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Mr Jones is an 86-year-old male who was recently widowed.  He lives alone in a single story house with two steps at the entrance. He usually mobilises independently without the assistance of any mobility aids.  He has 3 adult children who all live close by but do not visit regularly. My Jones was a businessman who used to work long hours and was often away from home travelling with his job.

Mr Jones was bought into hospital by ambulance after being found wandering up and down his street by the neighbour. Mr Jones was noted to be limping, favouring his left side. He has blood stains on his pants and socks and he has a skin tear to his left shin.  Mr Jones thinks he fell over but he can’t remember.  He is to remain on bedrest whilst awaiting X-rays to see if he has sustained any fractures from the fall. He has been complaining of pain in the left hip and leg where he has a wound (laceration from the fall).

Whilst talking to Mr Jones he mentions that he has not been eating well since his wife passed away two months ago. He tells you that he mainly eats frozen meals or take away meals. He stays at home and is reluctant to go out as he feels sad most of the time.

Consider the Patient

1) Consider the Patient

ISBAR is one of the most important tools that is used by healthcare team in order to safely transfer the patient information in a clinical handover. ISBAR refers to completion of five important steps for proper jotting down and referring the information to the others staffs for safe delegation, proper decision making and correct planning for intervention procedures. These would help in assuring the patient of a service which is high on patient safety as well as in quality (Salminen et al., 2014).

Isbar stands for identification, situation, background, assessment and recommendations. by applying the principle, it is important to jot down the information of the patient so that each and every member of the healthcare team are aware of the condition of the patient and how he arrived in the healthcare (Koivisto et al., 2016). Mr. Jones is a 86 year old male who has been found wandering on the stress of the neighborhood. He has been recently widowed with other family members living in close proximity but are seldom visitors. He was limping avoiding on the left side and he was also seen to have blood stains on his clothes. His left leg shin has a category three skin tear and has pain in the hip region. Other important information is that he is not having a proper balanced diet after the death of his wife he is leaving on frozen meals or takeaway meals. He is staying at home and does not go out as he often feels sad.

2) Collect cues/Information 

This step mainly comprises of three important sections which are reviewing, gathering new information and then recalling.

Review: He was suffering from too much pain mainly due to the fall on his hip but since he had no factures, therefore the nurse would not have to consider any surgical procedures with him. His blood pressure is found to be high and his pulse rate is also quite high. The respiration rate is also much higher than the normal level of 19 to 20 beats per minute. His BMI is also quite high for about 43 which gives an obese status to him. His tear is of category three and he has a high fall risk about 17. His Glasgow coma scale is 14.

Gathering new information: in this case, it is seen that the patient is having pain in his hip region and for this it is extremely important to know whether he has developed a fracture or not. This is extremely important as the development of the nursing interventions will depend on whether he had developed fractures (Owens et al., 2014). Moreover, it is also important to conduct an analysis of his cognitive power to confirm whether he is also suffering form any neurological problems or not.

Recall: It is important to know the main reason of his withdrawal from food and society as these are harming his overall health. Moreover his heavy weight is also seen to be one of the reason associated with restricted movement and arthritis is making the situation worse. He has been identified with large number of co morbidities like Hypertension, Asthma, Arthritis and Type 2 Diabetes.

Such a huge number of complex and co morbid diseases often create a very poor life quality (Liou et al., 2016). In handling such a patient with so many chronic disorders, the nurse here needs to develop a patient centered care by development of a therapeutic relationship with him. From his symptoms, it seems that he is also having symptoms of dementia or Alzheimer’s as patients often tend to forget facts and are found wandering on roads due to loss of memory of previously known things. Therefore, the care of the patient is very critical and all the information gathered from the report should be assessed before developing a care plan.

 

3) Process information 

This step mainly contains the important parts of interpreting the different information provided form the handover report, followed by discriminating  the steps between the relevant information as well as the irrelevant information. This then gets followed by relating the information to the patient’s situation and then inferring that main reasons for the occurrence of the disorder followed by correct predictions (Forsberg et al., 2016). From the above steps, it is seen that the patient has fallen on his hip portion somewhere for which he is experiencing terrible pain. The pain after assessment was found to be 7 which is quite high and needs interventions.

