Essay: Clinical Reasoning Cycle For Hip Fracture In Elderly.

Fall related fractures and risk factors

Discuss about the Clinical Reasoning Cycle for Hip Fracture in Elderly.

The second highest causation of morbidity and mortality rate amongst the general population is observed to be falling, succeeding road related accidents. Major injuries and mortality rates are caused by severe cases of falling and in other cases the patients become incapacitated, burdening their family members and community members (Grivna, Eid& Abu-Zidan, 2014).        The Centres for Disease Control and Prevention (CDC), published records that show head and bone injuries are now a major cause of hospitalization caused by falling. Over 700,000 people annually get admitted in the hospital due to falling with head and hip fractures. More than 95% of hip fractures, additionally are caused due to falling, more often in women than men (CDC, 2016). According to the estimation provided by world health organization (WHO), 28-35% of falling occurs in geriatric patients, over 65 per year (WHO, 2016). It is estimated that the world’s geriatric population is increasing faster than the young population, reaching 841 million in 2013. This rate has quadrupled its value after 1950.  Census estimation showed that, by 2050, the geriatric population will multiply three times, increasing the rate of falling amongst them and if preventive measures are not undertaken in time.  This will increase the burden of care in healthcare facilities (United Nation, 2013).

The process of clinical decision making cycle is described as the process by chich the nursing staff will deicide from options of planning which is relevant to the patient. The individual decisions are different depending on patient situation (Thompson, Aitken, Doran &Dowding, 2013). Component of decision making is based on a model approach called DECIDE. The model adheres to understanding of the problem, setting criteria, alternative analysis, identification of the best suitable option, care plan development and evaluation of the decided plan of care. It is important to focus on decision making to establish as a nursing staff  quickly affecting the care for patient and receiving safe outcome for patient (Guo, 2008). The paper discusses the risk related to falling association with fractures and injuries in geriatric patients, comparing the HAAD and JCI guidelines of standard practice relevant to the issue, demonstration of clinical reasoning cycle understanding, application of the cycle relevant to the situation and providing recommendation as well as interventional techniques to minimize the risk of falling, followed by a conclusion.

The definition of fall, given by WHO is “unintentional event where the person will come to rest in the ground or the floor excluding the intentional change of position to rest in the furniture” (WHO,  WHO global report on falls prevention in older age, 2007). Geriatric patients  who live in care homes of nursing facilities have more tendencies of falling than others living with a community (WHO, WHO global report on falls prevention in older age, 2007). There are four dimension of  risk factors associated with falling which are related to biology, behaviour, socio-economy and environment. Factors affecting biology are risk factors which cannot be improved in geriatric patients over 65 years, cognition, physical ability as well as chronic diseases.  Influence of behaviour is dependent on external factors like substance abuse of drugs and alcohol, sedentary lifestyle and footwear issues. The third dimension is related to factors influencing environment, associated with other factors like wet floors or staircases, dim lights, rough and bumpy roads and footpaths et cetra. Lastly, the factors influenced by socio-economic factors, like less income in family, illiteracy, health care inaccessibility, lack of housing and interaction with other people (WHO, WHO global report on falls prevention in older age, 2007).  Hips fracture is commonly associated with light-headedness complaint from the fall patients along with posture instability and distress. It was observed in a sstudy in 2013, Brazil that light-headedness was a common complaint among 45% of geriatric patients and amongst them women were reported to be 71.6% (Suzana Albuquerque de Moreas, Wuber Jefferson de Souza Soares, Eduardo Ferriolli & Monica Rodrigues Perracini, 2013). The HAAD standards and Joint commission international (JCI) regarding geriatric patients are discussed in the following section

