Community Nursing

Clinical reasoning is an approach of rational thinking of physician and nurses in the cure of patients. In clinical reasoning two prominent points to be reflected are medical inference to recognize exact problem of the patient and medical judgement to give appropriate cure and management to the patient. In this case presentation of clinical reasoning by the nurse in three areas like activities of daily living (ADL) performance, fall risk and medication assessment and management in Ellie Jones are discussed (Thompson and Dowding, 2002; Levett-Jones et al., 2010).        

Impact on ADL Performance:

In case of ADL performance, action taken by the focused intervention of the nurse can positively support Ellie Jones to lift physically and psychologically to progress her ADL performance (Tanner, 2006; 2010; Levett-Jones et al., 2010). Nurse should be mindful that Ellie Jones is having problem of fatigue. Nurse should be aware of Ellie’ disease and her daily tasks. This piece of evidence should be gathered from the observation and conversation with her. Nurse should be aware of what are her difficulties and ever since she is having problem in performing daily tasks. Nurse also should be aware of the way she wants to have support in performing her daily tasks. This helps to make her more comfortable in nursing care.

Nurse should take care that helping her should not hurt her self-esteem. From the gathered information nurse should understand kind of daily tasks in which she requisite help, most significant task for her, orders of tasks she required, is there any other improved way to her tasks, what change would be there in her previous tasks and intended tasks, whether it would really be advantageous and give respite and fulfilment to her by supporting her in daily tasks. Nurse should explain plan to Ellie and know her view on this plan. This conversation would be beneficial to make inferences of precise requirement of the Ellie in her daily tasks and likelihood to adjust and develop better plan according her wellbeing without affecting her dignity. Nurse should set some conclusive goal for Ellie for her ADL performance (Brännström et al., 1991; Carpenter et al., 2006; Ciro, 2014). This goal should make her more relaxed in her daily tasks by physically serving her, by providing her moral boost to accomplish her task, so that she can build her confidence.

Time plan should be fixed in stepwise mode. Assistance was provided to Ellie in terms of transfer within her home, dressing, eating, toilet use, and personal hygiene (Morris et al., 1999). These activities were divided into independent –eating, supervision–transfer within the home & eating, limited assistance – personal hygiene and extensive assistance – toilet use and dressing. These activities were evaluated after set time points like one week and month. In case of transfer within the home and eating there was improvement in the one month as compared to the first week. At the end of the month, Ellie didn’t required supervision as nurse got assurance that she can move inside the home and eat without help and without any distress. There was also progress in the limited assistance task of personal hygiene. In first week, Ellie required help for brushing tooth and bathing. However, at the end of the month, she was able to it under supervision without any help. Extensive assistance tasks such as toilet use and dressing didn’t exhibited improvement at the end of one month (Charles et al., 2007).

I was elated and excited to assist Ellie in her daily activities. I learned that management of patient in terms of non-medicine management is more challenging than management of patients with medicine management. I understood that, in the management of patient with non-medicine management like to assisting in ADL is not completely textbook and academic dependent, however it was more related to experience and understanding skills about others conditions and problems. In this case, I got more confidence about my capability of handling non-medicine management of the patient.      

Fall Risk:

Nursing management can be the paramount option for the management of fall and injury of Ellie (Tanner, 2006; Levett-Jones et al., 2010). Nurse should understand that Ellie is old, having fatigue and she is having difficulties in doing her regular tasks. To understand about the fall condition of the Ellie, nurse should gather evidence from her about her fall, she should follow all her earlier reports to get evidence related to fall, and nurse should verify earlier medications for fall. After gathering information, nurse should infer her situation and comprehends the causes for her fall. Nurse should evade immaterial information like fall due to the performing task beyond her capabilities. Nurse should relate fall during normal task and fall during performing task beyond the capabilities.

Nurse should assess fall risk of Ellie through shingle leg stance test and timed up and (TUG) test (Whitney et al., 2005; Phelan et al., 2015).  Nurse should make interpretations from the present condition and the previous evidence that fall during the normal task or daily activities is a serious problem in case of Ellie. Nurse should fix goals of one month to prevent fall of Ellie. Nurse should plan for exercise, administration of high dose of vitamin, and use of body protectors. Nurse should allocate exercise for Ellie daily for 15 minutes to keep balance of the body. Nurse should give her high dose of vitamin D for one month. Ellie should protected with body protectors like hip, elbow protectors while doing daily tasks and at the time of toilet use. After the accomplishment of each task, nurse should assess the result. In case of exercise, after initiating exercise fall frequency was assessed after one week and it was witnessed that there was no fall within this week. During the administration of vitamin D for the period of one month, there were two falls occurred in the first 15 days, however there was no fall in the next 15 days of vitamin D administration. After the body protector use, there was no injury observed for Ellie in one month period (Bell et al., 2012).

In this case of fall and injury management of Ellie, I learned to accomplish both medicine and non-medicine management of the patient in same case. I understood that giving confidence to the patient has significant impact on improvement in her condition.