Secondly, he has a category three skin tear which is mainly characterized by the complete absence of the skin flap which along with the loss of certain amount of tissues. With the growing ages, pathological skin chances occur such as flattening as well as thinning of the epidermis, loss of collagen as well as elastic followed by atrophy and contraction of dermis (Pennaforte et al., 2016). These cause wrinkles and folds to appear. Often decreased levels of sweat glands activity as well as decreased sebaceous gland results in drying out of the skin. Moreover arteriosclerotic changes also occur in different types of larger and smaller vessels which cause easy thinning of vessel wall s as well as reduction of blood supply in the extremities. The skin becomes fragile and therefore also becomes more prone to skin. This situation makes the skin more prone to tear by any sort of accidents, falls, conflicts and several such occurrences. Hence, this can be related with the patient’s condition in this case study and therefore his skin tear had taken place by the fall. His fall had mainly resulted from his restricted mobility which had been mainly occurred due to arthritis.

Arthritis must have occurred in the patient because of his excessive travelling in his younger years due to his business trips (Shah et al., 2015). Moreover, he is living on takeaway food as well as frozen food which are low in nutrients and also higher in calories. Lack of the ability to perform different exercises also resulted in the increase of his body weight which had resulted in increased rate of BMI. Moreover, researchers are of the opinion that increased obesity often creates excess pressure on the conditions of arthritis. Arthritis occurs when the cartilage of the bones gets degraded and bones rub against each other causing pain. Often huge bodyweight results in increased pressure on the bones and these add to the burden of the restricted mobility in arthritis (Moorhead et al., 2014).

His condition of hypertension is also found to be not managed properly by the patient and this is known from the blood pressure of 165/ 95 mmHg when his vital signs were taken. He also had a high respiratory rate of about 29 beats per minute and this shows that his arthritic conditions are also not managed. Moreover, from the present symptoms which were seen in the case, it is highly possible that he is gradually developing the symptoms of dementia as his age is highly probable to the occurrence of the disorder. Moreover, loss of memory, problems in recognizing roads, wandering attitude, forgetfulness, development of depression and many others are intricately associated with the occurrence of dementia (Gelinas et al., 2013). Therefore, the nurse should also be careful in developing interventions which will be directed to these symptoms as well

 

4) Identify problems/issues

What is the issue for the patient?

5) Establish Goals

What do you want to do here for the patient

6) Take  Action

What will you do here in the way of care for the patient?

7) Rationalise your nursing action

Why have you chosen the actions you want to do for the patient?

First Nursing Problem

 

 

A large number of nursing issues are identified in the case of Mr.
Jones. Mr. Jones has a very high paying score which shows the marks to be 7 out of 10.  This high amount of pain can we contribute into two important factors.  First of all he has fallen on his portion which has resulted in high pain in the Hip region. Moreover he is also having a category 3 skin care in his leg. This might be at another cause of his high level of pain. Therefore the nurse on duty should first provide intervention for management of the pain (Kozlowski et al., 2014).

One Nursing Goal –

The first goal which should be set for the patient by the nurse would be to maintain his pain effectively as he is having pain mainly due to two important factors.  Firstly due to the fall on his hip region and secondly due to the skin tear that he is having in his leg.  The nurse should effectively manage both the symptoms with the correct goals so that the patient may become free from pain.  The main goals that should be set for the patient would be to reduce the score from 7 to 3 or 4 out of a rating scale of zero to 10 (Schreiber et al., 20140. It should be also cared by the nurse that the patient should display improved well being in case of the baseline levels for blood pressure respiration pulse and relaxed Muscle Tone as well as body posture.  The nurse should also use appropriate pharmacological as well as non pharmacological pain relief strategies and also help the patient to improve his mood as well as cope with the pain.  Correct strategies for handling the wound should be taken by the nurse so that the wound get healed up properly without causing an infection.