HAAD and JCI standards

The governing body of HAAD amongst the sectors of healthcare is present in Abu Dhabi. The facility has the aim to provide excellent healthcare facility to the population and revive their safety. The JCI on the other hand strives to achieve improvement on the quality of care and sfety of the patient in healthcare facilities. Their standards of guidelines number six state that to minimize the risk of safety of patient goals are to be set to prevent falling incidents. The JCI, 2015 published sentinels to alarm the risk factors associated with falling in a health care settings. Credibility of such incidents are to be taken by the authority (Zhani, 2015)

The definition of clinical reasoning is as follows, “process whereby nurses will collect cues, process the information, identify the problem and patient situation, plan and implement the interventions, evaluate the outcomes, reflect on and learn from the process”. the importance of clinical reasoning is relevant to nursing to improve the patient conditions and achieve better outcomes.  Early recognition of condition is facilitated by clinical reasoning cycle application as well as minimizing the risk that can jeopardise patient outcome. Combination of more than one standard is possible using this cycle (Jones, 2013). The following paragraph describes the steps associated with clinical reasoning cycle.

The case study is about a patient named Mrs. S. Mariam, who is 70 year old. She was admitted in the emergency unit in 2 May 2016. The cause of admission was because she has slipped and fracture her pelvic on the left while inside the house. The patient’s daughter informed that Mrs. Mariam had been facing light-headedness for three months prior to the incident and her admission. The patient has a previous history of hypertension but no history of surgery. Mrs. Mariam is currently wedded, dwelling in Abu Dhabi along with her husband and family whom she is very close with.

This stage of clinical reasoning has three segments that is required to be followed.  The foremost segment is to review the information at hand. The patient has a medical history of hypertension for the past 25 years. She complained of having dizzy feeling but neglected it for the previous three months along with cerumen impaction in both ears. Analysis of vital signs of the patient showed that her blood pressure (BP) was 150/70 and pulse in the periphery was 88 beats per minute (BPM), respiratory rate of 16 breaths per minute and oxygen saturation (SpO2) of  99%. The patient is currently taking 5 mg of amlodipine to treat her hypertension, 16 mg of betahistine for treatment of vertigo, for cerumen impaction treatment, she takes docusate, 40 mg enoxaparin for anticoagulation. 0.5mg alprazolam for sleeping and nalbuphine 10 mg as needed. On the 1^st of march 2016, the patient’s blood test was taken which reflected that her red blood cell count was quite low; 3.14, haemoglobin was 81, hematocrit count was 0.250 mean corpuscle volume- 79.6, mean Hb corpuscle- 25.8 and mean platelet vlloum was 12.3. the x-ray scan was done for femur, spine lumboscaral, pelvis and hip on the right side on the 2 May 2016. Analysis of the report showed presence of fracture in the intertrochantric femur and lumbar scoliosis on the right side. Surgery was decided to be done on the 3 may 2016 on the left side femur utilizing Intermedullary (IM) nailing method.  Preceding the operation the patient was observed to high BP and Hb count decreased from 8 to 7. The patient was administered with two units of blood bag that same day. A second round of blood test was done on the patient to understand the cause of Hb declination that became 10g/L after blood transfusion. Physiotherapy was recommended to the patient for managing ache, complication aversion and exercise. The next step is to accumulate fresh data, after assessment the patient signs of proper cognition and her Glasgow coma score were 15/15. Mephore dressing covered her right leg which underwent surgery and she read 20 on Braden scale. The morse scale showed her risck of falling was 70 and her 20 canula gauge was placed in the right hand which is covered with crepe bandage along with Foley’s catheter insertion. The Wong Baker faces scale showed 4/10 pain score. The last segment is the recollection of found data; Mrs. Mariam, risk high from falling with a Morse score of 70.  She showed anaemic symptoms due to lowering of components of blood. She had high blood pressure postoperative condition along with normal pain threshold, cooperative and stabilized vital signs.

