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Clinical cycle

Introduction 

The given case study is concerned with a 93 year old patient Mr. X who has been shifted to the aged care two years back. The patient requires complex care as his health is associated with multiple complexities and health issues. In this document, the specific case study of Mr. X has been critically analysed using the clinical reasoning cycle. The clinical reasoning cycle is a process of patient health assessment that in a multi-step process that includes patient health consideration, collection of information and cues, processing of the collected information, and establishment of suitable goals (Hunter & Arthur, 2016). Further, the clinical reasoning cycle also focuses on prompting of suitable actions to address the primary problem of the patient and evaluate the subsequent outcomes followed by critical reflection of the overall case scenario. The process of clinical reasoning is essential as it aids in the establishment of analytical reasoning and consideration in the nurse professionals. 

Clinical reasoning cycle

Patient consideration 

The given case study is concerned with a 93 year old patient Mr. X who has been shifted to the aged care two years back as he lived alone and had no body to take care of him. Mr. X is a patient of diabetes mellitus and is dependent on insulin. The patient is also hypertensive and has acute myocardial infraction, urinary retention and a sepsis has also occurred due to the urinary tract infection. He also has a poor bowel control, cervical canal stenosis, osteoarthritis and amputation of the first and second toe has also happened. Due to the poor health of the patient, permanent indwelling of catheter has been done with placement of permanent pacemaker (PPM). 

Patient information and cues 

Mr. X has been long associated with diabetes mellitus and is insulin dependent. This has led to a number of secondary problems in Mr. X. He is also hypertensive and has cardiac health problems. Further patient has a permanent pacemaker PPM, acute myocardial infarction, congestive cardiac failure. He has also been associated with problems in urinary and faecal retention and urospesis. He has been provided with a permanent indwelling catheter IDC. With his old age, he has also developed osteoarthritis and suffers from chronic pain and cervical canal stenosis. Amputation has been processed on his first and second left toes as well. Also, osteoarthritis in the patient has hindered his mobility from last 15 years affecting the patient mobility and physical movements. Due to which the patient has also presented with a second degree pressure ulcer on his left buttock subjecting him to pain and extreme discomfort.  The patient therefore requires complex care. Further the patient has extremely high blood glucose level of 16.5mmol/L.The patient has been suffering from diabetes mellitus from last twenty years making it a chronic health problem for management in the patient.  The high blood pressure and poor cardiac and renal health of patient have also been associated with him last 8 years. 

Information processing and problem identification 

The patient demands complex care as his health is severely affected and is affected by a number conditions. The primary problems of the patient can be categorised into:

Diabetes mellitus: The blood sugar levels of the patient are extremely high and require immediate intervention. The patient has also had multiple amputations in his toes as a consequence of tissue necrosis that occurred due to poor management of sugar levels in the patient that lead to impaired blood circulation in the individual. Further, due to diabetes, the patient’s renal system has also been affected leading to problems in urinary retention and development of urosepsis. Therefore, the patient is directly dependent on insulin intake, making diabetes a primary health problem under consideration. 

Ulcer:  The second degree pressure ulcer in the patient requires immediate assessment. In diabetic patients, the healing process is slowed and leads to further complication and therefore must be treated with priority. 

Poor cardiac health: The patient has a permanent pacemaker installed and has acute myocardial infraction and congestive cardiac failure.

Other health problems: The patient also suffers from osteoarthritis making him suffer from chronic pain and limiting the patient mobility. The patient also has cervical canal stenosis and hypertension.

Pathophysiology of the primary problem 

The pathophysiology of diabetes mellitus is characterised by insulin resistance in the body, impairment in the regulation of the hepatic glucose production and decline in the β-cell function.  The impairment in the insulin secretion is associated with decrease in the responsiveness n glucose. Further, insulin resistance may develop in an individual. This resistance may develop due to desensitisation of insulin receptor substrate (IRS) (Minor, 2019). Type 2 diabetes mellitus is related with definite genetic susceptibility, environmental elements, choices of lifestyle, and the active interactions in between all the various aspects. This sickness is a state of disease that involves the delimitation of insulin-fabricating pancreatic beta cells (Zaccardi et al., 2016).

Another essential intervention is required for the pressure ulcer developed in the patient. The pressure ulcer in the patient is caused due to inadequate blood supply. The sore is advanced to ulcer in an individual when the membranes of the muscle cells are damaged due to extensive pressure (Mervis& Phillips, 2019). This complication mainly arises due to continuous bedridden condition of the patient.  

