NRSG 259 Nursing Care Provision

1.Consider the patient
Age related changes
Risk factors
Negative functional consequences
2.Collect information
3.Process information: to interpret, relate data
4.Identify problems/issues
5.Establish goals: setting up the goal with the patient
6.Take action
7.Evaluate outcomes showing the expected outcomes and how we would evaluate them
8.What have learned and what could be done differently.

Introduction

Clinical reasoning has been used interchangeably with other terms including problem-solving, clinical judgment, critical thinking, and decision making(Gee, Dalton & Levitt-Jones, 2015). This learning package term will be explained or defined as the process nurses and other clinicians use in collecting cues, processing the information, coming to an understanding of patient’s problems or issues, planning and implementing interventions, evaluating the outcomes while reflecting and learning from the process(Lin, Watson& Tsai, 2013). Clinical reasoning skills with nurses are important because it helps them to have a positive impact on the outcomes of the patients(Gee, Dalton & Levitt-Jones, 2015). Nurses with deficiencies of/poor clinical reasoning skill fail to rescue patients from their impending deteriorating health(Lin, Watson & Tsai, 2013). This essay will identify and prioritize the most important nursing care issues for the patient(s) using Millers’ Functional Consequence Theory to identify the influence impacting on the older persons and their level of function, and Levitt-Jones’ Clinical Reasoning Cycle as the tool to drive the process of identifying and assessing, implementing and evaluating care(Gee, Dalton& Levitt-Jones, 2015). It will contain part A involving identification of the nursing priorities and part B will choose the top priority of care(Michaud et al., 2013).  

Clinical reasoning cycle was introduced in 2012 by the School of Nursing and Midwifery and was developed by Universities of Western Sydney and Newcastle through an ALTC grant. Authors of clinical reasoning cycle describe it with five rights of clinical reasoning. They include reason, time, right cues, patient, and action.

Consider the patient

This is Mr. Dinh Nguyen an 83-year-old widower. He was diagnosed with Multiple Sclerosis (MS) six years ago and was also diagnosed with Osteoarthritis four years ago-now controlled on medication.

He currently lives alone in his home after his wife passed away 12 months ago. He is currently undergoing feelings of grief and isolation. He lives an independent life and has noticed a marked decline in his health with ongoing worsening exacerbations of his MS(Gee, Dalton & Levitt-Jones, 2015).

Mr. Dinh and his wife Ngoc did not have children and this makes him have no immediate family. He, however, has a brother, Bao, and family living by but he doesn’t want to bother his family with his life.

Dinh manages superannuation earning him a small income and he is very careful with his money.

This has enabled him the financial independence that only caters to his expenses and goes for a holiday once a year(Gee, Dalton & Levitt-Jones, 2015).

There are negative consequences associated with the problems facing Dinh and includes; physical- intracranial bleeding, bruising, lacerations, pain, scratches and other superficial wounds, fractures, and hematomas (Gee, Dalton & Levitt-Jones, 2015).

Falls sometimes instills fear of falling resulting in; self-imposed limitation to activities, and commencing a cycle of decreasing functional ability. Dinh did not manage a holiday this year due to his altered mobility.

He’s been experiencing blurred vision, numbness in his face and an electric shock when he tries to move his head and neck(Gee, Dalton & Levitt-Jones, 2015). This shock travels his back down to the legs which impact his movement and gait severely. The major cause of blindness experienced by elderly is Age-related macular degeneration (AMD)(Latimer-Cheung et al., 2013).   

He has difficulty in doing chores like cooking, showering, and dressing more particularly bending to tie his shoelaces.

He has also started experiencing some urinary incontinence.

Dinh has an Immune System deterioration which is a chronic, systematic low-grade inflammation as a result of influence by chronic anti-genetic stimulation (Gee, Dalton & Levitt-Jones, 2015).

The risk factors of the age include altered mobility, isolation and falls and risk.

Collect cues/information

Dinh had a history of Multiple Sclerosis (MS) in 6 years and Osteoarthritis four years and is undergoing feelings of grief and isolation in recent times(Latimer-Cheung et al., 2013). He is having feelings of some electric shock go through his back to his legs and he is unable to do his normal cooking, washing, and also dressing now. His disease seems to worsen and he is very uncertain about his future (Latimer-Cheung et al., 2013). He also feels isolated and grieved over staying alone since the wife died 12 months ago.