Clinical reasoning cycle

This stage with regard to the patient situation is considered to do interpretation, discrimination, relation, inference, matching, prediction, and analysis. Interpretation; except the MPV, all other blood components like Hb, RBC, Hct, MCH and MCV were found to decrease. This shows that the patient was showing anaemic symptoms. The Morse fall score showed that it was very risky for Mrs. Mariam to fall but Braden score was normal. Considering that the patient underwent surgery, the pain score was plausible.  Discrimination; the immediate priority is to lower the Morse fall score, vertigo and pain score. Relation; cerumen impact could be the result of vertigo and light-headedness in the patient’s case. Pain can induce high BP. Inference; in light of the recent events, it can be inferred that the patient is to be kept under strict monitoring to avoid any postoperative complication or issues related to prolonged bed rest. Reassessment is important to check for pain threshold to ensure proper medicine efficacy. Physiotherapy rehabilitation was recommended to her by the doctor. Matching; comparing with another similar case of a female patient showed same postoperative symptoms but did not undergo IM. Although the operation was successful, the showed anemic symptoms and high BP along with a development of fall anxiety.  Prediction; it is essential to ensure effective pain management as to avoid wound healing delay, immobilization repercussions like ulceration, deep vein thrombosis. Blood transfusion is referred if other signs of blood loss are noticed. A research conducted in 2014 by the World Journal of Orthopaedics (WJO), shows that anaemic symptoms, loss of urine retention, pressure scars, hospital acquired pneumonia, DVT, cardiac arrhythmia and postoperative delirium along with gastrointestinal bleeding is common is cases of hip fracture surgery (Carpintero, Caeiro, Carpintero, Morales, Silva & Mesa, 2014).

It is essential to bring about all the clinical data to formulate a summary of the patient condition. The three primary diagnosis of nursing was carried out keeping the patient’s age, gender and family support. Diagnosis for pain management is the first priority with respect to the condition of the surgery and pain score report along with motor skill assessment, nutrition, sleep assessment and administration of analgesics repeatedly. The next diagnosis is to provide physiotherapy to improve the patient’s mobility post surgery and check for ache manifestations along with motor skill assessment. The third diagnosis is to avoid falling risk post surgery, light-headedness which is common for people her age.

Consider the patient situation

It is necessary to make sure that the patient suffers no lingering post surgical ache, immobilisation issues, complications, wound healing delay, health restoration and dependency issue, activity assessment, cognition assessment and to make sure patient is aware of the repercussion of old age falling to avoid further complications.

My preceptor and I thought through interventional method that could be undertaken which would help the patient safety. The PQRST technique was applied to assess the pain which was also the foremost intervention to improve the patient’s health. Risk factors that would enhance the pain were assessed; sharp aching sensation radiating in the entire right limb (4/10) was initiated when the patient’s position was shifted.  Additionally, preventive measure to avoid falling was implemented with regards to the recommendation of HAAD policy. The measures were; lowered position of the bed, elevated side rails, personal items and calling bell kept within hands distance to the patient, night lights provided and the bed-wheels were locked. Constant monitoring of vital signs was maintained as per the norms of the hospital. Administration of analgesics to manage pain, enoxaparin for anti-coagulation to avoid DVT, amlodipine for BP regulation was provided.

Physiotherapist was able to mobilize her using wheel chair and prevent complication.

The nursing goals were partially fulfilled before completed before discharge planning was commenced. The patient’s pain level was null at resting phase but reached with 2 when mobilised. She was discharged with consent and referred to a care facility. Patient and her family were engaged throughout the care plan and were taught about the condition during discharge to ensure no medication or patient safety occurred post discharge. They were also informed about the common physiological malfunctions that elderly people go through to help care for her more precisely.

