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Personal Practice Improvement Episode (PPIE)

This assessment task requires you to write up an episode of care which includes evidence of professional accountability relevant to practice and capability development, demonstrating practice development through critical reflection.

Your episode should include all elements of the clinical reasoning cycle i.e (consider patient, collect cues, process information, identify problem/issue, establish goal take action evaluate outcome and reflect on practice )and demonstrate how you apply it to practice. Your paper should be well integrated with up-to-date scholarly literature to substantiate discussions on best practice.

Clinical Reasoning Cycle

Mrs. Brown was admitted to the emergency ward after she had a fall in her own house in the absence of her carer. When the carer had fetched to prepare her lunch, she heard a sound and cam to back to Mrs. Brown’s room tofind her lying on the floor. She had a fracture in her hop portion and was immediately admitted the orthopedic ward by her son and the carer. She is 67 years old and is suffering from extreme obesity, hypertension and osteoarthritis. She had lost the power of mobility and spends most of the time on bed only. She had also developed pressure ulcers and had been suffering for pain as well.  Her ADL are carried by the carer and medications are provided on time. However, she often tries to walk and perform activities independently as he cannot take the fact that she has become dependent. Her falls are mainly due to the fact that she tries to do her activities independently. Carer and son both revealed that she has become aggressive and does not properly converse with them making the situation more tensed. After immediate admission, she had undergone hip replacement and is currently under observation. She is quite stressed and anxious at the moment and is quite aggressive with the nursing professionals.

This step mainly involves the important steps like reviewing the current information like patients’ history, results of investigation and others. This step also includes gathering new information and recalling knowledge to develop an association of the physiology, pathophysiology, pharmacology and others with that of the patient’s condition (Alfaro-LeFevre 2015). The patient has been seen to be obese which is a harmful condition at such an old age as obesity is the main reason for different diseases like osteoarthritis and hypertension. Her BMI is quite high making her prone to the mentioned diseases. Moreover, she had also undergone several episodes of falls which however do not seem to be fatal unlike this time. in the last episode, she had fallen on her buttocks and the heavy weight had resulted in huge pressure on her parts resulting in the fracture of the bones. Moreover, she had also suffered bruises in arms and knees. Her pain quotient n analysis had been found to be quite high as 8/10. Moreover her blood pressure is also found to be quite high (145/95 mmHg) which has become one of the concern for her treatment as such high pressure often call for threat for lives. Moreover as she is not in a comfort zone with both her carer and her son, she is also mentally at unrest and this might have resulted in the development of anxiety and stress in her.

Patient Assessment and Analysis of Data

The step mainly involves the steps like analyzing the data to come to an understanding about the data and symptoms noted by the nurses. These steps also involves the discrimination that where the nurse needs to distinguish between the relevant and the irrelevant formation followed by relation the information to the present situation, inferring  logically and making suggestions about the situations (Victor-Chmil 2013). This step basically helps in solving the main rationales of the different symptoms and by relating the symptoms to specific habits and practices of the patients. Hs is followed by the prediction step. In the case study, it is found that the reason of fall is mainly due to the attempt the patient takes repeatedly to make herself feel independent. Basically, her carer as well as her son has not been able to develop a proper connection with the patient and therefore the patients suffered from different complexes when they helped her with her daily activities. Patient education was poorly done by the carer which had been the main result of her anxiety and stress (Shnayderman, Yugrakh and Levy 2016). Moreover even after several fall, proper fall prevention strategies and risk assessments were not done. From the BMI rate, it is evident that her diet plan was not proper and she also conducted no exercise sessions that made her more bed ridden. Moreover her pressure sores had been other symptoms of her frustration as proper rolling of her body positions and also use of proper mattresses was not prescribed by the carer (Nelson et al. 2014). Her pain for osteoarthritis also used to give her sleepless nights. Although the acre said that she provided regular medications, but absence of any sort of exercises and lack of physiotherapy had not helped in developing the situation Emotional health was also poor as she could not connect with her son and the carer (Bliddal et al. 2014).