Process information

Isolation and grief are related to overstaying indoor and lack of focus group discussion.

Blurred vision caused by old age or problem with the brain and cognitive impairment

    Identify problems/issues

Dinhs’ problems include;

• Falls and risks
• Altered mobility and

Maintaining the dignity of older people

Falls are common problems with the elderly with Multiple Sclerosis (MS). Research demonstrating falls and risks shows that falls rate are more than 50% in every 6 months period(Lin, Watson & Tsai, 2013).  People with MS factors are more risk of fracture than those who are not MS than those in the same age brackets. They also have an increased risk of fragile fractures especially hip fracture hazard ratio of 4.08 which is 95% confidence interval [95% CI]=2.21–7.56)(Kogan, Wilber &Mosqueda, 2016).

Falls increase loss of confidence and it becomes difficult for a person to sustain his or her usual life roles. However, it should be noted that that, there is limited research done on people with falls among people with MS. Fear of falls among adults are associated with loss of independence(Kogan, Wilber &Mosqueda, 2016). To identify those people at greater risk among people with MS, a therapist working with them should evaluate the key risk factors associated with falls so as to allow appropriate use of interventions and resources required to minimize falls(Kogan, Wilber &Mosqueda, 2016). Due to the nature of MS it is important to note that environmental, psychological, and physiological factors may lead to falls(Lin, Watson & Tsai, 2013). Research on the risk factors of MS have been given different approaches with some researchers focusing on investigating factors affecting postural stability, others between 9-12 evaluating specific risks factors for falling(Wong et al., 2014).  All these evaluated the risks associated with falling among people with MS.  

Take action

As said earlier falls is are common problems facing elderly with Multiple Sclerosis (MS). Referring the patients to the physical and/or occupational therapy may actually improve function and decrease disability(Papastavrou, Andreou&Efstathiou, 2014). Providing the patients with the time of discussing their feelings and experiences through the use of support groups while ensuring appropriate and proper use of mobility equipment may be helpful in adjusting to the changes of life and measuring the disease progression(Tadd, 2017).

Physical exercise reduces falls and should be used to prevent falls(Latimer-Cheung et al., 2013). According to the National Institute for Clinical Excellence (NICE), older people healthcare providers should routinely ask whether there are recent falls so that so that those who report falls may be observed for balance and deficit in gait(Hind et al., 2014). This will help in improving strength and balance (Gorman, 2017). Older individuals who appear to be at greater risks of falls should be offered an individualized, multifactorial intervention such as balance training, vision assessment, home hazard assessment intervention, and medication review among others(Kogan, Wilber &Mosqueda, 2016).

Dignity refers to the individual ability to maintain self-respect and be valued by other people(Dewar & Nolan, 2013). Autonomy, on the other hand, is the individual control of decision making and other activities concerning their lives(Dewar & Nolan, 2013). In most cases, the health care settings do not value the autonomy of the elderly.

Evaluate outcomes

Monitoring the total ambulatory walks(Coote, Hogan & Franklin, 2013). This is the total distance covered in a given time period in patients living environment and is a gold standard for measuring activities in walking(Bherer, Erickson & Liu-Ambrose, 2013). This is however limited as it cannot be routinely applied in clinical practices.Dihn is able to walk for a half a kilometer in one day and he has experienced reduced electric shock in is back and legs.

Dinh is able to share his feeling with people and family members since he was provided with time to discuss his feelings and experience through support groups and feels no lonely anymore(Dewar & Nolan, 2013). Measuring the maximum distance walked by a patient by the virtual of their use of walking aid(Asano & Finlayson, 2014). However, environmental factors may affect the maximum distance walked hence the wrong characterization of disability levels progression of the disease(Bherer, Erickson & Liu-Ambrose, 2013). Dinh has been walking around his home which is a small area, therefore, pausing challenge to measure his progress when he remains at home(Papastavrou, Andreou&Efstathiou, 2014).  The progress in the Dinh walking abilities and ability to do his normal activities is a significant measure of outcomes(Bherer, Erickson & Liu-Ambrose, 2013).

