Eight main steps are used in the clinical reasoning cycle and these are discussed in relation to the case of Mr Noel Smith (Levett-Jones, et al. 2010). He is 55 years old and has been found to suffer from breathing disorder as he was complaining about difficulty in breathing and wheezing sound during breathing in and out. Mr. Noel Smith has a past history of asthma diagnosed at the age of 35 years. He has worked in a mining company. His father had chronic obstructive pulmonary disease (COPD). Recent divorce with his wife has impacted his health adversely. He was facing difficulty in breathing. He has not been proactive for his illness and did not follow an asthma care plan. The steps of this cycle in relation to this person except the first stage are discussed as follows.
From the first phase it becomes clear that the patient has asthma which has worsened due to his lifestyle and the emotional stress which he had taken due to his divorce from his wife. He has ignored his asthma condition by skipping medicines and only taking when the situation is adverse. He is overweight and has high blood pressure.
Asthma is a type of inflammatory disease where the IgE mediated response create physical constrictions in the tracheal tubes. This response takes place due to the environmental stimuli like allergens. During asthma, there smooth muscles of the bronchi constricts and leads to narrowing of the airways (Mims, 2015). This is considered to be the clinical symptom of the disease. There is overproduction of mucus and this causes the bronchi to become swollen. The mucus is produced for expelling the allergen from the body. Wheezing is seen in the patients and this is resulting from the localized narrowing, airway obstruction or diffuse narrowing from the larynx to the smaller bronchi (Esposito et al. 2018). This narrowing of airways may happen because of the bronchoconstriction or mucosal edema. The sound of wheezing is produced by the vibration of the closed airways.
Asthma is accompanied by the obstructive sleep apnea (OSA) often. OSA presents itself by interruptions in breathing and snoring during sleep. The patient has symptoms like nocturia, depressions, paroxysmal nocturnal dyspnea (Kong, et al. 2017).
From the collected information, the normal and abnormal symptoms and signs are presented in this section. He faces issues of hypertension, high cholesterol, obstructive sleep apnea, gastroesophageal reflux disease, hay fever in some seasons and had recurrent chest infections during childhood. He has been taking medicines only when his situation worsened.
It is not normal to have blood pressure of 155/95 and this is indicating abnormal high blood pressure. He is obese as his weight should be in the normal range of 76.42 kg. His heart rate is also not normal at 100 beats per minute as he is having heart rate of 110. His respiratory rate is also high at 32 breathes per minute. His Sp02 level at 92 percent is indicating a normal COPD however, this is higher than for a normal adult. His was talking in short sentences and was wheezing and this is also not normal signs for an adult of his age.
From the processing of the information it is concluded that he had asthma which had worsened due to stress and lifestyle factors.
Mr. Smith can face acute issues and problems due to his asthmatic conditions. He may cough continuously particularly during night or in morning. He may have to face the issue of wheezing often. As a result of bronchoconstriction, he may face tightness, pressure and pain in chest. Owing to breathing problems he may it find difficult to sleep. Another major problem which he may face is the dyspnea or the shortness of breath (Bishwajit, Tang, Yaya & Feng, 2017). It is a common symptom and this occurs due the blockage of the airways as a result of lumen constriction due to narrowing of bronchi, edema of mucus membrane and overproduction of mucus. This creates difficulty in the patients as they cannot effectively breathe air in and out.
He can also face chronic issue from this health condition and this is the permanent structural remodeling of the airways. Owing to the chronic inflammation of the airways there can be structural changes in the airways and this is inclusive of the modifications in the cell structures and the tissues in the asthmatic airways.
Smart goal for Mr. Smith related to the chronic issue is to stop the airways from remodeling. In order to prevent the chronic issues, he must effectively manage his asthma conditions. He can do this by taking Peak Expiratory Flow meters. This would help him in assessing his own asthma condition with the help of peak flow chart which shows the volume of air coming out of the lungs at a time.
Take readings for peak flow from just once in a day to four times in a day
Day 1= one reading in the morning.
Day 2= two readings (morning and evening)
Day 3= three readings
(morning, evening and after taking inhaling medications).
Day 4= morning, evening, inhaling medications and during exacerbations
This is achievable as it does not require the patient to have the readings for four times. Rather, it is developed as a habit so that he is able to monitor his condition and save from the chronic asthma issues.
It is realistic to achieve. However, proper education has to be given to the patient regarding the use of the peak flow chart.
It shall be reviewed daily and shall be continued for weeks.
The nurses have to take action so that Mr. Smith continues to monitor his lung functions. The best nursing intervention in this case for Mr. Smith is educating him regarding his health condition of asthma. The nurse is required to teach him how to use the peak flow meters. He must be told the various strategies which he should adopt when his situation worsens. When the peak flow is less than 60 percent of the normal value then he must take help from healthcare organization as this is indicative of severe asthma attack. He must be educated of the medications and the effect on the peak flow rates. He must be taught to take medications properly and at right time. The nurse must teach him the effective use of respiratory inhalers when he faces difficulty in breathing.
