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Clinical Reasoning Cycle

Clinical Scenario

Mr. Longo Sante, 91-year-old was hospitalized at Sydney private rehabilitation hospital. He was admitted to concord hospital under the orthopedic department due to increased left knee pain, diagnosed with left femur insufficiency fracture in CT. Dementia is the primary condition diagnosed. The patient has a history of hypertension, atrial fibrillation, and urinary tract infection. The patients take nutritional supplement TID, Coloxyl and senna 2 Tab daily, 25 mg Apixaban for atrial fibrillation, 60 mg of calcium carbonate, 25mcg / day of Calciferol for reduced vitamin D, 40 mg Frusemide-for a fluid excess in the morning and 500 mg BD Magnesium sulphate as a substitute. The patient assessed for fall risk and ulcer pressure, and scored over 20 in both. The patient left leg splint for 6 weeks while weightless in situ carrying. The patient is also found to be MRSA positive. In this essay, the patient dementia condition is analyzed with the pathophysiology of dementia. The nursing care priorities have been discussed within a clinical scenario using the Levitt-Jones’ clinical reasoning cycle. The pharmacokinetics of drugs also have been discussed which the patient is taking.

Pathophysiology of Dementia

Dementia is a consequence of several common systemic brain disorders and multiple degenerations in the nervous system. Today, dementia is the most prevalent occurrence in the aged people. It results from triggering a cortical-subcortical disintegration of ascending cholinergic neurons and large pyramid-shaped cells inside the cerebrum. Clinically, the disorder primarily indicates loss of activity in the interaction cortex (Livingston et al., 2017). Pharmacologically and pathologically, defects are much more complex, and often spread to prefrontal regions of the sensorimotor. This implies the neurons in the brain of the affected individual start losing their function and structure, and may even die. The effect of this is brain shrinkage, called atrophy. It happens mainly in the hippocampus, the portion of the brain that is responsible for knowledge and direction. Even now scientists do not know exactly why this occurs, or whether this neuron loss cycle can be prevented or reversed. Vascular dementia is also another significant cause of dementia. Blood vessels are a critical organ for healthy brain activity, as they supply the brain with food and oxygen (Kalaria, 2018). Whenever anything happens to those blood vessels, the minds get impaired as the flow of oxygen is disrupted. Nerve cells stop working perfectly, or die in the affected portion of the brain. The symptoms that arise depend on the region of the brain at which injury occurred. Vascular dementia also results from several strokes that have occurred over time (Ngolab et al., 2017).

Levitt-Jones Clinical Reasoning for Nursing Priorities

The nursing team used the Levitt-Jones scientific thinking process to analyze the case study for Mr. Longo Sante's diagnosis. This form of thinking helps during his hospitalization to adapt to his medical condition in the medical ward and to ensure that he, as a patient, gets the best possible positive result in less time. Establishing clinical knowledge and logical thinking in nurses helps to foster the open-minded safety of patients and the holistic care that is the good outcome of this role (Labrague et al., 2017). The process of contemplation in the acute hospital environments assists in managerial skills and focuses on improving the care. The two nursing care priorities selected are the management of MRSA infection and hypertension conditions.

MRSA Infection Management

Staphylococcus aureus is present on the skin and nose of about one-third of people considered to be MRSA carriers, or staph for short. The patient is aged so he has a high risk of getting more complications because of MRSA. The nursing interventions include checking on the patient for any sores or pimples. When left untreated, the sore grows darker in red/purple color, is painful, can feel warm, and contains pus. The unchecked sore can also start boring deeper and infecting muscles, lungs, joints, and other tissues. This must be told the patient not to scratch at the blister-this will transmit the bacteria (Cassone et al., 2016). The nurse needs to perform an incision and drainage operation to produce a sample. Not only is the operation diagnostic, but recovery is often considered because it eases the pain of fluid and MRSA infection. When done, a cream or ointment with antibiotics may be applied and a dressing might well be put upon this wound. A medical practitioner can prescribe antibiotics proven to function against MRSA while anticipating culture results. Typically a sulfa-based antibiotic is used on patients' sores (Mantey et al., 2019). When the patient is allergic to sulfa then it is possible to use a medication such as clindamycin. The individual must be administered the medication as prescribed until it is over, and also follow-up with doctor as advised.