This step mainly involves the proper synthesis of all the facts that had been collected and analyzed in the previous step. By this step, the nurses who in charge of the care plan can successively connect the links and can identify the main issue with the patients. The nurse usually makes a definitive diagnosis of the patient’s problems and hence can also form out a proper framework of the care plan for the patients (Brand et al. 2014). The most important identification that the nurse would make is the proper caring of the patient due to her surgery of hip replacement. In this stage, the nurse should first try to recover the patient from the physical pain after the surgery and also the pain she is having due to the bruises over her body parts, her pain of osteoarthritis is also taking hard time on her and therefore care plan should be introduced. Moreover, her aggression and anxiety is the main reason of her frequent high rise of blood pressure (Yates et al. 2014). Proper care for the pressure sores also needs to be taken Therefore establishment of a proper therapeutic relationship is very important for the nurse with the patients. A patient who is happy and content can respond to medications and other interventions more effectively.

Nursing Care Plan Implementation

The first goal that would be developed is the proper interventions for maintenance of her physical condition in the post operation phase as in this phase; she is prone to different kinds of infection. The second goal would be to set up strategies which would help her to relieve her form pain both of the surgery and also of the osteoarthritis (Losina et al. 2015). The third goals would be proper management of the diet of the patient and also to educate her of the different mild exercises she can take at the moment which would be beneficial for both of her body weight reduction and also osteoarthritis management. The fourth goals would be to properly manage pressure sore issues and educate the carer and family members about the proper ways of handling such patients. The last goals would be establish a proper counseling session of the patients to understand her complexes and to develop a compassionate relationship with her where she can rely on the nurse and overcome all her complexes (Patnaik et al. 2017). All these would be set in a time frame of a week so that positive changes are noted in the condition of the patients.

Infection: in order to change dressings, the nurse should use strict antiseptic as well as clean techniques with instruction to the patient to not touch or scratch any incisions. This would prevent any kind of contamination. This would also reduce the risk of wound infection. Proper maintenance on place of drainage devices is also very important as it helps in reduction of infection risk by preventing blood accumulation and joint space secretions (Burland et al. 2013). The nurse should know that odorous, purulent, non serous drainage that indicates the presence of infection along with drainage form infusion shows developing skin tract which causes infection. Proper assessment of the skin color should be done along with temperature, integrity, presence of erythema and inflammation and other. This is because all of these signs provide information about the status of healing process.

Pain management: proper report of the patients’ incision pain and changing characteristics of pain should be noted as pain which is not only depp and dull but also aching in operative areas. These indicate development of infection in joints. The nurse need to also conduct reports on pain, noting intensity (scale 0 to 10), duration and location which will help in understanding the effectivity of interventions. Proper position of ehere the operated extremity is present should be maintained so that there can be reduction in  muscle spasm and reduction of  tensions on prosthesis and also in different surrounding tissues (Weiss and Tapen 2014). Comfort should be provided like back rub, frequent repositioning and diversion activities. Stress management techniques should be also involved like progressive relaxation, visualization, meditation and also guided imagery. This will reduce muscle tension and reduce attention. Promotion of sense of control, enhancement of coping abilities will also be enhanced. Ambulation, physical exercises, therapies and exercise will also help to minimize joint stiffness and relieve muscle spasm.

Goals and Interventions

Management of diet and exercises would be incorporated and the involvement of proper dietician who will assess her BMI and will accordingly create a diet chart which will encourage a reduction of food calories without affecting her hypertension issues

Management of pressure sores will be done by properly by making her lie on air filled mattresses which will help in releasing the pressure unlike normal beds. Moreover, [roper rolling of her position at interval of four hours is also necessary to reduce the chance of her pressure sores.