The patient education is the best nursing intervention for patients who are suffering from asthma (Dantic, 2014). This is owing to the fact that the patients who are having this condition have to monitor their condition and take steps for controlling and managing their symptoms and signs on their own. This helps them in engaging in self-management of their illness. Therefore, when they are educated about the illness and the possible ways of dealing with then better health outcomes are realized. This would be helpful for him as with education he would be able to handle his situation independently.
Another important nursing intervention for enhancing his peak flow rates is the proper use of medications like Salbutamol. These are belonging to the Short-acting beta-agonists and these are the primary drug used for the treatment of asthma (Katsunuma, et al. 2019). The use of this drug is topical and this is present in inhalers. It gives quick relief to the patient in the case of asthma attack. This is because this drug carries out the stimulation of the beta receptors in the smooth muscles of the lungs and this leads to relaxation hence, relieving the constriction and narrowing of airways. It can be taken when the patient is complaining of chest tightening, coughing, dyspnea or wheezing.
In order to evaluate the outcomes of nursing intervention, the nurses must use strategies. These shall be ascertaining the effectiveness of the imparted education in changing his health behaviors towards his own health condition of asthma. Educating the patients about their illness and the right technique for monitoring using peak flow meter and correct use of inhalation devices is important. This is owing to the fact that this promotes self-management, transition of care and patient-centered care.
For evaluating the outcomes of the educating intervention, the nurse can use the strategy of teaching-back (Dantic, 2014). In this technique the patients are asked to explain their understanding of the disease and the use of inhaling devices and the peak flow meters back to their instructors. This makes sure that the patients have understood the instructions. This has to be done until the nurse is sure that the patient has correctly understood the facts and is implementing for managing his asthma conditions (Dantic, 2014).
With this assessment I have comprehended that the nurses play a crucial role enabling the patients for the self-management and self-care. Self-management education has been found to be effective in asthma patients in controlling their symptoms (Ahmad, & Grimes, 2011). This helps them in achieving improved health outcomes from the suggested management and self-care techniques. The patients themselves have important role in the management of the asthma condition. They have to be empowered with education and knowledge so that they are able to take actions when they experience severe attack or issues like wheezing, chest tightening or pain.
I have learnt that it is important to use the clinical reasoning cycle for assessing the patient’s condition, deciphering the health issues, establishing health goals and then reviewing them for evaluating the health outcomes. This is helpful as demonstrated from the given case study. This cycle helped in approaching the health intervention using a step by step process.
Another important learning which I have gained from this exercise is the use of SMART goals for health goals. This is important as the health goals have to be objective and this helps in the proper evaluation of the outcomes as expected from the assigned goals. Further, I learnt that the patients who are suffering from asthma must engage in self-management like living a healthy lifestyle, remaining stress free, monitoring their asthma condition, taking medications, exercising and taking a healthy diet. Lastly, the important lesson from this exercise was the understanding of nursing intervention for the asthma patients which was education. The nurses by imparting education to the patient about their asthma condition and the possible strategies of using them helps them in engaging in self-management and self-care.
Therefore, Mr. Smith must take self-management and self-care in order to prevent the chronic issues from asthma like the permanent remodeling of the airways. With an effective self-management his acute symptoms will also be reduced and he could live a normal life.
Ahmad, E., & Grimes, D. E. (2011). The effects of self-management education for school-age children on asthma morbidity: a systematic review. The Journal of School Nursing, 27(4), 282-292.
Bishwajit, G., Tang, S., Yaya, S., & Feng, Z. (2017). Burden of asthma, dyspnea, and chronic cough in South Asia. International journal of chronic obstructive pulmonary disease, 12, 1093.
Dantic, D. E. (2014). A critical review of the effectiveness of ‘teach-back’technique in teaching COPD patients self-management using respiratory inhalers. Health Education Journal, 73(1), 41-50.
Esposito, S., Soto-Martinez, M. E., Feleszko, W., Jones, M. H., Shen, K. L., & Schaad, U. B. (2018). Nonspecific immunomodulators for recurrent respiratory tract infections, wheezing and asthma in children: a systematic review of mechanistic and clinical evidence. Current opinion in allergy and clinical immunology, 18(3), 198.
Katsunuma, T., Fujisawa, T., Maekawa, T., Akashi, K., Ohya, Y., Adachi, Y., ... & Sako, M. (2019). Low-dose l-isoproterenol versus salbutamol in hospitalized pediatric patients with severe acute exacerbation of asthma: A double-blind, randomized controlled trial. Allergology International, 68(3), 335-341.
Kong, D. L., Qin, Z., Shen, H., Jin, H. Y., Wang, W., & Wang, Z. F. (2017). Association of obstructive sleep apnea with asthma: a meta-analysis. Scientific reports, 7(1), 1-7.
Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y. S., Noble, D., Norton, C. A., ... & Hickey, N. (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), 515-520.
Mims, J. W. (2015). Asthma: definitions and pathophysiology. In International forum of allergy & rhinology (Vol. 5, No. S1, pp. S2-S6).
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