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Student are expected to use the Clinical Reasoning Cycle (Levett-Jones, 2018) as a framework to plan and evaluate person-centred care. You are being asked to think through the case scenario and then discuss how data was collected and the type of data collected, identify problems and nursing issues, identify and state the objectives and discuss how care was provided in order to address the issues and evaluate the interventions carried out: (analyse and identify a nursing issues/problems/needs, set objectives, discuss the nursing interventions and evaluate the interventions of care carried out). As per lecture notes, students are expected to apply the clinical reasoning cycle to address the case scenario:

Consider the person’s situation
Collect, process and present related health information
Identify and prioritise at least three (3) nursing problems/issues based on the health assessment data that you have identified for the person at the centre of care.
Establish goals for priority of nursing care related to the nursing problem/issues identified
Discuss the nursing care of the person; link it to assessment data and history.
Evaluate your nursing care strategies to justify the nursing care provided
Reflect on the person’s outcomes

Patient Assessment and Situation

The following essay is an evaluation and plan for Mrs. Janet McKay to attain person-centered aged care. Mrs. Janet McKay is an 86 years old window and she is residing in Sunset Residential Aged Care facility. She has a deteriorating health condition and requires effective health care to maintain her health condition. The essay applies Clinical Reasoning Cycle framework to consider Janet’s situation, process health information, identify nursing issues priorities, establish nursing goals, discuss, evaluate and reflect on her health outcomes to achieve person centered care (Alfaro-LeFevre, 2012). The structure will include consideration of patient or situation facts, collection of information, processing of collected information, identifying of the problem, establishment of nursing goals, action plan, evaluation and reflection, and conclusion to summarize the discussion.

Consideration of patient Situation

Mrs. Janet Mckay is 86 years old patient. She is a window and she is in an aged care facility. Janet had recently undergone hip replacement where she was placed in an acute care hospital. Janet therefore uses a wheelie walker to support her to walk but forgets regularly to use. She also has Vascular Dementia that is progressing slowly and Alzheimer’s disease that are in the early stages. Janet is intermittently incontinent because of inability to reach the toilet in time. She also has a skin tear on her leg that was as a result of bumping against the wheelie walker. The skin tear is on her lower right leg. In addition, Janet tends to argue with a strong opinion with staff that led her to pushing a carer when she was held her arm as she was led to get a shower. Therefore, Janet is in a situation that she forgets easily, has difficult in planning and has problems in understanding issues that are causing deteriorating health and relationships with her care givers.

Collection of information (cues)

Mrs Janet McKay has her hip that has been replaced and is healing. She has been diagnosed to have early strage Alzheimer’s disease and vascular dementia. It can also be observed that Janet has a skin tear on her right lower leg. Currently, Janet is taking Paracentamol OSTEO TDS and Asprin 100mg drugs to relief pain and inflammation in the body. Janet also takes Desmopressin 0.2mg nocte for reduce urinary incontinence.

From the patient assessment, Janet is forgetting regularly to use wheelie walker to support herself walk. Janet also has a larger skin tear on her right leg. In addition, Janet is getting to arguments with staff that in an occasion pushed a carer away who was trying to lead her to shower.

Nursing Issues and Goals

Alzheimer disease and vascular dementia have overlapping effects that weaken memory and cause an individual problem in understanding. These diseases also lead to an individual difficult in planning of activities. The hip pain is well managed by use of Paracetamol OSTEO TDS, Aspirin 100mg while intermittently incontinent is controlled by her uptake of Desmopressin 0.2mg drugs.

Processing Gathered Information

From the information gathered it abnormal for a person to forget an activity or idea regularly especially the ones that can cause damage to one’s health. Mrs. Janet McKay forgets to use wheelie walker to support herself that can lead to damaging of the replaced hip. The information also shows that the patient was resisting help which is abnormal. Janet doesn’t want to take a shower and even pushes away her carer who leads her to take a shower. Though Janet is having intermittently incontinence, she is under mediation that is recommended to manage the condition. Therefore, the worrying information about Janet is regularly forgetting what a normal person could not forget, problem understanding and difficult in planning issues.  

Janet forgetting signs and problems in understanding could be worsening Alzheimer disease and vascular dementia. The escalating arguments that are extreme could also be Alzheimer’s disease signs that are advancing to middle stage. Therefore, it can be said that the unmanaged Alzheimer’s disease and Vascular dementia are progressively leading to Janet’s conduct that is threatening her health.

 Alzheimer’s disease progresses slowly from early stage to middle stage and then severe stage. The early stage has no observable or notable clinical signs and a patient can live normally. According to Sawikr et al. (2017), an Alzheimer’s disease middle stage is characterized with a patient getting frustrated or angry, confusing words, or acting in an unexpected manner. Alzheimer damages nerve cells in a patient’s brain that make it difficult to one to express thoughts and do routine tasks. Janet Alzheimer disease has symptoms of middle stage that is causing her to forget and act unexpectedly. Alzheimer disease has no cure but can be managed. Therefore, if Janet Alzheimer disease is not managed, it will worsen her health condition leading to early death.  

Identification of the problem

Mrs Janet McKay health situation is deteriorating and need to be “rescued.” Several problems can be identified in her situation that threatens her life. First, Janet is forgetting very regularly as a result of loss of memory. The Alzheimer’s disease is damaging Janet’s brain cells reducing her ability to remember activities like a normal adult. The second problem is that Janet is resisting to be taken to a shower. This is as a result of unexpected acting symptoms caused by Alzheimer’s disease. Another nursing issue in Janet’s health situation is the relationship with the aged care center staff. Despite Janet having a strong opinion, she turns to be angered to extent of pushing a carer away. This shows that there is a therapeutic relationship problem than need to be addressed.