First action –

In order to reduce the pain, the first intervention that the nurse should take is to reduce the additional stress or sources of discomfort whenever possible.  It has been stated by researchers that patients often show better coping method to pain if the nurses are being able to handle the environmental, interpersonal and intrapsychic factors or stressors effectively. The nurse should also make sure that she provides rest periods to the patients in order to promote relief and sleep in the patient and also to give him relaxation (Brwon et al., 2016).  Researchers suggest that pain often results fatigue in a patient which may in turn lead to a feeling of exaggerated pain.  Developing a peaceful as well as a quiet environment for the patient would help the patient to overcome his feelings of pain in a much better way. The nurse may contain pharmacological interventions by the using of non opioids like that of acetaminophen or non selective NSAID or a selective NSAID.  It has been found that the letter work in peripheral tissues by blocking the synthesis of prostaglandins which in turn help in the stimulation of nociceptors (Briggs et al., 2013). This is usually provided when the patient would be suffering from mild to moderate pain in the patient is suffering from severe pain then the nurse may provide opioid analgesics intravenously systematically by PCA system or also as epidurally. The Nurse may also use local anaesthetic agents which might block the transmission of the pain (Boltz et al., 2014). The knots me also use cognitive behavioural strategies as non pharmacological methods.  this may include using imagery distraction techniques, relaxation exercises, music therapy, breathing exercises and many others.  These techniques usually help in diverting the patient's five senses away from the painful stimuli and also help in increasing his concentration which helps to decrease his pain experience (Eichler et al., 2014). The nurse may also massage the affected area as a massage helps in tracking the pain transmission and also helps in increasing endorphin levels and also helps in minimising tissue oedema. The nurse may also provide hot or cold compress to decrease the pain by the development of blood flow to the area and also helps in reduction of pain reflexes. After providing all the interventions for his pain in the Hip region the nurse should set her plans to us the treatment of the skin care.

Rationale -

 

 

This would relieve him form the pain in his hip region and will allow to manage the pain with the best outcomes

 

 

 

Second action –

. In order to manage the category 3 skin tear the nurse should first apply pressure and elevate the leg in an appropriate Position to control the bleeding (Scherrrer et al., 2014). Following this manner should take initiatives to clean the wound using warm saline or water in order to irrigate the wound and move if any sort of residual Hematoma or debris are present.  Then she should make the surrounding skin tissue try to avoid any sort of other injury. As the patient is having a category treat skin tear,  the skin flap will not be present and therefore the nurse should  overlook the step of fixing up the skin flap and directly move on to the dressing part. The nurse should then provide appropriate dressing considering the correct utilisation of addition wound closure strips.  It should be done in such a way so that it can facilitate drainage and also helps in avoiding tension over flexure sites.  Usually in most cases she tools and staples are not used but as the skin cut is quite deep and has full thickness therefore sutures and staples can be used by the nurse in this case (Scott et al., 2016) . The nurse would review and reassess the dressing changes. In expressing the nurse should monitor the changes in the wound and also take care for maintaining the skin integrity it is important for the nurse to assess the wound every 24 to 14 hours.  She should also assess whether any sort of infections symptoms are appearing or not along with assessing the pain exudates, erythema and malodour.

Rationale -

 

 

This would help in healing of the wound of the category three skin tear with positive outcomes.

 

 

 

 

Second Nursing Problem

He is also seen to suffer from restricted mobility and the main reason for this is arthritis.  As Mr. John used to take long business trips he might have gone through toilsome days which had resulted in the occurrence of arthritis. Arthritis is mainly ascertained by the wear and tear of the cartilage in between the bones.   Moreover, his obese condition is also having an effect on his Arthritis symptoms as it is creating more pressure on the bones resulting in restricted mobility.  Therefore the nurse should take interventions which would help in promoting his movement and locomotion. He should be properly educated about the beneficial effects of exercise we should help him to control his body weight as well as is Arthritis symptoms.