Reflect on the process and new learning

Next time I will make sure that the old who are living indoors are encouraged and avoid the feeling of being isolated and grieved(Asano & Finlayson, 2014). Those whose partners die should be encouraged to find friends to talk to avoid feelings of being tired, lonely, isolated and fearful. I should have given more time to the patient to share their life experiences and find the friends who can understand and be interested to stay with them(Strauss, 2017). I also know that physical and mental exercises are important to old people (Bherer, Erickson & Liu-Ambrose, 2013), (Coote, Hogan & Franklin, 2013).

I now understand that people who live lonely life and old are growing with fear and diseases continue worsening due to their state of mind(Geerligs, Renken, Saliasi, Maurits&Lorist, 2014). I also know that walking can be a way of measuring the ability of the body of old people to function well and also to determine the progress in fighting their disability(Geerligs, Renken, Saliasi, Maurits&Lorist, 2014). If I had enough knowledge of how many people are going through grieve and is feeling isolated to help them improve their situations (Heart,&Kalderon, 2013). I now understand long time loneliness and loss of loved ones has negative effects even to the old.  

Conclusion

To maintain the dignity of the older people patients and need to be given adequate information as well as their caregivers to make informed decisions about care at every stage of treatment to the end life treatment. Training also for the care providers is paramount to change their attitude. The fundamental principles of quality health care have been recognized as the effective communication and information provision to the patient and their caregivers.Older people are likely to have some issues that affect them in terms of emotions, body movements, psychological and physical well-being. More especially they are most likely to have difficulty in walking, dressing, reasoning, etc. They require to be treated By healthcare providers with dignity when hospitalized and at home. Proper education to the healthcare providers will be important in ensuring that they take older people with health issues as not a homogenous group but a special group of human beings.

References

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Bherer, L., Erickson, K. I., & Liu-Ambrose, T. (2013). A review of the effects of physical activity and exercise on cognitive and brain functions in older adults. Journal of aging research, 2013.

Coote, S., Hogan, N., & Franklin, S. (2013). Falls in people with multiple sclerosis who use a walking aid: prevalence, factors, and effect of strength and balance interventions.Archives of Physical Medicine and Rehabilitation, 94(4), 616-621.

Dewar, B., & Nolan, M. (2013). Caring about caring: developing a model to implement compassionate relationship centred care in an older people care setting. International Journal of Nursing Studies, 50(9), 1247-1258.

Gee, T., Dalton, L., & Levitt-Jones, T. (2015). Using Clinical Reasoning and Simulation based education to flip the enrolled nursing curriculum. In Sustainable Healthcare Transformation: International Conference on Health System Innovation.

Geerligs, L., Renken, R. J., Saliasi, E., Maurits, N. M., &Lorist, M. M. (2014).A brain-wide study of age-related changes in functional connectivity.Cerebral Cortex, 25(7), 1987-1999.

Gorman, M. (2017).Development and the rights of older people.In The ageing and development report (pp. 21-39).Routledge.

Heart, T., &Kalderon, E. (2013). Older adults: are they ready to adopt health-related ICT?.International journal of medical informatics, 82(11), e209-e231.

Hind, D., Cotter, J., Thake, A., Bradburn, M., Cooper, C., Isaac, C., & House, A. (2014). Cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: a systematic review and meta-analysis. BMC psychiatry, 14(1), 5.

Kogan, A. C., Wilber, K., &Mosqueda, L. (2016). Person?centered care for older adults with chronic conditions and functional impairment: A systematic literature review. Journal of the American Geriatrics Society, 64(1), e1-e7.

Latimer-Cheung, A. E., Pilutti, L. A., Hicks, A. L., Ginis, K. A. M., Fenuta, A. M., MacKibbon, K. A., &Motl, R. W. (2013). Effects of exercise training on fitness, mobility, fatigue, and health-related quality of life among adults with multiple sclerosis: a systematic review to inform guideline development. Archives of physical medicine and rehabilitation, 94(9), 1800-1828.

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Papastavrou, E., Andreou, P., &Efstathiou, G. (2014).Rationing of nursing care and nurse–patient outcomes: a systematic review of quantitative studies.The International journal of health planning and management, 29(1), 3-25.

Strauss, A. L. (2017). Psychological modeling: Conflicting theories. Routledge.

Tadd, W. (2017).Dignity and older Europeans.In Ethics, Law and Society (pp. 73-91).Routledge.

Wong, W. L., Su, X., Li, X., Cheung, C. M. G., Klein, R., Cheng, C. Y., & Wong, T. Y. (2014). Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. The Lancet Global Health, 2(2), e106-e116.