I will be using the Rolfe reflective model to express my thought regarding the case study and answer three main questions: What?, So what? and Now what?. Answering to the first query; Mrs. S. Mariam is a married elderly 77 year old woman living in Abu Dhabi with her family who fell own at home anf got a fractured pelvis. She has admitted to the facility and diagnosed with extracapsular hip fracture on the right side and a medical history of hypertension which persisted for more than 25 years. My preceptor and I were the designated nurses given to take care of her. I tried to maintain her safety and applied preventive measures against falling along with nursing support o reduce her distress. I tried the application of massage in the affected area and spoke through her care to reduce pain and distress non-pharmacologically.  The act was appreciated by my preceptor as according to her emotional support helps patients overcome their recovery faster. I was empathising for her situation and provided pain medication along with emotional support.  Answering to the question So what?; If I had let the patient carry on suffering with her pain, she would have been unable to receive slumber, move properly and intake less food. All this would have affected her condition and the healing span would have been lengthened. Thirdly, Now what?; I received praising from my preceptor who pointed out that my care plan for her was successful as we were regarded the norms of the HAAD guidelines for patient safety and helped her calm her aching sensation that lead to her proper motor functionality like using the toilet, eating and getting used to the wheel chair et cetra.  The only dispute worth mentioning was the inefficiency of the nursing team. The workload could have been reduced if the fellow staffs cooperated to reduce pressure. Good team work would have helped the patient improve faster in a safer manner.   

Collect cues / Information

Keeping a goal to achieve patient safety ensures better health concern and minimizes the risk of hospital readmissions amongst the old aged people. Patient safety should be the focus of the care plan along with including the family ensures improvement of patient’s quality of life. Patient as well as family education is important to ensure no disparity in the support system.  Encouragement should be provided to care givers to note down the implication of adverse threats, which would help the care facility opportunity to provide proper assessment and improve acre management in times of error. Contemplation, foreseeing and double checking is importance before any decision is made so as to reduce patient safety risk.       

Conclusion

Summation of the discussion, provide insight that the primary reason for hospital admission is falling. Women are commonly observed to be admitted in the hospital than men, when it comes to hip or bone fractures. Geriatric show a common reasoning for hospital admission that is light-headedness along with other risk factors as a resultant of falling anf other bone injury. Clinical reasoning along with good decision making skills provides accuracy in care planning in hospitals which minimizes rate of falling or other similar incidents.    

References

Carl Thompson, Leanne Aitken, Diane Doran & Dawn Dowding. (2013). An agenda for clinical decision making and judgement in nursing research and education. International journa of nursing studies, 50, 1720-1726.

CDC. (2016, January 20). Home and recreational safety. Retrieved on March 23, 2016, from Centers for disease control and prevention: https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

Guo, K. L. (2008). DECIDE: A decision-making model for more effective decision making by health care managers. Lippincott nursing centre, 27 (2), 118-127.

Jones, L. (2013). Advanced clinical decision making. Australia : Pearson.

Michal Grivna, Hani O Eid & Fikri M Abu-Zidan. (2014). Epidemiology, morbidity and mortality from fall-related injuries in the united arab emirates. Scandinavian journal of trauma, resuscitation and emergency medicine, 22 (51), 1-7.

Nations, U. (2013). world population ageing. New York: United nations department of economic and social affairs.

Pedro Carpintero, Jose Ramon Caeiro, Rocio Carpintero, Angela Morales, Samuel Silva & Manuel Mesa. (2014). Complication of hip fracture: A review. World journal of orthopedics, 5 (4), 402-411.

Suzana Albuquerque de Moreas, Wuber Jefferson de Souza Soares, Eduardo Ferriolli & Monica Rodrigues Perracini. (2013). Prevalence and correlates of dizziness in community-dwelling older people: a cross sectional population based study. Biomedical central geriatrics, 13 (4), 1471-2318.

WHO. (2016). Violence and injury prevention. Retrieved on March 23, 2016, from World health organization: https://www.who.int/violence_injury_prevention/other_injury/falls/en/

WHO. (2007). WHO global reporton falls prevention in older age. Switzerland: World health organization.

Zhani, E. E. (2015, September 28). New sentinel event alert focuses on preventing patient falls. Retrieved on March 23, 2016, from The joint commission: https://www.jointcommission.org/new_sentinel_event_alert_focuses_on_preventing_patient_falls