One Nursing Goal –

.   Apart from   the goal of reducing the pain of the patient for the two factors , the second goal would be to develop his mobility so that he can experience freedom and independence in the activities he  takes  and his mobility is developed (Perme et al., 2013) . The nurse should make sure that the patient performs physical activity independently and also demonstrate measures to develop mobility.  He may also use adaptive devices to increase mobility along with the up taking of different safety measures to minimize potential for injury from fall..  Then she should also set goal that the patient should be free from complications of immobility and therefore she should check the evidences of the saint goal by assessing intact skin, normal bowel pattern, absence of thrombophlebitis and clear breathing sounds. Apart from this then she should also care for his obese condition, unmanaged symptoms of arthritis situation as well as hypertension and also handle the preliminary symptoms of dementia carefully (Wallace et al., 2014).

 

First action –

In order to develop the mobility of the patient the nurse should first introduce muscle exercises which will mainly include abdominal tightening exercises and events, hop on foot and standing on toes.  She should also take interventions to reduce the risk for fall by introducing bed rails, bed in down position and placing important items close by

Rationale –

This should help him to overcome his restricted mobility.

Second action –

 

 

The nurse should also promote and facilitate ambulation and at the same time have the patient with dangling legs sitting on chair and others (Orrell & Brayne, 2015).  This will help the patient by increasing his self esteem about the acquiring independence. The nurse should also teach him the use of different mobility devices such as crutches or walkers.

Rationale –

This would hep him to increase independence of the patient and develop his self esteem

 

8) Evaluate

Evaluation is one of the very important steps of the clinical reasoning cycle where the nurses need to evaluate whether the interventions taken by her are providing beneficial outcomes or not. In order to evaluate the result of his first intervention of pain management, the nurse should conduct the  the pain assessment at every interval of 8 hours of the day in order to assess that whether the pain of the individual is decreasing or not.  She should then make documentation on it to follow the effects of the intervention.

 She should also set up a time frame for her intervention after which she will be mainly monitoring the response of the patient on the pain management score in order to understand whether both the pharmacological and non pharmacological interventions are acting on the patient.  For the second intervention the nurse should mainly try to read the gesture and body language of the patient to develop an understanding of the developed mobility of the patient.  The nurse at the same time should encourage the patient to take a walk or movement by himself in order to understand the stiffness of the movement of the   Limbs as well as other parts of the body.  

The nurse should also try to understand the patient satisfaction level in order to assess the effect of the interventions, In this case she should also  set up a time frame for evaluation after which she should assess the result of the intervention (Chen et al., 2015).  After properly documenting the evaluation reports, she should try to understand whether the reports are depicting betterment of the patient or far better interventions are required or not.  If evaluation report is positive she should try to continue the interventions which she had planned before.  If the reports are not satisfactory then she should communicate with the mentors and come to a conclusion about changing the interventions so that the second setup interventions will bring down the positive results for the patients.

 References

Boltz, M., Resnick, B., Capezuti, E., & Shuluk, J. (2014). Activity restriction vs. self?direction: hospitalised older adults' response to fear of falling. International journal of older people nursing, 9(1), 44-53.

Briggs, R., Coughlan, T., Collins, R., O'neill, D., & Kennelly, S. P. (2013). Nursing home residents attending the emergency department: clinical characteristics and outcomes. QJM: An International Journal of Medicine, 106(9), 803-808.

Brown, C. J., Foley, K. T., Lowman, J. D., MacLennan, P. A., Razjouyan, J., Najafi, B., ... & Allman, R. M. (2016). Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA internal medicine, 176(7), 921-927.

Chen, H. M., Huang, M. F., Yeh, Y. C., Huang, W. H., & Chen, C. S. (2015). Effectiveness of coping strategies intervention on caregiver burden among caregivers of elderly patients with dementia. Psychogeriatrics, 15(1), 20-25.

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.

