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Clinical Reasoning Cycle for Leonard

Leonard is a 65-year-old man who was admitted to an acute medical ward via the Emergency Department after falling at the local shops. He did not sustain a fracture, although he had severe bruising of his face and hip. His main diagnosis was decompensated liver disease. His presenting symptoms included dyspnoea, anorexia, lethargy, jaundice and ascites. Leonard is being seen by a social worker as he was not coping at home prior to admission. He has also been referred to a dietitian. Leonard’s past medical history includes alcoholic liver disease caused by heavy alcohol intake (180 g/day for years, 40 g/day for last month). He recently claimed to have ceased drinking alcohol. Leonard has mental and behavioural disorders due to alcohol dependence, a decubitus ulcer on the shin of his left leg (0.5 cm long), arthritis in his lower back, anaemia, industrial deafness, mild hypotension, some evidence of urinary incontinence, lower limb oedema, and regular falls. Leonard lives with a housemate in his own house, although both men are independent of each other. The housemate has a mental illness and is rarely home, so is unable to provide support for Leonard. Leonard’s wife died of cancer 15 years ago at the age of 43. They have no children. Leonard cared for her at home for many months before she died. Leonard’s sister believes that he developed a fear of hospitals from that time, and began drinking heavily after his wife’s death. Leonard has two sisters, both older than him, who live nearby and are supportive, but cannot provide care at night. Both sisters have expressed their concern that Leonard will need community support to manage at home.
Six months ago Leonard was independent in all self-care, but his functioning has deteriorated over the last six months. His personal care has declined, and he has become quite unkempt over this time. The house and garden have also been neglected, and his sisters have been cleaning the house occasionally. Leonard appears quite confused and disorientated. 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. Leonard is keen to return home and cooperates with treatment interventions. He is, however, resistant to suggestions that he should have support services at home.

Leonard uses a walking frame for mobility. He is currently very slow and can be impulsive when mobilising. He requires the physical assistance of one person to negotiate steps with a rail in the hospital, needs supervision for transfers, and can participate in self-care activities when set up. Leonard has some difficulties planning tasks needed to get dressed. He lives in a single storey house, with four steps to the front and two steps at the back with no rails. There is one 300 mm internal step down to the toilet via a sliding door. There are no grab rails in the toilet. The bathroom is adjacent to the bedroom and consists of a separate bath and shower recess with a 100 mm shower hob and curtained access, but no rails. Leonard usually sits in a low recliner armchair and his bed is low and soft. He has an electric stove and microwave oven to prepare food.

Leonard used to work as a boilermaker in a very noisy factory prior to giving up work to care for his wife. Following her death, he worked casually doing a range of manual and labouring jobs, prior to his deterioration. Leonard used to be a keen gardener, and enjoyed fishing prior to his wife’s illness. Over the past six months Leonard has been spending more and more time in bed with no activities to interest him.

Residential care has been offered to Leonard, but he has declined, insisting that he wants to remain at home.

In your report you will address the following issues for Leonard based on this case study.

1. Identify, using the clinical reasoning cycle, Leonard’s falls and other health risk factors. 
2. Critically evaluate three best-practice assessment tools appropriate for this case. 
3. Critically apply a person-centred approach to support Leonard’s rights, while meeting your obligations as a health professional.

