Effective clinical reasoning skills are vital for a nurse to improve patient’s health condition and ensure positive outcomes. The process of clinical reasoning developed by Levett Jone is the cycle of linked and ongoing clinical situations (Dalton et al. 2015). The paper deals with the case study of Leonard who is presented to the acute medical ward after fall. The report discusses Leonard’s falls and other health risk factors using the reasoning cycle framework. The report further critically evaluates the best-practice assessment tools appropriate for the case. Lastly, the report presents the support given to Leonard applying the person-centred approach while meeting the obligations as health professional.
Collection of information
As per the case history of Leonard, his age is 65 years. He is admitted to acute medical ward by the Emergency Department after falling at local shop. He did not sustain a fracture, although he had severe bruising of his face and hip. He is diagnosed with decompensate liver disease due to heavy alcohol intake (40 g/day for last month). His clinical handover shows present symptoms of anorexia, dyspnoea, jaundice, and lethargy. He was not coping with his illness prior to his admission. His admission history shows mental and behavioural disorder due to alcohol dependence, a decubitus ulcer on the shin of his left leg, anaemia, industrial deafness, some evidence of urinary incontinence, mild hypotension, lower limb oedema, and regular falls. After his wife death, Leonard has lost support system. He lives in a single storey house, with four steps to the front and two steps at the back with no rails. He lives with his housemate, who is mentally ill and rarely home. He receives mild support from his two elder sisters. Over the last six months, he is unable to carry his activities of daily living independently. In addition, he has some evidence of urinary incontinence and lower limb oedema. He had a Mini Mental State Examination (MMSE) score of 28/30, but appears to have little insight into his problems and also exhibits motor planning difficulties. In addition, Leonard also has industrial deafness as he worked as boilermaker in a very noisy factory. The patient denies support services at home; however, he is keen to return home. The cause of physical deterioration was due to range of manual and labouring jobs. He is mostly restricted to home with no entertainment.
Leonard has severe risk of fall in future as he his physically fragile. His physical frailty is also evident from his need of walking frame for mobility. Recently, his functioning has detoriated due to which he is not able to perform his activities of daily living independently. Due to dyspnoea, anorexia, arthritis in his lower back, mild hypotension, he is at risk of poor physiologic condition and poor mobility (Shen et al. 2015). According to Soenen and Chapman (2013. P. 643) lack of grab rails on the toilet is adding to the risk of fall. Adding to the risk is his muscle weakness, poor balance and risk of gait. MMSE score of 28/30 is indicative of normal cognition. However, Motor planning difficulties and confusion can lead to frequent accidents and decrease confidence (Schoene et al. 2014).
He needs dietitian to maintain healthy nutritional status, as he is anorexic and anaemic. His alcoholic liver disease also increases the risk of gastrointestinal tract upset. His symptoms of dyspnea increase the risk of respiratory diseases (Yeluru et al. 2016). Leonard has poor coordination and is not mentally alert. It is evident from his poor planning of tasks and inability to get dressed (Mihaljcic et al. 2015). He lacks support and care needed as he lives alone with his housemate too has mental illness. He receives inadequate support and assistance from his two elder sisters. He was in bereavement after his wife’s death due to cancer. It may have caused him to developed fear of hospitals. This fear is depriving him of receiving adequate physical and mental health care (Keyes et al. 2014). His alcohol dependence is also the outcome of his bereavement and has caused decompensate liver disease. He lacks love, belongingness and affection, which is decreasing his coping with illness (Feng et al. 2014). Lack of family member’s support and hearing impairment decreases social life and depression. It decreases functional and emotional status. Leonard has low energy to take part in recreational activities such as gardening and fishing. Financial constraints in addition to illness may be adding to the depression (Roets-Merken et al. 2015).
In conclusion, Leonard has high risk of fall. In addition to that, other health risk factors of Leonard include
The three best practice assessment tools appropriate for this case are Falls Risk Assessment Tool or FRAT, Mini-mental state examination or MMSE, and Alcohol use screening assessment tool.