Eichler, T., Thyrian, J. R., Dreier, A., Wucherer, D., Köhler, L., Fiß, T., ... & Hoffmann, W. (2014). Dementia care management: going new ways in ambulant dementia care within a GP-based randomized controlled intervention trial. International psychogeriatrics, 26(2), 247-256.

Forsberg, E., Ziegert, K., Hult, H., & Fors, U. (2016). Assessing progression of clinical reasoning through virtual patients: An exploratory study. Nurse education in practice, 16(1), 97-103.

Gelinas, C., Arbour, C., Michaud, C., Robar, L., & Côté, J. (2013). Patients and ICU nurses' perspectives of non?pharmacological interventions for pain management. Nursing in critical care, 18(6), 307-318.

Koivisto, J. M., Multisilta, J., Niemi, H., Katajisto, J., & Eriksson, E. (2016). Learning by playing: A cross-sectional descriptive study of nursing students' experiences of learning clinical reasoning. Nurse education today, 45, 22-28.

Kozlowski, L. J., Kost-Byerly, S., Colantuoni, E., Thompson, C. B., Vasquenza, K. J., Rothman, S. K., ... & Monitto, C. L. (2014). Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Management Nursing, 15(1), 22-35.

Liou, S. R., Liu, H. C., Tsai, H. M., Tsai, Y. H., Lin, Y. C., Chang, C. H., & 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), 707-717.

Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2014). Nursing Outcomes Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences.

Morton, P. G., Fontaine, D., Hudak, C. M., & Gallo, B. M. (2017). Critical care nursing: a holistic approach. Lippincott Williams & Wilkins.

Orrell, M., & Brayne, C. (2015). Dementia prevention: call to action. The Lancet, 386(10004), 1625.

Owens, D. K., & Sox, H. C. (2014). Biomedical decision making: probabilistic clinical reasoning. In Biomedical Informatics (pp. 67-107). Springer London.

Pennaforte, T., Moussa, A., Loye, N., Charlin, B., & Audétat, M. C. (2016). Exploring a New Simulation Approach to Improve Clinical Reasoning Teaching and Assessment: Randomized Trial Protocol. JMIR research protocols, 5(1).

Perme, C., Nalty, T., Winkelman, C., Nawa, R. K., & Masud, F. (2013). Safety and efficacy of mobility interventions in patients with femoral catheters in the ICU: a prospective observational study. Cardiopulmonary physical therapy journal, 24(2), 12.

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, 16(1).

Scherrer, K. S., Ingersoll-Dayton, B., & Spencer, B. (2014). Constructing couples’ stories: narrative practice insights from a dyadic dementia intervention. Clinical social work journal, 42(1), 90-100.

Schreiber, J. A., Cantrell, D., Moe, K. A., Hench, J., McKinney, E., Lewis, C. P., ... & Brockopp, D. (2014). Improving knowledge, assessment, and attitudes related to pain management: evaluation of an intervention. Pain Management Nursing, 15(2), 474-481.

Scott, T. L., Liddle, J., Pachana, N., Beattie, E., & Mitchell, G. (2016). Study protocol: translating and implementing the Uqdrive-people-with-dementia intervention to improve driving cessation outcomes for people with dementia. International Journal of Psychology, 51, 55-56.

Shah, U. A., Henderson, M. C., Abourjaily, P., Thaler, D., & Rencic, J. (2015). Exercises In Clinical Reasoning. Journal of general internal medicine, 30(6), 860-863.

Wallace, R., Lees, C., Minou, M., Singleton, D., & Stratton, G. (2014). Effects of a 12-week community exercise programme on older people: Nurses should promote exercise to reduce patients’ social isolation and increase their independence, say Ricky Wallace and colleagues. Nursing older people, 26(1), 20-26.

Watt-Watson, J., Stevens, B., Costello, J., Katz, J., & Reid, G. (2016). Impact of preoperative education on pain management outcomes after coronary artery bypass graft surgery: a pilot. Canadian Journal of Nursing Research Archive, 31(4).

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