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Complete a case study which discusses the provision of ethical, legal, evidence based, holistic person-centred care including the establishment of realistic and relevant goals through the theoretical examination of a particular nursing specialty case study using the Clinical Reasoning Cycle (Levett-Jones, 2013).

Considering Patient Situation

Critical decision making is one of most important responsibilities of the practicing nurses and in order to be able to provide safe, effective and person centred care, and the nurses require the skill of critical analytical thinking and clinical reasoning (Hunter & Arthur, 2016). Researchers are of the opinion that nurses that have active clinical reasoning skills, often are associated with a higher rate of positive patient care outcomes than nurses with lower clinical reasoning skills and competence. Hence, undoubtedly the importance of the clinical reasoning cycle coined by the Tracy Levett Jones is optimal (Dalton, Gee & Levett-Jones, 2015). This essay will attempt to implement the steps of the clinical reasoning cycle with respect to providing culturally safe and effective care planning and implementation for the multicultural patients taking the assistance of a case study.

The patient is Kath, a 62year old Indigenous Australian woman who visited the health acre facility due to the large vascular ulcer on the medial aspect of her right calf following a fall. The vascular ulcer subsequently becoming infected and turning gangrenous over 6 months and even with treatment there had not been any positive response. As a result she had to undergo amputation right below the left knee for which she had been admitted to the facility.

The past medical history of the patient states that she had peripheral vascular disease (PVD) which has developed secondary to the type II diabetes that she had. PVD is a common blood circulation disorder which is caused by blocked and narrowed blood vessels facilitated by the process of arteriosclerosis (Khalil et al., 2015). Kath had type II diabetes which is a common etiologic trajectory for the patients acquiring organic PVD, which is the case for Kath as well, which indicates at poorly controlled diabetes. Furthermore, Kath sustained a fall which resulted in a large vascular ulcer, unresponsive to treatments. Exploring further, the PVD is associated with venous inefficiency which limits the blood flow through the veins and slows down the process of wound healing (Li et al., 2018). In case of Kath as well, the venous insufficiency is the major cause to the lack of wound healing which eventually led to the amputation as well. Considering the acre requirement in the post-operative care unit, the impact of PVD and associated venous inefficiency will need to be considered for her amputation wound healing. As per the last recent patient records, Kath was responding well and is in track for recovery and requires assistance for rehabilitation care. Hence, the nursing care for her will need to focus on mobilization safety, proper diabetes management and surgical wound infection control (van Twillert et al., 2015). Her existing medication includes Metformin 1g TDS.

Collecting and Processing Health Related Information

Identification of health issues or problems based on the processing of the assessment data is an essential step of the clinical reasoning based care planning. For, Kath there are various health issues that needs to be addressed in the rehabilitation unit. The nursing problems are:

  • Mobilization with prosthetics will be a significant care need in the rehabilitation setting for Kath due to her amputation surgery.
  • Pain management due to her amputation surgery
  • Slowed surgical site wound healing and infection control due to her peripheral vascular disease and type II diabetes (van Twillert et al., 2015).
  • Need for patient education on lifestyle modification to better manage her diabetes and PVD
  • Assistance in better coping with empowerment and independence based living due to the disability and loss of limb
  • Culturally safe and appropriate community care and support due to living alone with no one to care about her

Although each of the care needs are needed to be addressed by the health care staff while planning care for the patient, prioritizing the care needs as per the situation of the patents is another very important task that the nurses are required to deal with. In this case, Kath had a few pressing care needs that are needed to be considered in order for the recovery progress of the patient not be affected in any manner. The first care priority which will require immediate attention before her discharge includes proper education and training to assist Kath in safe mobilization with the help of prosthetic devices and support advice that she can attain from different community care services and organizations (Li et al., 2018). The second care priority for her will be education and collaborative planning to assist her in better management of the type II diabetes while being disabled with respect to diet, lifestyle modification and physical activity. The third care priority for her will be better wound management and better infection control while taking into consideration her diabetes and PVD (Chrvala, Sherr & Lipman, 2016).

After the outlining of the care priorities, the next step for the nurse is to outline care goals for the patient with respect to the care needs and decided outcomes for the patient. In this case, for the first care priority identified, the care goal will be to assist and educate Kath with best practice evidence so that she can be well acquainted with the prosthetic device that will help her mobilize better and be able cope with her loss of leg better. For the second care priority, the care goal will focus on providing best practice evidence based education on better management of her diabetes with respect to her present disabled condition and collaborate with her to arrive at a lifestyle modification plan. For the third care priority, the care goal will be to ensure proper infection control and wound management initiatives along with culturally safe community support.

This forms the next part of the clinical reasoning cycle that aims to formulate a plan and implement it accordingly in the form of different pharmacological or non-pharmacological interventions that are able to adequately meet the identified care priorities of the patient. Some research studies have elaborated on the fact that after the first year of undergoing an amputation surgery, more than half of the amputees suffer falls (Hunter et al., 2017). This creates devastating impacts on their residual limb. Additionally the first care priority has also been established on the fact that relearning basic mobility functions after a surgery is often challenging. Thus, the ultimate goal is to help the client ambulate successfully, by using prosthesis. Such education programs will primarily focus on the process of rehabilitation where Kath will be made to participate in different phases namely, prosthetic training, community integration, and vocational rehabilitation (Chuka et al., 2017). These commonly encompass a range of simple exercises that are designed in a way that enhances balance and promotes the weight bearing property over the prosthetic limb, which will greatly benefit Kath.