The best practice assessment tools for Leonard for his fall are Peninsula Health FRAT. It is commonly used in Australia for elderly people living in community (Hill et al. 2016). The study evaluating the reliability and validity of FRAT has been published in Cattelani et al. (2015). FRAT has three sections. The first section assesses falls risk status followed by the second section consisting of risk factor checklist and the last section dealing with action plan. The tool requires approximately 15-20 minutes. The tool has criterion that is Medium risk: score of 12–15 and a High risk: score of 16–20. This assessment tool gives detailed information on the underlying factors contributing to the patients fall. It serves as screening test only
The best practice assessment tools for cognition are MMSE. This tool is effective for grading the cognitive state of the client. The tool gives information on the degree of cognitive impairment (out of 30 if the score is 21-24 then it is mild impairment, 10-20 as moderate and
The third assessment tool appropriate for Leonard is the Short Michigan Alcoholism Screening Instrument – Geriatric Version (SMAST-G). The instrument has scoring system where a score of 2 or more responses for “Yes” indicates the alcohol dependency problem. This tool is the first step to develop interventions and referral to treatment (Taylor et al. 2014). Nurses can use the scores to determine the degree to cut alcohol intake when scored high above the recommended state. In older adults the score helps to determine the risk of depression, anxiety, gastrointestinal problems. The instrument can only be used for screening and has been commonly used for older adults who are drinking at higher levels. The tool has been found to have high sensitivity and specificity. The feasibility and the acceptability of the tool has been tested and its reliability and validity has been published in Randall-James et al. (2015)
In nursing practice, person-centred care is essential to improve patient’s health outcomes. As a nurse, focus will be put on Leonard’s individual needs and goals. The family member of the client will be involved as appropriate. His right of autonomy will be ensured by involving him in making heath related decisions. His rights to access health care information, treatment options and express personal concerns will be maintained. The patient’s right to dignity will be maintained by knowing the patient as an individual, being responsive, and respecting his values, needs and preferences. While caring and promoting physical and emotional comfort emphasis will be given on his freedom of choice. Patient’s Privacy will be respected while caring and confidentiality of the information will be protected. The standards set by the Nursing and Midwifery Board of Australia in respect to the code of ethics will be complied. The standards set by the board will be strictly followed for providing the right care to the patient considering the spiritual, cultural and ethnic factors (Gray et al. 2016).
The paper has highlighted the health risk factors of Leonard supporting with literature. It has discussed the effective assessment tools for Leonard. In conclusion, nurses need effective clinical reasoning skills to identify the health risk factors and priority needs of patient. Nurse must be aware of the necessary tools for health assessment of patients to develop effective care plan. Nurses must protect patient’s rights, as it is important for their satisfaction of health care services. Nurses need to be competent in implementing the person centred approach and must be efficient in placing the patient’s needs above those identified as priorities by the heath cafe professional.
Cattelani, L., Palumbo, P., Palmerini, L., Bandinelli, S., Becker, C., Chesani, F. & Chiari, L., 2015. ‘FRAT-up, a web-based fall-risk assessment tool for elderly people living in the community’. Journal of medical Internet research, vol. 17, no. 2.
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, vol. 33, no.2, p. 29.
Feng, L., Nyunt, M.S.Z., Feng, L., Yap, K.B. & Ng, T.P., 2014. ‘Frailty predicts new and persistent depressive symptoms among community-dwelling older adults: findings from Singapore longitudinal aging study’. Journal of the American Medical Directors Association, vol. 15, no. 1, pp.76-e7.
Gray, M., Rowe, J. & Barnes, M., 2016. ‘Midwifery professionalisation and practice: Influences of the changed registration standards in Australia’. Women and Birth, vol. 2, no. 1, pp.54-61.
