Levett-Jones Clinical Reasoning In Nursing Care: A Case Study Of Mrs Amalie Jones

Question:

Discuss about the Evidence Based Nursing Research for Transitional Patient & Family.

Levett-Jones clinical reasoning is crucial in nursing field because it can be useful in identifying and prioritising nursing care issues. Levett-Jones clinical reasoning consist of different steps like considering patient, collecting information, processing information and identifying problems for prioritising nursing care. Miller’s Functional Consequences Theory is implemented in identifying these cares prioritise. Establishing goals, taking action, evaluating outcomes and reflecting on the case are the remaining steps in the Levett-Jones clinical reasoning which cab be useful in planning care and evaluating outcomes of the provided care. In this paper, case of the Amalie is discussed. Information related to Amalie is collected and processed based on the steps of Levett-Jones clinical reasoning cycle and nursing care prioritise are established. Suitable intervention plan implemented according to the identified nursing prioritise (Hunter, 2016; Levett-Jones, 2013). Cultural background and dignity of the Amalie are considered throughout the process of care.

Mrs Amalie Jones is 89 years old woman. She is staying alone in a single-story home because Henry, her husband passed away two years ago. Her son, Dominik is living in Germany and visits her on few occasions. Tracy, her daughter living in Australia and visits her frequently. Few of the family members of Henry live in Australia and meet her on regular basis. She was teacher by profession and also worked as fundraising activist for local Catholic Church. In last two years she was not participating in any activities because her health gets deteriorated. Macular degeneration, hypothyroidism, rheumatoid arthritis and osteoarthritis are her prominent health issues. Her diet gets reduced and she is losing weight.

Due to rheumatoid arthritis and osteoarthritis, she is exhibiting mobility problem. Hence, she stopped visiting her friends and members of German association. Her doctor mentioned that she is losing weight because she is not eating properly. After completion of assessment, GP stated symptoms like joint stiffness, swollen feet and enlarged joints, painful joints like knee, hip, figures and back and limited joint movement. Other than this, she is also exhibiting symptoms like constipation, occasional dizziness, vision deficit, non-significant weight loss and occasional non-adherence to medication consumption due to pain. She is being administered medicines like paracetamol, ibuprofen, thyroxine and hydroxychloroquine.

Her symptoms like stiffness, swelling and pain in joints reflects her arthritic condition. Rheumatoid and osteoarthritis are the chronic conditions related to older age. As compared to the rheumatoid arthritis, osteoarthritis is more degenerative in nature. In rheumatoid arthritis, there is occurrence of inflammation and autoimmunity is also one of the prominent causes of it. Osteoarthritis mainly occurs due to wear and tear of joints (Kourilovitch, Galarza-MaldonadoC and Ortiz-Prado, 2014). Degradation and loss of articular cartilage are mainly responsible for wear and tear in osteoarthritis patients. In rheumatoid arthritis, multiple joints get involved while in osteoarthritis joints like hands, fingers or knees get involved (Kung and Bykerk, 2014). As a result of occurrence of both the types of arthritis, Amalie’s all the joints get affected. Age also play important role in the occurrence of osteoarthritis because osteophytes are more common in older people. However, radiographic assessment cannot correlate osteophytes and severity of pain. Moreover, anatomical alterations in joints due age and degeneration of musculoskeletal system are responsible for the occurrence of osteoarthritis in Amalie (Abhishek and Doherty, 2013). As she is consuming less food, she is exhibiting constipation and occasional dizziness. Less consumption of food in Amalie might be due to rheumatoid arthritis because in patients with rheumatoid arthritis loss of appetite increases with the progression of disease. Macular degeneration in older people can lead to vision loss. Damage to the macula of retina can produce blurred or no vision. Macular degeneration can be of two types like dry and wet. Amalie developed dry macular degeneration which exists in approximately 90 % of the cases. (Mehta, 2015). She is having her medications regularly, however as a result of consistent pain, she become non-adherent to the medicine consumption. 

Assessment

Painful swelling occurs in patients with rheumatoid arthritis due to inflammation of the lining of joints. Bone erosion and joint deformity can occur due to inflammation of the lining of the joints. Wear and tear of the joints in osteoarthritis patients lead to pain. Amalie need to perform activities like pushing, pulling and twisting. During performing these activities, Amalie might feel pain. Repetitive stress on the joints during these activities can worsen joint pain and joint deformity. Pain can lead to loss of appetite, less consumption of food and fatigue in Amalie (Sarzi-Puttini et al., 2014). Pain is also responsible for the non-adherence to consumption of medication in Amalie. Stiffness of joints, inflammation of joints, pain in joints and degenerative joint disease can lead to impaired physical mobility in Amalie. Hence, both rheumatoid arthritis and osteoarthritis are responsible for impaired mobility in Amalie. Body cannot be moved purposefully and unable to perform activities due to impaired physical mobility (Shin, Julian and Katz, 2013). Macular degeneration, age related ocular changes and rheumatoid arthritis are mainly responsible for the vision loss in Amalie. Moreover, dryness of eye can occur in patients with rheumatoid arthritis (Lim et al., 2012). After collecting information, analysing it and processing the information nursing prioritise like, pain, impaired physical mobility and vision loss are selected for Amalie.