Identifying the Care Problems


The care priority can be easily accomplished owing to the fact that such prosthetic training programs focus on the importance of assessing the functional strength of the major groups of muscles in the limbs, thus determining the potential skills of a patient in performing several activities such as, wheelchair management, transfers, and ambulation (Gaunaurd et al., 2015). Integration into the community generally focus on resumption of the roles in community and family activities. Furthermore, Kath will also be made to participate in recreational activities that have a relatively low impact. Diabetes self-management on the basis of education forms a critical component of care for all people at a risk of or suffering from diabetes (Powers et al., 2017). Education for type 2 diabetes management is important for preventing and/or delaying the complications that are associated with diabetes owing to the fact that it comprises of several elements that are associated with lifestyle modifications (Chrvala, Sherr & Lipman, 2016).

Diabetes educators will implement evidence-based education and provide support to Kath for self-management of the condition. This education program would incorporate nutritional management, physical activity, and dietary changes into lifestyle, such as intake of food that are rich in fibre content and a reduced consumption of sugar or fat-rich food products (Pereira et al., 2015). Clinicians will take into account the drainage amount for maintaining a moist wound environment. Some of the fundamental elements encompassed in this infection control policy is hand hygiene, cleansing, dressings and wound treatments. Assessing the entire limb, and not just the site of amputation, in addition to the cautious use of antibacterial dressings will reduce risks of contamination (Andrews, Houdek & Kiemele, 2015).

Reflection and Conclusion:

Thus, it can be concluded that this case study provided me an outstanding opportunity for gaining a deeper understanding of the different stages of a clinical reasoning cycle. It also helped to gain an insight into the challenges or barriers that can be encountered in a real-time setting, while providing care to a patient who has similar problems as Kath. Diabetes has often been found to contribute to the development of peripheral artery diseases that result in a constriction or narrowing of the blood vessels, thus reducing the flow of blood to the feet and the legs (McDonald, Sharpe & Blaszczynski, 2014). In addition, high blood glucose levels damage the nerves and result in a loss of sensation from the affected area, thereby increasing the likelihood of developing an injury, and subsequent gangrene (Shigemoto et al., 2018). This assignment provided me with the opportunity to understand the care plan that must be implemented in such scenarios and the way by which different interventions can be implemented upon the affected individuals, in future practice.

Care Priorities

References:

Andrews, K. L., Houdek, M. T., & Kiemele, L. J. (2015). Wound management of chronic diabetic foot ulcers: from the basics to regenerative medicine. Prosthetics and orthotics international, 39(1), 29-39.

Chrvala, C. A., Sherr, D., & Lipman, R. D. (2016). Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient education and counseling, 99(6), 926-943.

Chrvala, C. A., Sherr, D., & Lipman, R. D. (2016). Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient education and counseling, 99(6), 926-943.

Chuka, R., Abdullah, W., Rieger, J., Nayar, S., Seikaly, H., Osswald, M., & Wolfaardt, J. (2017). Implant Utilization and Time to Prosthetic Rehabilitation in Conventional and Advanced Fibular Free Flap Reconstruction of the Maxilla and Mandible. International Journal of Prosthodontics, 30(3).

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.

Gaunaurd, I., Spaulding, S. E., Amtmann, D., Salem, R., Gailey, R., Morgan, S. J., & Hafner, B. J. (2015). Use of and confidence in administering outcome measures among clinical prosthetists: Results from a national survey and mixed-methods training program. Prosthetics and orthotics international, 39(4), 314-321.

Hunter, S. W., Batchelor, F., Hill, K. D., Hill, A. M., Mackintosh, S., & Payne, M. (2017). Risk factors for falls in people with a lower limb amputation: a systematic review. PM&R, 9(2), 170-180.

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

Khalil, H., Cullen, M., Chambers, H., Carroll, M., & Walker, J. (2015). Elements affecting wound healing time: an evidence based analysis. Wound Repair and Regeneration, 23(4), 550-556.

Kumar, S., Gupta, A., Aswal, V., & Barala, P. D. (2017). Prevalence of Asymptomatic Peripheral Vascular Disease Among Type 2 Diabetes Mellitus Patients. Int J Cur Res Rev| Vol, 9(10), 49.

Li, W. S., Chan, S. Y., Chau, W. W., Law, S. W., & Chan, K. M. (2018). Mobility, prosthesis use and health-related quality of life of bilateral lower limb amputees from the 2008 Sichuan earthquake. Prosthetics and orthotics international, 0309364618792720.

McDonald, S., Sharpe, L., & Blaszczynski, A. (2014). The psychosocial impact associated with diabetes?related amputation. Diabetic Medicine, 31(11), 1424-1430.

Pereira, K., Phillips, B., Johnson, C., & Vorderstrasse, A. (2015). Internet delivered diabetes self-management education: a review. Diabetes technology & therapeutics, 17(1), 55-63.

Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., ... & Vivian, E. (2017). Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes Educator, 43(1), 40-53.

Shigemoto, R., Anno, T., Kawasaki, F., Irie, S., Yamamoto, M., Tokuoka, S., ... & Okimoto, N. (2018). Non-clostridial gas gangrene in a patient with poorly controlled type 2 diabetes mellitus on hemodialysis. Acta diabetologica, 55(1), 99-101.

van Twillert, S., Postema, K., Geertzen, J. H., & Lettinga, A. T. (2015). Incorporating self-management in prosthetic rehabilitation: case report of an integrated knowledge-to-action process. Physical therapy, 95(4), 640-647

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