Action Plan

Establishing of nursing goals

There is need to promote Janet’s independence and quality of life by managing her situation. Alzheimer’s disease can progressively cause severe deterioration of a person’s functionality and cognitive abilities. The first goal is to get Alzheimer’s disease medication. Though there is no cure for Alzheimer’s disease, cognitive enhancing drugs and physical exercises have proved to help manage the condition (George, & Nayak, 2013). The medications will also reduce some behaviors and enable the patient to control some behavioural symptoms. The second goal is to improve Janet’s and her carers’ therapeutic relationship. An effective relationship is important for provision of person centered care (Johannesen & LoGiudice, 2013). This will require briefing or training on how to objectively interact with Janet without interfering with her wishes. The other goal will be enabling Janet maintain her independence. This will be achieved by managing the Alzheimer’s disease and ensure that Janet doesn’t lose her cognitive abilities and functionality. Janet is independent minded and this will be important to enabling her pursue her own will.  

Take Action

The action plan will help manage and contain Janet’s deteriorating health situation. The first action will be getting Alzheimer’s disease prescription. These medications will be cholinesterase inhibitors to improve memory, alertness, thoughts, and judgments (VanItallie, 2013). The cholinesterase inhibitors can also stop Alzheimer’s disease destruction of nerve cells. According to Hibberd (2011), cholinesterase inhibitors are effective boosters of the amount of acetylcholine that is available in the nerve cells by stopping its breakdown in an individual brain. The second action will be organizing memory clubs for Janet with other people. Memory clubs retrieve memories while providing connections to the community (Hungerford, Jones, & Cleary, 2014). A memory club will enable Janet to engage in controlled conversations that will help improve her cognitive dysfunction. Another action will be training the carer on effective therapeutic relationship with Janet. A therapeutic relationship is important for establishing understanding that makes a patient feel safe, reliable, and confident with appropriate boundaries (Kitson, Marshall, Bassett, & Zeitz, 2013). According to Edwards, McDonnell & Merl (2013), therapeutic relationship can facilitate communication of distressing feeling and thoughts, assists patients with problem solving of daily activities, help patient examine self defeating behaviors and promote self care and independence. The training will equip career with therapeutic skills that will be consistently focused on Janet’s problems and needs. This will ultimately enhance the relationship enabling person centered care.

Effectiveness of Clinical Reasoning Cycle

Evaluation and Reflection

The discussion outline three interventions to improve Janet’s deteriorating health situation. The interventions act as strategies to manage the situation to prevent or stop further destruction of Janet’s health. The interventions also aim at creating an effective therapeutic relationship that will enable the staff at Sunset Residential Aged Care Facility relate in understanding, safe and confident manner to enhance person centered. The interventions are therefore effective because they solve Janet’s health problem of forgetting, resisting help to shower, getting a skin tear, and pushing away her carer.

From the discussion, it is evident that clinical reasoning cycle is effective to solving a nursing problem. The Clinical Reasoning Cycle (CRC) provides a framework that is systematic to getting deeper to a problem and finding solutions to the problem (Hur, & Roh, 2013). The intervention could be improved by engaging Janet to physical exercises. The CRC therefore provides logical and confidence when solving and making nursing decisions (Dalton, Gee, & Levett-Jones, 2015). 

Conclusion

A nursing decision requires systematic and well founded information to enhance the appropriateness of interventions for a certain problem. A Clinical Reasoning Cycle is an appropriate tool to collecting information, processing information, outlining intervention, prioritizing interventions, evaluation of and reflection of a nursing situation. Therefore, it can be concluded that Clinical Reasoning Cycle is an important tool and skill for nurses for understanding and providing person centered care where there is a nursing problem or issues.

References

Alfaro-LeFevre, R. (2012). Applying nursing process: the foundation for clinical reasoning. Lippincott Williams & Wilkins.

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.

Edwards, C. A., McDonnell, C., & Merl, H. (2013). An evaluation of a therapeutic garden's influence on the quality of life of aged care residents with dementia. Dementia, 12(4), 494-510.

George, L. S., & Nayak, A. K. (2013). Nursing Aspects in care of patients with Dementia. Nitte University Journal of Health Science, 3(2), 86.

Hibberd, P. (2011). The admiral nurse academy: a clinical academic pathway to support a specialist dementia nursing service. Quality in Ageing and Older Adults, 12(2), 95-102.

Hungerford, C., Jones, T., & Cleary, M. (2014). Pharmacological versus non-pharmacological approaches to managing challenging behaviours for people with dementia. British journal of community nursing, 19(2), 72-77.

Hur, H. K., & Roh, Y. S. (2013). Effects of a simulation based clinical reasoning practice program on clinical competence in nursing students. Korean Journal of Adult Nursing, 25(5), 574-584.

Johannesen, M., & LoGiudice, D. (2013). Elder abuse: A systematic review of risk factors in community-dwelling elders. Age and ageing, 42(3), 292-298.

Kitson, A., Marshall, A., Bassett, K., & Zeitz, K. (2013). What are the core elements of patient?centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. Journal of advanced nursing, 69(1), 4-15. 

Sawikr, Y., Yarla, N. S., Peluso, I., Kamal, M. A., Aliev, G., & Bishayee, A. (2017). Neuroinflammation in Alzheimer's disease: the preventive and therapeutic potential of polyphenolic nutraceuticals. In Advances in protein chemistry and structural biology (Vol. 108, pp. 33-57). Academic Press.

VanItallie, T. B. (2013). Preclinical sporadic Alzheimer's disease: target for personalized diagnosis and preventive intervention. Metabolism, 62, S30-S33

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