Clinical Reasoning Cycle for Leonard

Clinical reasoning cycle is a culmination of the critical thinking and clinically reasonable evaluation of the symptoms of the patients and arrives at a concluding set of interventions that will help the patient. The first step to this clinical reasoning cycle is to consider the patients situation, in this case the patient is suffering from health conditions that pose a high risk to the heath and wellbeing of the patients there are a number of risk factors associated with him. He is pale, has encountered a fall, and is extremely weak. Upon this stage the health care professional is supposed to collect cues from the patient about his apst and present conditions. This is the second stage to the clinical reasoning cycle, and is concerned with eliciting all kinds of information’s from the patient about his past and present medical history. In this case scenario the patient has been suffering from medical conditions like malnutrition, anorexia and extremely fatigue. Along with that the patient has also suffered a fall and has attained a number of injuries as well. The nets step to a succinct clinical reasoning approach is processing the information collected by the health care professional. This is the step in which the health care professional assigned to him will evaluate and analyse the information collected and will attempt to determine the causes behind the medical conditions he has developed, In is old age he already is going through deteriorating health conditions and his long history of alcoholism has complicated his health further. He is in walking support and is in high of falling and unconsciousness which can potentially harm him further (Dalton, Gee and Levett-Jones 2015). Apart from that the patient is going through severe dyspnoea and being in acute care he has high risk of respiratory tract infection as well. And along with that the anaemia can cause further complications in the patients. In order to process the medical information about the patient, it is important to process the history of alcoholism as well. It has also been found out that the alcohol addiction has also generated behavioural and personality disorders in him, with the grief he endured due to the loss of his wife this can generate multiple personality disorders and psychological problems like agitation, hallucination, paranoia, and anxiety as well (Zeng, et al. 2015). His motor skills are at a risk of getting impaired as well at this point and he is in dire need of a multidisciplinary and highly impactful complex treatment plan and intensive care. Although the mental state examination score for him was 28 out of 30 so the patient was not in any immediate risk mental disorders (Fernandes, D’Cunha and Suresh 2014). However if his behavioural disorders are addressed with proper counselling and cognitive behavioural therapy coupled with the treatments that he is in need of for his other health care concerns like airway clearance, proper diet and iron supplements for the anaemia, he can approach multiple serious health concerns that can be lethal (Zeng, et al. 2015).

Person-Centred Care for Leonard

The last stage to a compact clinical reasoning cycle is drawing a conclusion depending on the information collected and processed about the case study of the patient and the consideration for this assignment. All the information that have been accumulated about the patient and his medical condition,  indicate at the 3 major risk factors, the first being is heavy risk to falling. It has to be understood that the patient is aging and in a aging condition, with all the medical complications that he has developed he could again face a fall and this time get more injuries (Taylor, Dowding and Johnson 2017). The second risk to him being the lack of nutrition in him that has already started manifesting into fatigue and the third risk to him is the loss of cognitive abilities due to all medical complexities and extensive medication that he is under (Taylor, Dowding and Johnson 2017). 

Best practice assessment tools are one of those health care innovations that helped the he heath care plan to be moulded in a manner that suited the specific and unique needs of different patients dealing with different health care problems (Liou et al. 2016).

First and foremost, it has to be considered that the patient is aging and is weak, and his major clinical risk is falling. . In the clinical reasoning of approach the health care professionals utilize a series of step by step actions to ensure that the patient does not succumb to any other fall situation (Martin 2014).  For this purpose the best practice assessment tool that can be used is the fall assessment tool which is essentially a geriatric assessment tool. Apart from risk of falling and attaining injury the patient is malnutrioned and extremely fatigued (Valentine, Nembhard and Edmondson 2015).

In case of aging patients, any changes in their medical condition, be it the change in their severity of the medical issue they are suffering from, or change in their medication, or change in their response to the medication can result in falling (Valentine, Nembhard and Edmondson 2015). Moreover the weakened and malnutritioned state of the patient also increases his risk to falling and sustaining a much more severe injury. In such cases a fall risk assessment done periodically for the patient will be beneficial on a paramount level. A fall risk assessment comprises of a questionnaire filled up by the nurse commencing the assessment regarding the condition of the patient, why he is in risk, how much risk is he in and what can be done to avoid the risk (Valentine, Nembhard and Edmondson 2015).

Along with a fall risk assessment tool, nutritional assessment tool and cognitive assessment tools are the three extremely important best practice assessment tools required for the patient under consideration in this case study (Means et al. 2015). As the patient is aging and is malnutrition and fatigued nutritional assessment tool will be required to generate a proper diet for him. Human body is heavily dependent on the nutritional uptake and the energy it in turn provides the body. Health care has advanced significantly from what it used to be years ago, with the advancements to the biomedical science there are a hundred treatment options available for the patients to choose from. Health care today is completely patient centred, prioritizing the preferences and needs of the patients above all. Along the course of revolution in the health care industry, changes have not just occurred in the treatment procedures, changes have occurred in diagnosis, nursing care and even documentation and record keeping that has morphed health care in to a logical cause and effect science minimizing the scope of mistakes completely (Bourgeois, Nirgin and Harper 2015). In this report a step by step care strategy will be curate following the clinical reasoning cycle based on a case study.

Conclusion

There is a critical requirement for different minerals and vitamins along with carbohydrate, protein and fat that helps in our bodily functions running smoothly. If a patient is malnutritioned, then his chance of recovery is reduced to a drastic level and will rather be detrimental to is health (Turner and Clegg 2014).