Medication Assessment and Management:

Ellie is 73 years old and she is under chemotherapy and facing fatigue problem. Currently she taking oxycodone 5 mg every six hours, movicol twice every day and metoclopramide 10 mg every 4 hours. Her pain level is in the range of 5-6, she is not suffering from nauseas and vomiting and there is no problem of constipation for her. Oxycodone is administered to relieve from pain, movicol to get relief from constipation induced by chemotherapy and metoclopramide to prevent form nausea and vomiting due to chemotherapy (Kalso, 2005; Richart, 2015). After taking pain medication also she is feeling pain. Nurse should not worried more about pain because pain can be physiological or psychological problem specifically in elderly patients. Due to pain and fatigue, Ellie was trying to stop chemotherapy. Ellie don’t have any issue about other medications like oxycodone, movicol and metoclopramide, as she is ready to continue with the medication. If she stops chemotherapy, her cancer may become more severe and difficult to control. Nurse should take care that she should not stop chemotherapy at the same time she should not worry about other problems like pain and fatigue.

Nurse should set goal for three months to continue her chemotherapy and also convince her about pain and fatigue. Nurse should design intervention for continued chemotherapy and relief from fatigue in case of Ellie. Nurse should discuss her plan with Ellie and get her in confidence to implement intervention strategy. Ellie also felt dignified because her issues were considered while designing intervention strategy. For pain and fatigue assessment nurse should give questionnaire to Ellie and she should answer it every 15 days for 3 months (Glowacki, 2015; Lee et al., 2014). For chemotherapy, nurse maintained record of number of chemotherapies in three months. Outcome of this intervention was evaluated and it has been observed that there was improvement in fatigue and pain perception by Ellie in three months and at the same time she didn’t deny to continue with the chemotherapy.      

Important learning for me from this case is that, it is very difficult to convince the older person. I am able to convince Ellie to continue chemotherapy and at the same time to manage pain and fatigue. I think, this is great achievement for me because I am successful in relieving Ellie from painful condition and giving her confidence of continuing chemotherapy which is necessity for her.            

Conclusion:

Levett-Jones clinical reasoning was succefully practiced in the three areas like ADL performance, fall risk and medication assessment and management in case of Ellie Jones.  

References:

Bell, J.S., Blacker, N., Edwards, S., et al. (2012). Osteoporosis-pharmacological prevention and management in older people. Australian Family Physician, 41, 110–8.

Brännström, B., Gustafson, Y., Norberg, A., & Winblad, B. (1991). ADL performance and dependency on nursing care in patients with hip fractures and acute confusion in a task allocation care system. Scandinavian Journal of Caring Sciences, 1, 3-11.

Carpenter, G.I., Hastie, C.L., Morris, J.N., Fries, B. E., Ankri, J. (2006). Measuring change in activities of daily living in nursing home residents with moderate to severe cognitive impairment. BMC Geriatrics , 6(7), DOI: 10.1186/1471-2318-6-7.

Charles, P.D., Shen, R., Chen, M., & Sherman, M. (2007). Evaluating nursing home performance indicators: An illustration exploring the impact of facilities on ADL change. The Gerontologist, 47(5), 683-689.

Ciro, C.A. (2014). Maximizing ADL Performance to facilitate aging in place for people with Dementia. Nursing Clinics, 49(2), 157–169.

Glowacki, D. (2015). Effective pain management and improvements in patients’ outcomes and satisfaction. Critical Care Nurse, 35(3), 33-41.

Kalso, E. (2005). Oxycodone. Journal of Pain and Symptom Management, 29(5S), S47–S56.

Lee, K.A., Dziadkowiec, O., & Meek, P. (2014). A systems science approach to fatigue management in research and health care. Nursing Outlook, 62(5), 313–321.

Levett-Jones, T., Sundin, D., Mark, B., Hague, K., et al. (2010). Learning to think like a nurse.  HNE Handover For Nurses And Midwives, 3(1), 15-20.

Levett-Jones, T, Hoffman, K., Dempsey, J., Jeong, S.Y., et al. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today, 30(6), 515-20. doi: 10.1016/j.nedt.2009.10.020.

Morris, J.N., Fries, B. E., & Morris, S. A., (1999). Scaling ADLs within the MDS. Journal of Gerontology: Medical Sciences, 54A, M174-M182.

Phelan, E.A., Mahoney, J. E., Voit, J. C., & Stevens, J.A. (2015).  Assessment and management of fall risk in primary care settings. Medical Clinics of North America, 99(2), 281–293.

Richart, H. (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition. Jones & Bartlett Learning.

Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.

Thompson, C. and Dowding, D. (2002). Clinical Decision Making and Judgement in Nursing. Churchill Livingstone, Sydney.

Whitney, S.L., Wrisley, D.M., Marchetti, G.F., Gee, M.A., Redfern, M.S., & Furman, J.M. (2005). Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the Five-Times-Sit-To-Stand Test. Physical Therapy, 85(10), 1034-45.

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