Discuss about the Clinical Reasoning and Treatment Guidelines.
Clinical reasoning is a mode of judgment of nurses in the managing of patients. In clinical reasoning a couple of significant aspects to be taken into account are clinical diagnosis to find out accurate risk of the patient and clinical judgment to implement suitable management to the patient. It has been proved that effective and efficient clinical reasoning has positive outcome in patients. Clinical reasoning becomes very important aspect of healthcare system because there are increasing evidences of unfavourable patient results. Modern-day learning and teaching techniques are not all the time aid in the improvement of clinical reasoning skills, however it can be acquired through experience. Implementation of clinical reasoning in two priority areas such as impact on ADL performance and increased fall and injury risk in Johann Silvermann are considered in this case of Johann Silvermann (Levett-Jones et al., 2010).
Impact on ADL performance:
Impact on ADL performance was the first clinical priority considered for Johann Silvermann. Johann Silvermann is suffering with tremors in his hands. As a result, he is facing difficulties in his daily activities such as doing buttons of shirt, tea making, cooking, , and doing shoe laces. Tremors are regular problem in aged patients and as Johann is suffering from Parkinson's disease, it is adding more complications to his tremors. Due to these tremors there can be positive as well as negative functional consequences in case of Johann. Negative consequences can be reflected as helplessness of Johann in performing his daily activities and posstive consequences can be reflected by developing positive attitude and determination to carry out his daily activities with confidence. (Mauk, 2013).
Identifying issues : Nurse can play significant role in improving daily activities of Johann by developing physical, psychological and social confidence in him (Levett-Jones et al., 2010). Nurse should take into account that he is living alone as he is denied to go to his brother’s home. Nurse should be aware that his economic condition is not sound and he is not in position to have attendant to assist in his daily activities. Nurse should identify his illness and schedule of his daily activities. Nurse should be capable of collecting this information through observation and also should discuss with to collect information. Nurse should make a note of type of problems faced by Johann in current situation and in the past and total duration since he was facing these problems. Nurse should gather information about interests of Johann and particular tasks and mode of assistance he required. This person centred intervention by the nurse, helps in maintaining the comfort level and relaxed condition of Johann (Dalton et al., 2015; Levett-Jones et al., 2010). Nurse should take care that there should not be any effect on dignity of Johann while providing nursing care to him. Nurse should make sure that Johann should not feel helpless while assisting in his daily activities and he should lose his self confidence and self esteem in the society and community. After the collection of information about the daily activities of the Johann, nurse should make inference about the particular activities for which he requires help, vital daily task for him, order in which he perform his tasks, any alternative method is there to perform his task which is more comfortable to him, what is change in current activities form his earlier activities, are these activities really beneficial to him and he would feel more relived and relaxed due to planned activities. Nurse should take in confidence Johann about planned activities by demonstrating him planned activities and seeking his opinion on planned activities. This exercise would assist nurse in making final conclusion on type of activities and mode of activities, Johann seeking. This would help nurse to make necessary changes in the plan according Johann suggestions and make this plan more acceptable and suitable to Johann.
Goals: Next step for nurse in clinical reasoning of Johann is to establish perfect goals for improvement of Johann. (Brown & Shah 2013). Goals should be set to give Johann to seek improvement in performing daily tasks of Johann not only in physical way but also to give him psychological, mental and social advantage to him. These goals should be time bound and these goals should assess improvement of Johann in ascending order.
Take action: Support to Johann was extended in the daily activities like movement within the home, clothing, during meals, at the time of toilet use and maintaining personnel hygiene (Cooper, 2013). Decided daily tasks were categorised into independent activities like meals, activities under supervision like movement within the home, activities seeking limited assistance like personnel hygiene and activities seeking extensive assistance like clothing and toilet use.
Evaluation: To assess improvement in the daily activities, these activities were evaluated at set predetermined time points like seven days and thirty days. There was improvement observed in the movement within the home, in taking meals, personnel hygiene, however there was no improvement in the clothing and toilet use (Ciro, 2014).
Reflection: I was energized and delighted to help Johann in his routine tasks. I understand that care of patient in non-medication mode is demanding than care of patient with medication. It requires lot of experience, expertise and interpreting capability about the exact situation of the patient. These things cannot be acquired in classroom teaching; however your skills can teach things. This experience will definitely help me to take responsibility such type of patients.
Fall and injury risk:
Fall and injury risk was the second priority area considered for Johann. It has been well established that fall risk is the major problem in aged people like Johann and moreover, Parkinson's disease of Johann is added complication for his fall risk. Without any help, he is living in as two-storey building. Johann has to take care of all his daily tasks without help of anybody and in near past he experienced problem in performing his tasks on his own. Furthermore, while he is living in two-storey building, there are chances of his fall. There can be both positive as well as negative consequences of his fall and injury (Mauk, 2013). In negative impacts owing to the fall, he may have severe injuries, further it can be complicated by remained unnoticed as he is staying alone and suitable treatment not feasible before condition becomes worsened. In terms of positive consequences, Johann can become more alert due to the fall and he can perform all his routine activities more carefully and avoid performing risky tasks .
