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Clinical Reasoning Cycle as a Process

Discuss about the Analysis Of Nursing Care And Prioritization.

According to Moorhead et al. (2014), numerous factors influence the care plan of patients who are suffering from chronic conditions. It is the duty of the primary health care nurse to procure care based on clinical priority and the requirement of the patient. According to Lehne and Rosenthal (2014), prioritization is an integral part of nursing care and prioritization of care helps to maximize the effectiveness of nursing interventions. Lehne and Rosenthal (2014) have further opined that prioritization can be achieved via integration and collaboration of different aspects of patients’ requirement. The following essay aims to analyze two main priorities of care via critically evaluating the case study of Peter Mitchell under the light of the clinical reasoning cycle.

Clinical reasoning cycle can be defined as the process via which the healthcare personnel employ their deductive, inductive cognitive skills in order frame the clinical decisions on priority basis, and this in turn helps to procure safe care to the patient (Audétat et al, 2013). Audétat et al (2013) has also stated that clinical reasoning cycle helps the nursing professionals to step wise tabulate the process involved in framing and procuring care starting from the collection of cues, processing the information, establishment of goals, action taking and simultaneous evaluation of outcomes.


The first step of the clinical reasoning cycle is “considering the patient situation”. The main factors that must be taken into consideration in the case study of Peter Mitchell is, he is suffering from morbid obesity along with type 2 diabetes mellitus. The major symptoms experienced by him include obesity ventilation syndrome, poorly controlled diabetes and sleep apnoea. Other associated symptoms include increased hunger, diaphoresis and symptoms of shakiness. These facts are important in relation to clinical reasoning towards the direction of framing priority based patient care plan. According to Sturm and Hattori (2013), morbid obesity entails serious health consequences in comparison to the moderate obesity. Sturm and Hattori (2013) have further opined that severely over-weight individuals who are 100 or 200 pounds ( 90 to 45 Kgs) or even more than that have far more complex health issues and encounter various challenges in healthcare system in comparison to the moderately obese individuals. In case of Peter Mitchell, he is 145 Kg and hence his obesity can surely be considered an important factor to describe the patient’s conditions. Poorly controlled Type 2 Diabetes is another factor for describing patient situation because, glycemic control in type 2 diabetes patients who are also severely obese are difficult to achieve and is frequently associated with hypertension and high concentration of bad lipoprotein or low-density lipoprotein in blood (Brethauer et al. 2013).

Other important list of facts

Age

52 years

Gender

Male

Other symptoms

Difficulty in breathing while sleeping

Other habits

Smokes 20 cigarettes per day for the last 30 years

 

Step 1: Consideration of Patient Situation


The second step of clinical reasoning cycle is “collecting cues or information” (Audétat et al, 2013). The past medical history of entails that Peter Mitchell was obese weighing around 145 Kilograms approximately. Initially he use to weigh around 105 but after he lost his job and went on the insulin medication because of diabetes, his weight bar escalate exponentially. Peter Mitchell has been diagnosed with type 2 diabetes mellitus 9 years ago and has also been suffering from depressing (3 months ago) along with hypertension. According to Inzucchi et al. (2012), uncontrolled rate of type 2 diabetes mellitus leads to severe obesity and this might be the case in case of Peter Mitchell. Moreover, his depression which might have stem due to sudden loss of job but this depression has further aggravated the chronicity of the type 2 diabetes. According to the reports published by Rotella and Mannucci (2013), depression is an important risk factor behind the development of the type 2 diabetes mellitus and persistent depression increases the severity of type 2 diabetes mellitus. As per the research findings of Cheung and Li (2012), diabetes and hypertension frequently occur together. They are of the opinion that there is substantial overlap between diabetes and hypertension in etiology and disease mechanisms and increase in hypertension leads to increase in severity of diabetes mellitus or vice-versa. Moreover, he still smokes 20 cigarettes per day for which further resulted in uncontrolled condition of hypertension high blood pressure making him susceptible towards developing chronic cardiac anomalies in the near future (Pan et al., 2015). Peter Mitchell has not followed the diet plan provided by his dietician and this might be another reason behind his high gain in weight (Markwald et al., 2013).

The third step of clinical reasoning cycle is “processing of information” (Audétat et al, 2013). Two important connections that are found in the case study are uncontrolled type diabetes mellitus and weight gain. The scenario is significant because of high abnormal weight, high blood pressure.

Name of the condition

Patient parameter

Normal parameter

Weight

145 kg in respect to 170 cms of height

60 to 72 Kg

Blood pressure

180/92

120/80


The main gaps in the cue is whether Peter Mitchell is a addicted to any kind special diet plan (fat rich or sweet rich) which has further acted as a catalysts towards the high gain in weight. Moreover, the information is relation to gastro oesophageal disease reflux disease (GERD) seems irrelevant under this context because, here the focus is diabetes and obesity. According to Chen, Magliano and Zimmet (2012), there is no direct relation behind the development of type 2 diabetes mellitus or its associated weight gain with GERD.  