A patient centred care for him should consider keeping him as comfortable and relaxed as possible. It has to be considered that a patient has right to safe and sound environment that does not provoke or harm him or her. When discussing about logical health care, the most revolutionary innovation that the health care industry has seen is the emergence of clinical reasoning cycle. On a more elaborative note a clinical rezoning cycle is nothing but a highly logical and strategic step by step actions that aids in the health care professional eliciting valuable information about the health related abnormalities that the patient is experiencing and by the virtue of evaluating those signs and symptoms arrive at a verdict formulating the prognosis and commencing the treatment phase.

The patient should be allowed complete privacy and should be informed about his conditions and should be actively involved in the treatment options taken for him (Nys 2014). Patient consent and patient education are two vital and elemental components of the patient centred care and these rights should not be overlooked. If the patient refuses to go for aged care,  he could use community service as a regular help as living in his house without a supportive care will be very risky for him (Mousavi 2016).

According to the aged care act in Australia, the patients are allowed to decide whether or not they want to undergo certain medical procedures and have a right to determine whether the health care professional addressing them are skilled or not other than the patients have a right to confidentiality of their medical data and complete privacy should also be ensured for them (Means et al. 2015).

References:

Bourgeois, F.C., Nigrin, D.J. and Harper, M.B., 2015. Preserving patient privacy and confidentiality in the era of personal health records. Pediatrics, 135(5), pp.e1125-e1127.

Dalton, L., Gee, T. and 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), p.29.

Delany, C. and Golding, C., 2014. Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators. BMC medical education, 14(1), p.20.

Farzianpour, F., 2014. Evaluation of international standards of patient and family rights (PFR) from chief nurses’ point of view in hospitals of Iran. Pensee, 76(6).

Fernandes, A.B., D’Cunha, S. and Suresh, S., 2014. Patient rights, awareness and practice in a tertiary care Indian Hospital. International Journal of research foundation of hospitals & Health Care Administration, 2(1), pp.25-30.

Kuiper, R., Pesut, D.J. and Arms, T.E., 2016. Clinical reasoning and care coordination in advanced practice nursing. Springer Publishing Company.

Liou, S.R., Liu, H.C., Tsai, H.M., Tsai, Y.H., Lin, Y.C., Chang, C.H. and Cheng, C.Y., 2016. The development and psychometric testing of a theory?based instrument to evaluate nurses’ perception of clinical reasoning competence. Journal of advanced nursing, 72(3), pp.707-717.

Martin, J.F., 2014. Privacy and Confidentiality. In Handbook of Global Bioethics (pp. 119-137). Springer Netherlands.

Means, J.M., Kodner, I.J., Brown, D. and Ray, S., 2015. Sharing clinical photographs: Patient rights, professional ethics, and institutional responsibilities. Bulletin of the American College of Surgeons, 100(10), p.17.

Mousavi, A., 2016. The role of clinical governance in achieving the charter of patient rights. Medical Ethics Journal, 5(18), pp.161-178.

Nys, H., 2014. The Transposition of the Directive on Patient'Rights in Cross-Care Healthcare in National Law by the Member States: Still a Lot of Effort to Be Made and Questions to Be Answered.

Salminen, H., Zary, N., Björklund, K., Toth-Pal, E. and Leanderson, C., 2014. Virtual patients in primary care: developing a reusable model that fosters reflective practice and clinical reasoning. Journal of medical Internet research, 16(1), p.e3.

Taylor, P., Dowding, D. and Johnson, M., 2017. Background Pain assessment and management are key aspects in the care of people with dementia approaching the end of life but become challenging when patient self-report is impaired or unavailable. Best practice recommends the use of observational pain assessments for these patients; however, difficulties have been documented with health professionals’ use of these tools in the absence of additional... BMC Palliative Care, 16(1), pp.1-11.

Turner, G. and Clegg, A., 2014. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age and ageing, 43(6), pp.744-747.

Valentine, M.A., Nembhard, I.M. and Edmondson, A.C., 2015. Measuring teamwork in health care settings: a review of survey instruments. Medical care, 53(4), pp.e16-e30.

Zeng, X., Zhang, Y., Kwong, J.S., Zhang, C., Li, S., Sun, F., Niu, Y. and Du, L., 2015. The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta?analysis, and clinical practice guideline: a systematic review. Journal of Evidence?Based Medicine, 8(1), pp.2-10.

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