Hill, K.D., Flicker, L., Logiudice, D., Smith, K., Atkinson, D., Hyde, Z., Fenner, S., Skeaf, L., Malay, R. &Boyle, E., 2016. Falls risk assessment outcomes and factors associated with falls for older Indigenous Australians. Australian and New Zealand journal of public health, vol. 40, no.6, pp.553-558.
Keyes, K.M., Pratt, C., Galea, S., McLaughlin, K.A., Koenen, K.C. & Shear, M.K., 2014. ‘The burden of loss: unexpected death of a loved one and psychiatric disorders across the life course in a national study’. American Journal of Psychiatry, vol.171, no. 8, pp.864-871.
Mihaljcic, T., Haines, T.P., Ponsford, J.L. & Stolwyk, R.J., 2015. ‘Self-awareness of falls risk among elderly patients: characterizing awareness deficits and exploring associated factors’. Archives of physical medicine and rehabilitation, vol. 96, no. 12, pp.2145-2152.
Mitchell, A.J., 2017. ‘The Mini-Mental State Examination (MMSE): update on its diagnostic accuracy and clinical utility for cognitive disorders’. In Cognitive Screening Instruments. Springer International Publishing, pp. 37-48.
Randall-James, J., Wadd, S., Edwards, K. & Thake, A., 2015. ‘Alcohol screening in people with cognitive impairment: an exploratory study’. Journal of dual diagnosis, vol. 11, no.1, pp.65-74.
Roets-Merken, L.M., Draskovic, I., Zuidema, S.U., van Erp, W.S., Graff, M.J., Kempen, G.I. & Vernooij-Dassen, M.J., 2015. ‘Effectiveness of rehabilitation interventions in improving emotional and functional status in hearing or visually impaired older adults: a systematic review with meta-analyses’. Clinical rehabilitation, vol. 29, no. 2, pp.107-119.
Salminen, H., Zary, N., Björklund, K., Toth-Pal, E. & Leanderson, C., 2014. ‘Virtual patients in primary care: developing a reusable model that fosters reflective practice and clinical reasoning’. Journal of medical Internet research, vol. 16, no. 1, p. e3.
Schoene, D., Valenzuela, T., Lord, S.R. & de Bruin, E.D., 2014. ‘The effect of interactive cognitive-motor training in reducing fall risk in older people: a systematic review’. BMC geriatrics, vol. 14, no. 1, p.107.
Shen, H.W., Feld, S., Dunkle, R.E., Schroepfer, T. & Lehning, A., 2015. ‘The prevalence of older couples with ADL limitations and factors associated with ADL help receipt’. Journal of gerontological social work, vol. 58, no. 2, pp.171-189.
Soenen, S. & Chapman, I.M., 2013. ‘Body weight, anorexia, and undernutrition in older people’. Journal of the American Medical Directors Association, vol. 14, no. 9, pp.642-648.
Stein, J., Luppa, M., Kaduszkiewicz, H., Eisele, M., Weyerer, S., Werle, J., Bickel, H., Mösch, E., Wiese, B., Prokein, J. & Pentzek, M., 2015. ‘Is the Short Form of the Mini-Mental State Examination (MMSE) a better screening instrument for dementia in older primary care patients than the original MMSE? Results of the German study on ageing, cognition, and dementia in primary care patients (AgeCoDe)’. Psychological assessment, vol. 27, no. 3, p.895.
Taylor, C., Jones, K.A. &Dening, T., 2014. ‘Detecting alcohol problems in older adults: can we do better?’. International psychogeriatrics, vol. 26, no. 11, pp.1755-1766.
Yeluru, A., Cuthbert, J.A., Casey, L. & Mitchell, M.C., 2016. ‘Alcoholic Hepatitis: Risk Factors, Pathogenesis, and Approach to Treatment’. Alcoholism: Clinical and Experimental Research, vol. 40, no. 2, pp.246-255.
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