Hypertension Management

Hypertension is a blood pressure that reaches regularly over 90 mmHg by 140. Evaluate the individual's reaction to the exercise, considering pulse rates more than 20 beats per min faster than rest levels; pronounced rise in BP after and during activity (diastolic pressure rise of 20 mm Hg or systolic pressure increase of 40 mm Hg o), chest pain, extreme fatigue, diaphoresis, blurred vision or health conditions are monitored. The reported criteria are useful in evaluating physiological reactions to activity stress and are measures of over-exertion where present. Offering help only when required fosters flexibility when carrying out activities. Assess patient complaints, exercise resistance, evidence of acute fatigue, extremity swelling, gradual weight gain, and gradual breathlessness.

Health Education on Care Priorities for Dementia

Health education aims to increase awareness of dementia as a concern for public health, formulate an approach to public health, and promote action at all levels. Dementia is debilitating not just to the individuals who have it, and also to the carers and their friends. In several places, there seems to be a lack of knowledge and comprehension of dementia, resulting in stigmatization, diagnostic and treatment barriers, and mentally, psychologically, and economically affecting caregivers, families, and communities. It is hoped the study would foster dementia as a global priority for public health and social care. This is important to inform the patient and the families about the condition of the dementia, and the phycological status of both the patient and family members (Phillipson et al., 2019). The patient is expected to follow a daily routine and to maintain a consistent schedule of sleep, eating, and other daily activity. Routines help to soothe the dementia patients. The patient's relatives are asked to look after the everyday life is maintained. Communicate with patients in exercise throughout the day to keep them rejuvenated, which will allow them to sleep well at night. Sleep disruptions and pent up energy can lead to destructive behavior. Physical activity often provides a healthy body and prevents aches and pains that can cause anger and frustration (Haapala, Biggs & Kurrle, 2018). The family members are required to pay consideration to indications of discomfort, pain, thirst, and hunger because dementia patients frequently find it hard to communicate such emotions. Ask the patients if they need anything, or are comfortable.

Pharmacodynamic Activities of Drugs

Apixaban prevents both free and clot-bound factors in many thromboembolic conditions including reducing the risk of strokes in non-valvular atrial fibrillation. Apixaban's total oral bioavailability is around 50%. Nutrition does not affect the bioavailability in a medically important way. The exposure to apixaban increases dosage proportionally to 10 mg for oral doses. Apixaban is easily absorbed, with maximum concentration occurring 3-4 h after oral administration, and has a half-life of around 12 hours (Byon et al., 2019). Elimination takes place through multiple mechanisms including absorption, biliary excretion, and direct intestinal excretion, with about 27 percent of overall apixaban clearance occurring by renal excretion. Apixaban's pharmacokinetics are acceptable in a wide variety of patients, and apixaban has minimized important clinical interaction with one of the most widely prescribed drugs, allowing for stable dosages but without medical control of the product. Apixaban's pharmacokinetic behavior is closely related to apixaban plasma levels (Mavrakanas et al., 2017).

