The Clinical Reasoning Cycle Approach

Discuss About The Exploring Disjuncture Between Daily Lives.

Ageing refers to the process of growing older and encompasses several aspects related to psychological, physical and social changes. Furthermore, ageing is often considered as the primary risk factor that increases the susceptibility of individuals to get affected by a range of diseases. In other words, healthy ageing can be defined impetrative for healthy living and often creates a significant impact on the overall health and quality of life of the geriatric population (Bacsu et al., 2012). Gerontological nursing refers to the nursing specialty that pertains to older adults and these nurses most commonly work in collaboration with the elders, their families and the entire community to support maximum functioning of the elders (Neville, Dickie & Goetz, 2013). Thus, in order to meet the health needs of an aging individual, it is essential to employ the clinical reasoning cycle that will allow making appropriate healthcare decisions through adoption of a systematic process that considers the major predisposing factors (Levett-Jones, 2013). The assignment will also utilise the Miller’s Functional consequences theory for facilitating adoption of a holistic perspective of the spirit, mind and body inter-relatedness, while discussing a case study of a geriatric patient, Mrs. Amalie Jones (Hirst, Lane & Miller, 2015).

Considering the patient situation forms the first step of the clinical reasoning cycle (Levett-Jones, 2013). In the case scenario, the patient Mrs. Amalie Jones is German and aged 89 years. She migrated to Australia, following her marriage with Henry Jones, an Australian sailor. She is found to maintain good contacts with her son from a previous marriage, Dominik. Furthermore, she also has cordial realtions with Henry’s daughter Tracy and her family, and reports having regular conversations with them over the telephone. However, recent deterioration in her physical condition due to the onset of macular degeneration, and subsequent development of rheumatoid arthritis and osteoarthritis has resulted in impairment in mobility. This has restricted her movement outside the house premises and led to loss of contacts with members of her community. The fact that she has been socially active throughout, has made this social withdrawal create significant negative impacts on her quality of life, by increasing frailty and leading to possible decline in the overall health condition.

Collecting essential patient cues or information refers to conducting a review of the current and available information related to patient history, charts and recalling knowledge of the underlying pathophysiology of the presenting compliant. This forms that second step of the clinical reasoning cycle (Levett-Jones, 2013). In addition to her medical history of hypothyroidism and arthritis, the Mrs. Jones also presents complaints related to swollen feet, stiffness in joints, limited joint movements, and pain in the joints of fingers, knee, hips and back. All of these factors significantly contributed to limitations in her movement, which in turn prevented her from going outside her home and socializing with the community members, thereby leading to social isolation (Nicholson, 2012). Presence of constipation can be attributed to the fact that she is not consuming appropriate nutrients (Bailes & Reeve, 2013). Furthermore, vision impairment, as a direct manifestation of macular degeneration, has also worsened her health. The aforementioned information related to the patient might contribute significantly to deterioration in physical and psychological health condition, which can increase isolation and lead to possible depression.

Patient Situation

Analysis of the patient symptoms and matching the current situation to information collected previously forms the third part of the clinical reasoning cycle, and is commonly referred to as processing information (Levett-Jones, 2013). Osteoarthritis refers to a joint disorder, which commonly results from breakdown of bones and joint cartilages. In other words, it commonly refers to the condition that involves inflammation of the joints due to cartilage degeneration. Heredity, aging and injuries due to trauma are the most common factors that increase the likelihood of a person to suffer from osteoarthritis (Weinans et al., 2012). Disorganisation of the collagen matrix decreases the content of proteoglycan present in the cartilage and brings about a net increase in the content of water. This directly contributes to exacerbation of degeneration, thereby resulting in pain, stiffness, and loss of motor abilities, all of which are presented by Mrs. Jones (Roman-Blas & Herrero-Beaumont, 2013). In addition, the patient is also seen to suffer from rheumatoid arthritis, a long-term autoimmune disorder that is found to primarily affect the joints (Furst & Emery, 2014). Congestion and swelling in the synovial membrane might have contributed to swollen feet and enlarged joints in the patient (Choy, 2012). A plethora of risk factors might be considered accountable for the development of symptoms presented by Mrs. Jones such as, gender, age and physical activities (Pahor et al., 2014). Arthritis has been found to affect women disproportionately, with a female to male ratio of 3:1 (Eder et al., 2013).