Step 2: Collection of Cues or Information


So the main identified problems, which is the fourth step of the clinical reasoning cycle include poor quality of life along with lack of self-awareness along and depression arising out of social isolation.

“Establishment of goals” and “setting of action plans” is the fifth and sixth steps of clinical reasoning cycle. From the case study, it can be clearly stated that although Peter is well aware of his urgent weight loss requirement, he suffers from lack of confidence and determination which is required towards adapting different weight loss weight loss intervention. Proper health literacy along with a detailed weight loss regime will help Peter to understand from where he should start his weight loss regime. Moreover, proper education in the domain of type 2 diabetes mellitus will further help Peter to understand that his severe obesity is the driving force behind his poorly controlled diabetes and thereby helping him to work towards self-management programs (Khunti et al., 2012). This education should be given in the form of proper oration, lectures with creative posters or presentations along with proper counselling with Peter in one-to-one scenario in order to educate him while analysis his understanding gaps (Khunti et al., 2012). A proper diabetes educator must also be assigned as he will help Peter to learn how to measure is blood glucose level while educating his about proper administration of insulin in order to keep in BGL level under the normal bracket (Khunti et al., 2012).  Peter also needs assistance towards reducing his escalated smoking habits. A substance abuse counsellor is the best person for Peter to help him stay motivated and live enthusiastic to lead to smoking free life. Nicotine replacement therapy (NCT) will be best suited for Peter. According to Stead et al. (2012), NCT is found to provide best possible outcome with the patients having addiction towards chain smoking. Decrease in smoking tendency will help to reduce the severity of diabetes mellitus and obesity and thereby improving quality of life (Pan et al., 2015; Tian et al., 2015).


The second priority of care in case Peter Mitchell is social isolation. It is highlighted in the case study that Peter is divorcee and lives alone and his sons rarely visit him. Moreover, he is embarrassed with his body size and thus refuses to socialise. The condition of Peter Mitchell is accordance with the findings of Steptoe et al. (2013). Teo (2013) further opined that social isolation generates loneliness and this loneliness generates a sense of depression as in case of Peter Mitchell. Depression arising out of social isolation eventually gives rise to significant morbidity and mortality and hence priority of care (Steptoe et al. 2013). The main nursing interventions in order to reduce the sense of depression among Peter Mitchell will be generation of acceptance and awareness of self. Awareness of self will be done via providing a detailed insight about his physical appearance and how he can fight the same. Peter should be advised to perform free-hand exercise initially for 10 minutes and then gradually increasing the tenure of exercise regime. This exercise will be done in groups composed of other groups of people who are also trying to fight against their obesity. According to Tilvis et al. (2012), performing group task increase a sense of self-confidence and helps individuals to socialise and thereby helping to reduce depression. In this exercise class, Peter’s entire mental (psychologist) and physical health conditions (primary care providers) will be checked and diabetic diet along with exercises will be recommended accordingly. This type of care is popularly known as collaborative care (Archer et al., 2012). Archer et al. (2012) further opined that residing amidst same group of people who are also suffering from identical problems, gives the patient a metal and thus reducing social isolation. Moreover, weight loss helps in psychological improvements, helping to gain personal confidence and thereby increasing social participation (Staiano, Abraham & Calvert, 2013). Gillen et al. (2012), further opined that interval exercise helps to reduce postprandial glucose response and thereby reducing the prevalence of hyperglycaemia among the patients with type 2 diabetes mellitus.

Step 3: Processing of Information

The last two steps of clinical reasoning cycle is evaluation and reflection stage. Here Peter would be asked to fix appointments with the nearby healthcare centres once in a month so that the healthcare professionals can evaluate how the health parameters of Peter is improving and how Peter is abiding by the healthy lifestyle regime. This monthly evaluation of Peter’s health parameter will help the healthcare professionals to understand the effectiveness of the weightless strategies and diet plan implemented on Peter and simultaneously work on the same towards further improvement (Prezio et al., 2013).  The evaluation will also be based on the assessment of the depression; here Peter will be accessed on the parameter of how his social participation has increased and whether he is open to participate in community activities (Prezio et al., 2013).

Thus from the above discussion, it can be concluded that clinical reasoning cycle is an important tool that help the healthcare professionals to determining the priority of nursing care among the patients with chronic disease. In the case study, proper education about the disease and interventions for the maintenance of healthy lifestyle are considered two most prioritise care for Peter who was suffering from prolong period of diabetes mellitus and morbid obesity.

References

Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C. & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 10.