It has been well established from the prior evidences that nursing intervention is the paramount option for the prevention of fall and injury in case of Johann (Dalton et al., 2015).
Identifying issues: Nurse should keep in mind that due to his old age and as he is living alone in his two-storey, there is possibility of fall for Johann while performing his routine tasks. Before initiating nursing strategy for fall to Johann, nurse should know about the fall history of Johann and whether he is consuming any medicines which are responsible for his fall. Nurse should collection information about fall condition of Johann by asking him questions and nurse should have keen observation on his movements. Next task for nurse post information collection is to study the evidences form collected information and make inferences about the causes and risk factors of his fall. Nurse should circumvent inappropriate information such as fall occurred due to manual mistakes. Nurse should compare fall reasons of Johann due to natural reasons and manual reasons. Nurse should assess reasons for fall of Johann by applying well established techniques like One-Legged Stance Test (OLST) and Timed Up and Go (TUG) test (Phelan et al., 2015). From this techniques nurse should acquire information about the fall reasons of Johann in current situation. Based on the information collected information from these tests and from earlier evidences, nurse should interpret that main reason behind fall of Johann in his daily tasks and it is a severe issue in case of Johann.
Goals: Directed towards these reasons of fall, nurse should decide some goals for Johann to prevent his fall. These goals should include both medical and non-medical interventions.
Take action: Medical interventions include vitamin D administration at high doses and abandonment of or reduced frequency of Parkinson's disease medicines. Exercise or physical training and application of body protectors specifically for joints and hip region are the non-medical interventions for fall in Johann. Nurse should initiate vitamin D administration to Johann at high doses and continued upto one month. Also, nurse should reduce administration rate of Parkinson's disease medicine for one month. Nurse should teach some exercise to Johann and asked him to continue up to one month. Also, nurse asked him to walk daily at least 15 minutes in the front space of his home. Nurse offered him accessories like hip protectors and body protectors.
Evaluation: Nurse evaluated each goal at predermined time points and at the end of one month. At the end of one week, there was improvement in the fall of Johann in case of exercise. In case of vitamin D administration, there was small fracture in his elbow in first week, however after that there was no fracture upto completion of one month. Three were two falls in the first week in case of Parkinson's disease medicine withdrawl, however there were no fall after that upto completion of one month. In case of body protector use In case of body protector use, there were two small injuries to Johann in first week, however there were no injuries after that upto the end of one month (Levett-Jones et al., 2010).
Reflection: While managing fall and injury condition of Johann, I understand problems of older people and how difficult it is to convince these people to convince them. I learned that it is very important to maintain these peoples self-belief and I succefully achieved this. So, I got confidence on myself also to handle such type of patients in future also. Foe the very first time, I managed a patient both for his physiological and psychological disturbances. For this, I used both medication based and non-medication based interventions.
Clinical reasoning was implemented in the two priority areas like impact on ADL performance and increased fall and injury risk in Johann Silverman. In this process of application of clinical reasoning, nurse evaluated both the negative and positive consequences of respective priority areas. Before initiating particular intervention, nurse studied the patient and made inference of his current clinical situation. In doing this process nurse collected all the information related to the patient, analysed it, made rational diagnosis of the condition, identified risk factors, decided nursing intervention goals, discussed with patient, amended these goals according to patient comfort level to maintain patient dignity, implemented nursing intervention tasks with fixed goal, evaluated these goals and analysed the outcome of the nursing intervention in that particular task. It has been concluded that implementation of Millers functional consequences theory of framework and Levett-Jones clinical reasoning demonstrated positive outcome in the treatment of patient condition.
Bell, J.S., Blacker, N., Edwards, S., et al. (2012). Osteoporosis-pharmacological prevention and management in older people. Australian Family Physician, 41, 110–8.
Brown, T. A., & Shah, S.J. (2013). Evidence-Based Clinical Reasoning in Medicine. People's Medical Publishing House USA.
Cooper, C. (2013). Fundamentals of Hand Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity. (2nd edition). Elsevier.
Ciro, C.A. (2014). Maximizing ADL Performance to facilitate aging in place for people with Dementia. Nursing Clinics, 49(2), 157–169.
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, 33(2), 28-34.
Levett-Jones, T., Sundin, D., Mark, B., Hague, K., et al. (2010). Learning to think like a nurse. HNE Handover For Nurses And Midwives, 3(1), 15-20.
Levett-Jones, T, Hoffman, K., Dempsey, J., Jeong, S.Y., et al. (2010). The 'five rights' of clinical reasoning: an educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients. Nurse Education Today, 30(6), 515-20. doi: 10.1016/j.nedt.2009.10.020.
Mauk, K. L. (2013). Gerontological Nursing: Competencies for Care. (3rd edition). Jones & Bartlett Learning.
Phelan, E.A., Mahoney, J. E., Voit, J. C., & Stevens, J.A. (2015). Assessment and management of fall risk in primary care settings. Medical Clinics of North America, 99(2), 281–293.