the nurse should use proper pain assessment scales, maintain proper position of the operated extremity and also provide her with comfort measures that include frequent repositioning and diversion activities. Stress management techniques should be encouraged like progressive relaxation, meditation, guided imagery and others (Wilson, 2017). Proper pain management medications should be provided on a regular schedule and before activities. The nurse should also be alert and investigate reports for suffering severe joint pain, muscular spasms and changes in joint mobility, severe chest pain and restlessness. Application of ice packs, initiation and maintenance of extremity mobilization ambulation, light exercise and physical therapies should also be conducted. For the bruises, she should use the correct dressing depending upon the depth and condition for the wound, change them at the correct interval and apply the right medication so that the wound may dry as rapid as it can (Benditz et al., 2016).

For maintaining her incontinence issue, the nurse should first introduce a toileting schedule, eliminate all the environmental barriers to the washroom in the care, improve lighting in hallways and bathrooms and also remove rugs form the floor is any present. The nurse can also use urinary receptacle in 3 in 1 commode, containment device. Clothing should be such that it maximizes toileting access of the patient. A prompted voiding program or patterned urge response toileting program should be initiated. Frequency of urination with the sue of alarm clock, changing device, noting urinary elimination and incontinence pattern, starting prompted toileting program on the results of the toileting frequency, parsing the patient when toileting occurs with prompting all helps in managing the situation effectively (Zarowitz et al., 2015).

Nursing Care for the Person

For each of the nursing priorities, the nurse should set up a timeframe until which she would be continuing the interventions. Then she would be conducting an evaluation of the results of each of the interventions. If they are achieved successfully or are showing positive results, the interventions should be carried out. If the outcomes are not positive, the nurse should discuss the case with mentor and introduce new interventions in accordance with the situation.

While handling the case study, it was getting really difficult for me to handle so many co-morbidities together and I was getting stressed and was not being able to manage the interventions properly. However, with the guide of the mentor, I correctly made a care plan for the patient and followed ach of the intervention appropriately.  Moreover, as she was not complying with us, I had a counselling session with her, where I treated her with compassion and empathy providing her the autonomy and dignity to take her own decisions. This helped me to develop a therapeutic relationship with her where she also started helping me in the interventions and her cooperation’s made the process easier and also made me stress free.

Conclusion:

From the case study, the nursing priorities were first indentified. Following the identification of the priorities, proper interventions were introduced.  Effective pain management, proper management of incontinence, proper care for her fall management risks had been taken effectively. Following the application of the intervention, evaluation of the outcomes is needed to be done by the nurse to ensure safe practice and quality care. The nurse should reflect the entire process in order to gain new insights from the experience. Therefore, following a clinical reasoning cycle, a nurse can effectively manage patient and care for her to give her a better quality life.

References:

Benditz, A., Greimel, F., Auer, P., Zeman, F., Göttermann, A., Grifka, J., … & von Kunow, F. (2016). Can consistent benchmarking within a standardized pain management concept decrease postoperative pain after total hip arthroplasty? A prospective cohort study including 367 patients. Journal of pain research, 9, 1205.

Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based education to’flip’the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, The, 33(2), 29.

Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement: Clinical educators’ perceptions. Nurse education in practice, 18, 73-79.

Joshi, G. P., Schug, S. A., & Kehlet, H. (2014). Procedure-specific pain management and outcome strategies. Best Practice & Research Clinical Anaesthesiology, 28(2), 191-201.

Koivisto, J. M., Multisilta, J., Niemi, H., Katajisto, J., & Eriksson, E. (2016). Learning by playing: A cross-sectional descriptive study of nursing students’ experiences of learning clinical reasoning. Nurse education today, 45, 22-28.

Kuiper, R., Pesut, D. J., & Arms, T. E. (2016). Clinical reasoning and care coordination in advanced practice nursing. Springer Publishing Company.

Miake-Lye, I. M., Hempel, S., Ganz, D. A., & Shekelle, P. G. (2013). Inpatient Fall Prevention Programs as a Patient Safety StrategyA Systematic Review. Annals of internal medicine, 158(5_Part_2), 390-396.

Palvanen, M., Kannus, P., Piirtola, M., Niemi, S., Parkkari, J., & Järvinen, M. (2014). Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: a randomised controlled trial. Injury, 45(1), 265-271.

Teunissen, D. T., Stegeman, M. M., Bor, H. H., & Lagro-Janssen, T. A. (2015). Treatment by a nurse practitioner in primary care improves the severity and impact of urinary incontinence in women. An observational study. BMC urology, 15(1), 51.

Vlaeyen, E., Coussement, J., Leysens, G., Van der Elst, E., Delbaere, K., Cambier, D., … & Dejaeger, E. (2015). Characteristics and Effectiveness of Fall Prevention Programs in Nursing Homes: A Systematic Review and Meta?Analysis of Randomized Controlled Trials. Journal of the American Geriatrics Society, 63(2), 211-221.

Wilson, A. (2017). Assistive devices, hip precautions, environmental modifications and training to prevent dislocation and improve function after hip arthroplasty. International Journal of Nursing Studies.

Zarowitz, B. J., Allen, C., O’Shea, T., Tangalos, E., Berner, T., & Ouslander, J. G. (2015). Clinical burden and nonpharmacologic management of nursing facility residents with overactive bladder and/or urinary incontinence. The Consultant Pharmacist®, 30(9), 533-542.