Furthermore, research evidences have correlated development of arthritis symptoms among individuals over 50 years of age (Frisell et al., 2013). The fact that the patient is an octogenarian, might have increased her susceptibility to the current health condition. In addition, researchers have also identified a list of occupations that involve wear and tear of the bones, with a higher risk of osteoarthritis (Prodinger et al., 2014). The fact that Mrs. Jones and her husband were extensive travellers and participated in several community activities, post-retirement might be considered as a major risk factor. Furthermore, she also complains of constipation that has been correlated by several studies, with intake of low fibre diet, inactive lifestyle, and lack of consumption of appropriate food supplements (Kranz et al., 2012). Macular degeneration symptoms, as presented by the patient can also be linked to her old age that acts as the strongest predictor of the condition and results in gradual worsening of vision in the eyes (Wong et al., 2014).

Collecting Essential Patient Cues or Information

Identification of the problem or issue forms the fourth step and will facilitate making an appropriate diagnosis for the health abnormality (Levett-Jones, 2013). An analysis of the previous steps helps in deducing that mobility impairment in the elderly patient is the major problem that is contributing to significant disability and worsening the overall health related quality of life. The second nursing care priority would be focused on constipation that makes it difficult for the patient to empty her bowels. This condition will be considered as a care priority since it can lead to bloating and abdominal pain. Visual impairment due to macular degeneration is the third care priority as partial or complete loss of vision can increase risks of injurious falls and can also make it difficult for the patient to identify places and people. Owing to the fact that she lives alone, visual problems might also lead to medication errors.

Goal establishment forms the fifth step where the desired health outcome will be discussed, that is intended to be achieved within a pre-determine time span (Levett-Jones, 2013). The major care goals will be related to adoption of effective home-based exercise, as a part of fall prevention measures that will help in reducing or eliminating chances of Mr. Jones getting suffering injurious falls that can lead to hospitalization or can even be fatal. Further goals are related to implementation of dietary modifications to improve her bowel movements. 

Selecting a course of action in order to accomplish the intended goals, form the sixth step of the clinical reasoning cycle (Levett-Jones, 2013). The elderly people are prone to experience a plethora of functional consequences due to several age related variations, in addition to a wide range of environmental, lifestyle and genetic risk factors (Stewart et al., 2012). Hence, inadequate implementation of nursing intervention might create potential negative effects on the functional consequences, experienced by the client The nurse should focus on recognition of the effect of older age on the current health condition of the patient. The probable factors that might have created negative functional consequences should be identified, with the aim of initiating interventions that will enhance patient outcomes (Hirst, Lane & Miller, 2015). The nurses should make Mrs. Jones follow easy home-based exercises that involve knee bends, toe raises, turning and walking around, heel toe standing and walking the stairs. These exercises will be conducted in presence of a physiotherapist (Stevens & Phelan, 2013). Further interventions include, installing grab rails in the bathrooms to prevent tripping over slippery surfaces. Installation of bed-side alarms will also allow create provisions for the caregiver to monitor the patient’s activity, thereby reducing fall risks (Ungar et al., 2013). Providing walking aids, removing clutter and loose rugs from the floor, and installing bright light bulbs in the stairways and hallways would also help. Constipation can be prevented by forming a diet plan that makes the patient drink enough water, avoid caffeinated beverages and eat vegetables and fruits that are rich in fibre. This will act as a natural laxative and help in bowel movement (Yang, Wang, Zhou & Xu, 2012). The nursing care strategies should be implemented in a manner that recognizes her cultural background, preferences and traditions. Furthermore, efforts will be taken to maintain her dignity and ask for her consent, before implementing any of the strategies.

Analysis of Patient Symptoms

Evaluation of the outcomes forms the next part of the reasoning cycle (Levett-Jones, 2013). Expected outcomes will include the fact Mrs. Jones is able to move on her own and is able to perform the daily activities independently, such as, dressing, washing and feeding. Given the devastating effects of falls on the patients and their family members, the in suggested interventions have shown meaningful results in most people. Demonstrating an ability to take the steps or move outside her home and interact with the community members will indicate success of the interventions. Furthermore, easy bowel movements, and reports of less constipation are also expected. This can be related to the fact that fibres act as natural laxatives and increase water content of the stool.

The above discussion helped me learn that there are several lifestyle factors that create substantial effect on the lifespan of individuals. I realize that solitary lifestyle contributes greatly to falls among the elderly. Next time I would also involve the patient’s family in the decision making process with the intention of determining their choices that would guide the behaviour.