Goals for pain: Amalie will exhibit improvement in the pain scale from 4 to 2 in two-month period. Amalie will exhibit improvement in mood and coping ability due to pain in two-month period.

Goals set for impaired mobility are: Amalie will perform activities of daily living like bathing, clothing and cooking independently like other same age people in two-month period. Amalie will be able to acquire skills to use adaptive and supporting devices for walking and climbing the stairs within two-month period. Amalie will use protective devices for getting protection from the fall in two-month period.

Goals for impaired vision: Amalie will be free of risk of fall due to impaired vision in two months period. Amalie will use call light and express requirement for help in two weeks period (Gulanick and Myers, 2016).

Asses degree and severity of pain in Amalie, hence effective care plan can be prepared for Amalie. Provide both medical and occupational therapy for Amalie to reduce severity of the pain. Pain scale need to be used because these are the robust sources for distinguishing severity of pain. Assess Amalie’s physical and psychological response to pain and implement appropriate intervention for pain. It is evident that there can be emotional disturbance and mood alterations in patients with pain. Provide counselling through psychologist for the management of emotional disturbance and coping with the mood alterations (Walsh and McWilliams, 2014; Durham et al., 2015). Self-respect and dignity of Amalie can be improved by providing counselling. It is necessary to consider her cultural background before providing counselling to her.

Assess Amalie’s capability to perform activities of daily living which can be helpful in providing suitable intervention for the improvement in the activities. Assessment can also be useful in identifying potential barriers. Provide with necessary supportive devices like wheelchairs, canes, transfer bars for Amalie for support and improvement in the activities. These supportive devices can enhance activity and reduce danger of fall in Amalie (da Silva et al., 2015). Demonstrate call light utilization to patient. Use call light for managing vision impairment in Amalie. Call light use can reduce risk of fall in Amalie (Elliott, McGwin, Kline and Owsley, 2015).

Nursing Priorities

There is improvement in pain scale in Amalie from 4 to 3 in the pain scale of 0 – 10. This improvement is achieved after providing intervention in the form of medicines and physiotherapy collectively. In the literature, it is evident that combined intervention in the form of medicine and physiotherapy can be more effective as compared to the individual intervention. Mood of the Amalie improved and there is augmentation of the coping ability of Amalie. Sensitivity of pain can be altered based on the individual because it is a subjective parameter. Hence, it is very necessary to improve mood and coping ability of Amalie (Sarzi-Puttini et al., 2014).

There is improvement in the performance of activities of daily living in Amalie and she learned use of assistance devices. Due to use of assistance devices there is reduction in the fall frequency in Amalie. It is well established that fall frequency and risk injury is more in older people which can be efficiently controlled in older people by using assistance devices (Krist, Dimeo and Keil, 2013). Amalie acquired skills to use call light and she is practicing it efficiently. Hence, vision problem can be effectively avoided and she can call nurse for her assistance. Risk of fall and injury can be effectively reduced in older people by using call light (Dev, Paudel, Joshi et al., 2014).

I understand and realized that arthritic disease and vision impairment can negatively impact activities of daily living. Henceforth, it is mandatory to extend them assistance for carrying out their activities and provide them with appropriate assistance devices. I had extended information about arthritic disease, I would have realized influence of these disease on the daily activities. Provision of support and assistance for the people with arthritic diseases in the preliminary stage can reduce risk of fall and further complications can be avoided. 

I understood that pain can affect patient both physically and psychologically. I should have started psychological counselling in arthritic patients in older people (Carpenito, 2013).

Conclusion:

Levett-Jones clinical reasoning cycle and Miller’s Functional Consequences Theory are applied in case of Amalie for collecting information related to rheumatoid arthritis, osteoarthritis, macular degeneration and hypothyroidism. Three cares prioritise such as pain, impaired physical mobility and impaired vision are identified in Amalie by applying information collection and processing steps of the Levett-Jones clinical reasoning cycle. Goals of care were set for Amalie. For each of the set goals, actions were planed and executed for assessment and intervention of Amalie. Pain severity is reduced in Amalie and there is improvement in the mood and coping ability of Amalie. Amalie’s ability to perform activities of daily living improved and there is reduction in the fall frequency. Hence, from this case study, it is evident that implementation of Levett-Jones clinical reasoning cycle and Miller’s Functional Consequences Theory can be helpful in executing stepwise procedure for providing holistic care to older patients like Amalie. This type of care can be considered as robust care for older people because all these steps are taken from the robust framework.

References:

Abhishek, A., and Doherty, M. (2013). Diagnosis and clinical presentation of osteoarthritis.

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