Counseling of the patient is very important as she needs to openly discuss her self-insecurity and ego with the professional (Depuree et al. 2014). Accordingly the professional would be able to identify the main reason of aggression and counsel her properly to make her overcome her anxiety and aggression. Education of the family members is also important as they also need to understand the patient’s pony of view and modify their activities accordingly

After the introduction of the strategies, the entire planning would be given a one week time to check and note the response of the patient in each of the five goals. Depending on the patient’s response and results, the nurses should alter their care plan accordingly for the best benefit of the patients

While preparing the care plan, I have noticed that following the clinical reasoning cycle has helped me to properly note down all the symptoms of the patients and thereby helped me to analyze the main rationale behind occurrence of the disease. This procedure helped me to connect the emotional and physical state of the patients and thereby this helped me to understand her better. The different intervention were only proposed after thoroughly forming a network of connections behind the various diseases that the patient was suffering and this helped me to provide an overall  care plan which was a patient centered approach. Hence, this cycle prevented me from being disillusioned and confused with such a co morbidity situation of the patient and helped me to solve the entire care systematically without creating any issues or flaws.

References:

Alfaro-LeFevre, R., 2015. Critical Thinking, Clinical Reasoning, and Clinical Judgment E-Book: A Practical Approach. Elsevier Health Sciences.

Bliddal, H., Leeds, A.R. and Christensen, R., 2014. Osteoarthritis, obesity and weight loss: evidence, hypotheses and horizons–a scoping review. obesity reviews, 15(7), pp.578-586.

Brand, C.A., Harrison, C., Tropea, J., Hinman, R.S., Britt, H. and Bennell, K., 2014. Management of osteoarthritis in general practice in Australia. Arthritis care & research, 66(4), pp.551-558.

Burland, E., Martens, P., Brownell, M., Doupe, M. and Fuchs, D., 2013. The evaluation of a fall management program in a nursing home population. The Gerontologist, 53(5), pp.828-838.

DuPree, Erin, Amy Fritz-Campiz, and Donise Musheno. "A new approach to preventing falls with injuries." Journal of nursing care quality 29.2 2014: 99-102.

Losina, E., Paltiel, A.D., Weinstein, A.M., Yelin, E., Hunter, D.J., Chen, S.P., Klara, K., Suter, L.G., Solomon, D.H., Burbine, S.A. and Walensky, R.P., 2015. Lifetime medical costs of knee osteoarthritis management in the United States: impact of extending indications for total knee arthroplasty. Arthritis care & research, 67(2), pp.203-215.

Nelson, A.E., Allen, K.D., Golightly, Y.M., Goode, A.P. and Jordan, J.M., 2014, June. A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the US Bone and Joint Initiative. In Seminars in arthritis and rheumatism (Vol. 43, No. 6, pp. 701-712). WB Saunders.

Patnaik, S., Swain, N., Behera, C.K., Jain, M.K. and Nayak, M.K., 2017. Evaluation of knowledge, perception, attitudes, and practices of pain management of children among pediatric nursing personnel of a tertiary care hospital. Indian Journal of Child Health, 4(1), pp.75-78.

Shnayderman, M., Yugrakh, M.D. and Levy, O.A., 2016. Clinical Reasoning: A middle-aged man with episodes of gait imbalance and a newly found genetic mutation. Clinical Reasoning in Neurology: A Case-Based Approach, p.142.

Victor-Chmil, J., 2013. Critical thinking versus clinical reasoning versus clinical judgment: Differential diagnosis. Nurse Educator, 38(1), pp.34-36.

Weiss, S.A. and Tappen, R.M., 2014. Essentials of nursing leadership and management. FA Davis.

Yates Jr, A.J., McGrory, B.J., Starz, T.W., Vincent, K.R., McCardel, B. and Golightly, Y.M., 2014. AAOS appropriate use criteria: optimizing the non-arthroplasty management of osteoarthritis of the knee. Journal of the American Academy of Orthopaedic Surgeons, 22(4), pp.261-267.

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