To conclude, it can be stated that various factors related to loss of loved person or disabilities put the older adults at an increased risk of getting socially isolated, or becoming lonely. Hence, such socially isolated elderly people are likely to experience a poor quality of life and need assistance from the healthcare professionals and the community, to deal with concerns about their aging in place. Progressing diseases in the older age often contributes to functional limitations that lead to a decline in mobility and limits their access to life-spaces. Such limitations often contribute to high rates of falls in the geriatric population that leads to recurrent hospitalization. Moreover, isolated life also leads to harmful impacts on the feeding habits of older adults. Hence, efforts must be taken to implement all strategies and interventions that have been proved successful in reducing fall rates, improving mobility, and enhancing bowel patterns among the elders. This would directly enhance overall health and wellbeing of the elderly and improve patient satisfaction

References

Bacsu, J. R., Jeffery, B., Johnson, S., Martz, D., Novik, N., & Abonyi, S. (2012). Healthy aging in place: Supporting rural seniors’ health needs. Online Journal of Rural Nursing and Health Care, 12(2), 77-87.

Bailes, B. K., & Reeve, K. (2013). Constipation in older adults. The Nurse Practitioner, 38(8), 21-25.

Identification of the Problem

Choy, E. (2012). Understanding the dynamics: pathways involved in the pathogenesis of rheumatoid arthritis. Rheumatology, 51(suppl_5), v3-v11.

Eder, L., Thavaneswaran, A., Chandran, V., & Gladman, D. D. (2013). Gender difference in disease expression, radiographic damage and disability among patients with psoriatic arthritis. Annals of the rheumatic diseases, 72(4), 578-582.

Frisell, T., Holmqvist, M., Källberg, H., Klareskog, L., Alfredsson, L., & Askling, J. (2013). Familial risks and heritability of rheumatoid arthritis: role of rheumatoid factor/anti–citrullinated protein antibody status, number and type of affected relatives, sex, and age. Arthritis & Rheumatology, 65(11), 2773-2782.

Furst, D. E., & Emery, P. (2014). Rheumatoid arthritis pathophysiology: update on emerging cytokine and cytokine-associated cell targets. Rheumatology, 53(9), 1560-1569.

Hirst, S. P., Lane, A. M., & Miller, C. A. (2015). Miller’s nursing for wellness in older adults. Wolters Kluwer. NSW: Lippincott, Williams and Wilkins.

Kranz, S., Brauchla, M., Slavin, J. L., & Miller, K. B. (2012). What do we know about dietary fiber intake in children and health? The effects of fiber intake on constipation, obesity, and diabetes in children. Advances in Nutrition, 3(1), 47-53.

Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia. NSW: Pearson.

Neville, C., Dickie, R., & Goetz, S. (2013). What’s stopping a career in gerontological nursing?: literature review. Journal of Gerontological Nursing, 40(1), 18-27.

Nicholson, N. R. (2012). A review of social isolation: an important but underassessed condition in older adults. The journal of primary prevention, 33(2-3), 137-152.

Pahor, M., Guralnik, J. M., Ambrosius, W. T., Blair, S., Bonds, D. E., Church, T. S., … & King, A. C. (2014). Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial. Jama, 311(23), 2387-2396.

Prodinger, B., Shaw, L., Stamm, T., & Rudman, D. L. (2014). Enacting occupation-based practice: Exploring the disjuncture between the daily lives of mothers with rheumatoid arthritis and institutional processes. British Journal of Occupational Therapy, 77(10), 491-498.

Roman-Blas, J. A., & Herrero-Beaumont, G. (2013). Osteoarthritis pathophysiology: similarities and dissimilarities with other rheumatological diseases and the role of subchondral bone. Medicographia, 35, 158-163.

Stevens, J. A., & Phelan, E. A. (2013). Development of STEADI: a fall prevention resource for health care providers. Health promotion practice, 14(5), 706-714.

Stewart, T. L., Chipperfield, J. G., Perry, R. P., & Weiner, B. (2012). Attributing illness to ‘old age:’consequences of a self-directed stereotype for health and mortality. Psychology & health, 27(8), 881-897.

Ungar, A., Rafanelli, M., Iacomelli, I., Brunetti, M. A., Ceccofiglio, A., Tesi, F., & Marchionni, N. (2013). Fall prevention in the elderly. Clinical Cases in mineral and bone metabolism, 10(2), 91.

Weinans, H., Siebelt, M., Botter, S. M., Piscaer, T. M., & Waarsing, J. H. (2012). Pathophysiology of peri-articular bone changes in osteoarthritis. Bone, 51(2), 190-196.

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.

Yang, J., Wang, H. P., Zhou, L., & Xu, C. F. (2012). Effect of dietary fiber on constipation: a meta analysis. World journal of gastroenterology: WJG, 18(48), 7378.