Audétat, M. C., Laurin, S., Sanche, G., Béïque, C., Fon, N. C., Blais, J. G., & Charlin, B. (2013). Clinical reasoning difficulties: a taxonomy for clinical teachers. Medical teacher, 35(3), e984-e989.

Brethauer, S. A., Aminian, A., Romero-Talamás, H., Batayyah, E., Mackey, J., Kennedy, L., ... & Chand, B. (2013). Can diabetes be surgically cured?: long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus. Annals of surgery, 258(4), 628.

Chen, L., Magliano, D. J., & Zimmet, P. Z. (2012). The worldwide epidemiology of type 2 diabetes mellitus—present and future perspectives. Nature Reviews Endocrinology, 8(4), 228.

Cheung, B. M., & Li, C. (2012). Diabetes and hypertension: is there a common metabolic pathway?. Current atherosclerosis reports, 14(2), 160-166.

Elliott, M., & Coventry, A. (2012). Critical care: the eight vital signs of patient monitoring. British Journal of Nursing, 21(10), 621-625.

Gillen, J. B., Little, J. P., Punthakee, Z., Tarnopolsky, M. A., Riddell, M. C., & Gibala, M. J. (2012). Acute high?intensity interval exercise reduces the postprandial glucose response and prevalence of hyperglycaemia in patients with type 2 diabetes. Diabetes, Obesity and Metabolism, 14(6), 575-577.

Step 4: Identification of Problems

Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., ... & Matthews, D. R. (2012). Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia, 55(6), 1577-1596.

Khunti, K., Gray, L. J., Skinner, T., Carey, M. E., Realf, K., Dallosso, H., ... & Davies, M. J. (2012). Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. Bmj, 344, e2333.

Lehne, R. A., & Rosenthal, L. (2014). Pharmacology for Nursing Care-E-Book. Elsevier Health Sciences.

LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., & Reid-Searl, K. (2015). Medical-surgical nursing. Pearson Higher Education AU.

Markwald, R. R., Melanson, E. L., Smith, M. R., Higgins, J., Perreault, L., Eckel, R. H., & Wright, K. P. (2013). Impact of insufficient sleep on total daily energy expenditure, food intake, and weight gain. Proceedings of the National Academy of Sciences, 110(14), 5695-5700.

Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2014). Nursing Outcomes Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences.

Pan, A., Wang, Y., Talaei, M., Hu, F. B., & Wu, T. (2015). Relation of active, passive, and quitting smoking with incident type 2 diabetes: a systematic review and meta-analysis. The lancet Diabetes & endocrinology, 3(12), 958-967.

Pan, A., Wang, Y., Talaei, M., Hu, F. B., & Wu, T. (2015). Relation of active, passive, and quitting smoking with incident type 2 diabetes: a systematic review and meta-analysis. The lancet Diabetes & endocrinology, 3(12), 958-967.

Prezio, E. A., Cheng, D., Balasubramanian, B. A., Shuval, K., Kendzor, D. E., & Culica, D. (2013). Community Diabetes Education (CoDE) for uninsured Mexican Americans: a randomized controlled trial of a culturally tailored diabetes education and management program led by a community health worker. Diabetes research and clinical practice, 100(1), 19-28.

Rotella, F., & Mannucci, E. (2013). Depression as a risk factor for diabetes: a meta-analysis of longitudinal studies. The Journal of clinical psychiatry.

Staiano, A.E., Abraham, A.A. & Calvert, S.L. (2013). Adolescent exergame play for weight loss and psychosocial improvement: a controlled physical activity intervention. Obesity, 21(3), pp.598-601.

Stead, L. F., Perera, R., Bullen, C., Mant, D., Hartmann-Boyce, J., Cahill, K., & Lancaster, T. (2012). Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev, 11(11).

Steptoe, A., Shankar, A., Demakakos, P. & Wardle, J. (2013). Social isolation, loneliness, and all-cause mortality in older men and women. Proceedings of the National Academy of Sciences, 110(15), pp.5797-5801.

Sturm, R., & Hattori, A. (2013). Morbid obesity rates continue to rise rapidly in the United States. International journal of obesity, 37(6), 889.

Teo, A.R. (2013). Social isolation associated with depression: A case report of hikikomori. International Journal of Social Psychiatry, 59(4), pp.339-341.

Tian, J., Venn, A., Otahal, P., & Gall, S. (2015). The association between quitting smoking and weight gain: a systemic review and meta?analysis of prospective cohort studies. Obesity reviews, 16(10), 883-901.

Tilvis, R.S., Routasalo, P., Karppinen, H., Strandberg, T.E., Kautiainen, H. & Pitkala, K.H. (2012). Social isolation, social activity and loneliness as survival indicators in old age; a nationwide survey with a 7-year follow-up. European Geriatric Medicine, 3(1), pp.18-22.

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