Furosemide is an effective diuretic loop that works mostly on kidneys to gradually raise body fluid loss. This is a component of anthranilic acid. This shows variable bioactivity from oral dosage types, ranging between 10 to 90 percent. Furosemide absorption occurs, to a lesser degree, primarily in the kidneys and liver. Roughly 85 percent of total removal of furosemide is accounted for the kidneys, where around 40 percent requires conversion. The kidneys are responsible for 85 percent of the overall clearance of furosemide, where approximately 43 percent of the drug needs to undergo renal excretion (Matsue et al., 2017). Significantly more furosemide is excreted in the urine after IV. Injection than after oral or tablet solution. Around 50 percent of the furosemide load is metabolized unchanged in the urine and the remainder is metabolized in the kidney into glucuronide. The half-life of the 40 mg furosemide dose was 4 hours after oral administration, and 4.5 hours after intravenous administration. Furosemide's terminal half-life is about 2 hours after parenteral administration. For patients with serious renal failure, the final half-life can be extended up to 24 hours (Ibrahim & Amal El Sayeh, 2017).

References for Mr. Longo Sante Case Study

Byon, W., Garonzik, S., Boyd, R., & Frost, C. (2019). Apixaban: A Clinical Pharmacokinetic and Pharmacodynamic Review. Clinical Pharmacokinetics, 58(10), 1265–1279. https://doi.org/10.1007/s40262-019-00775-z

Cassone, M., McNamara, S. E., Perri, M., Zervos, M., & Mody, L. (2016). Impact of intervention measures on MRSA clonal type and carriage site prevalence. MBio, 7(2), e00218-16.

de Almeida, C., Pollo, C., & Meneguin, S. (2019). Nursing interventions for patients with intracranial hypertension: Integrative literature review. Aquichan, 19(4). e1949

Haapala, I., Biggs, S., & Kurrle, S. (2018). Social aspects of dementia and dementia practice. International Psychogeriatrics, 30(11), 1579-1581.

Ibrahim, M., & Amal El Sayeh, F. (2017). Optimized furosemide taste masked orally disintegrating tablets. Saudi Pharmaceutical Journal, 25(7), 1055-1062.

Kalaria, R. N. (2018). The pathology and pathophysiology of vascular dementia. Neuropharmacology, 134, 226-239.

Labrague, L., McEnroe-Petitte, D., Gloe, D., Thomas, L., Papathanasiou, I., & Tsaras, K. (2017). A literature review on stress and coping strategies in nursing students. Journal of Mental Health, 26(5), 471-480.

Livingston, G., Sommerlad, A., Orgeta, V., Costafreda, S., Huntley, J., Ames, D et al., (2017). Dementia prevention, intervention, and care. The Lancet, 390(10113), 2673-2734.

Mantey, J., Min, L., Cassone, M., Gibson, K., & Mody, L. (2019). Changing dynamics of colonization in nursing facility patients over time: Reduction in methicillin-resistant Staphylococcus aureus (MRSA) offset by increase in vancomycin-resistant Enterococcus (VRE) prevalence. Infection Control & Hospital Epidemiology, 40(9), 1069-1070.

Matsue, Y., Damman, K., Voors, A., Kagiyama, N., Yamaguchi, T., Kuroda, S., et al., (2017). Time-to-furosemide treatment and mortality in patients hospitalized with acute heart failure. Journal of the American College of Cardiology, 69(25), 3042-3051.

Mavrakanas, T., Samer, C., Nessim, S., Frisch, G., & Lipman, M. (2017). Apixaban pharmacokinetics at steady state in hemodialysis patients. Journal of the American Society of Nephrology, 28(7), 2241-2248.

Ngolab, J., Trinh, I., Rockenstein, E., Mante, M., Florio, J., Trejo, M., et al., (2017). Brain-derived exosomes from dementia with Lewy bodies propagate α-synuclein pathology. Acta Neuropathologica Communications, 5(1), 1-10.

Phillipson, L., Hall, D., Cridland, E., Fleming, R., Brennan-Horley, C., Guggisberg, N. et al., (2019). Involvement of people with dementia in raising awareness and changing attitudes in a dementia friendly community pilot project. Dementia, 18(7-8), 2679-2694.

Theofanidis, D., & Gibbon, B. (2016). Nursing interventions in stroke care delivery: An evidence-based clinical review. Journal of Vascular Nursing, 34(4), 144-151.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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