Goals established 

The patient needs essential care in the aged care setting with multidisciplinary team efforts. The patient health can be improved by achieving the following goals:

Actions take

To achieve the established goals, a concise, articulate and composite action plan must be designed. This will include effective management of the blood glucose levels of the patient by immediate administration of the insulin in the patient. This will lower the blood glucose levels of the patient (American Diabetes Association, 2018). To treat the ulcer, essential care will be taken to prevent the infection and therefore the site of ulcer will be disinfected and off loaded. Debridement of the ulcer will be preceded and proper dressing of the ulcer shall be preceded. Also, the air mattress will be used to prevent the further pressure ulcers of the patient. It is essential to monitor the blood glucose levels in the patient to direct proper heeling of the ulcer. Further, the pain of the patient will managed by proper administration of the analgesics as per the doctor’s prescription. Patient will be provided essential care and education about the severity of his condition so that he can take preventive measures and precautions so that his health condition is not worsened further (Boyko et al., 2018). 

Care priorities and patient education 

The core priorities for the treatment of patient care health in the given case study will include:

Patient education: Another essential priority of the nurse should be to educate the patient about the health condition. Essential information about the consequences of poor management of sugar levels must be provided to the patient so that the patient cooperates and the blood glucose levels of the patient are maintained. The health education can be provided to patient by face to face interactions and critical discussions (Coppola et al., 2016). 

Pharmacokinetics

Pharmacokinetics of the two medicines that have been administered to the patient are: 

Loxalate: It is a type of antidepressant that works on nerve cells inside the brain to treat stages like major depression and common disorder of anxiety. It is the drug type called as selective serotonin reuptake inhibitor that assists to restore the stability of serotonin within the brain. It is dose-proportional and linear in a range of dose of 10 to 30 mg per day. Biotransformation of citalopram is mainly tactile with a mean tend half-life of almost 27-32 hours (Chung et al., 2017).

Furosemide: It is a strong loop diuretic that works on the kidneys to eventually increase loss of water from the body. It is an acid derivative of anthranilic. Furosemide is utilized for hydrops secondary to several clinical stages, such as congestive heart failure, exacerbation failure of liver, kidney failure, and high blood pressure. Furosemide is diuretic which is used as therapy for anti-hypertensive and for the relief of hydrops. Following oral management furosemide is highly but not completely absorbed, thus outcomes in bioavailability that is oral with almost 60 % acceptance (Silbert et al., 2016).

Outcomes

Effective management of the patient condition and administration of suitable interventions should lead to management of the blood glucose levels in the patient. Further, proper care and treatment of the patient should lead to successful healing of the ulcer of the patient. 

Conclusion 

The clinical assessment analysed a specific case of Mr. X and provided crucial insights to the health condition of the patient by gathering patient information and cues and their processing. Further, it also provided the pathophysiology of the primary identified health condition, established the nursing care priorities and predicted the outcomes after application of successful interventions. 

Reflection 

Through this case study and effective analysis of the clinical cycle, I gained knowledge and information about different aspects of nursing and clinical care of aged people. It also helped understand the significance of application of suitable intervention in the healthcare, particularly in context of aged care and diabetes mellitus. 

References 

American Diabetes Association.(2018). 4. Lifestyle management: Standards of medical care in diabetes—2018. Diabetes Care, 41, 38-50.

Atalla, H. R. A. (2016). Effectiveness of nursing intervention regarding self insulin administration among diabetic patients. Clinical Nursing Studies, 4(2), 57-66.

Boyko, T. V., Longaker, M. T., & Yang, G. P. (2018). Review of the current management of pressure ulcers. Advances in Wound Care, 7(2), 57-67.

Chung, H., Kim, A., Lim, K. S., Park, S. I., Yu, K. S., Yoon, S. H., ... & Chung, J. Y. (2017). Pharmacokinetics and effect on the corrected QT interval of single-dose escitalopram in healthy elderly compared with younger adults. International Clinical Psychopharmacology, 32(1), 20-26.

Coppola, A., Sasso, L., Bagnasco, A., Giustina, A., &Gazzaruso, C. (2016). The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine, 53(1), 18-27.

Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement: Clinical educators' perceptions. Nurse Education in Practice, 18, 73-79.

Mervis, J. S., & Phillips, T. J. (2019). Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. Journal of the American Academy of Dermatology, 81(4), 881-890.

Minor, M. (2019). The Pathophysiology of Diabetes Mellitus, Current Treatments, and The New Utilities of Inhibiting Sodium-Glucose Linked Transporters 1 and 2. Lynchburg Journal of Medical Science, 1(4), 47.

Silbert, B. I., Ho, K. M., Lipman, J., Roberts, J. A., Corcoran, T. B., Morgan, D. J., ...& Mori, T. A. (2016). Determinants of urinary output response to IV furosemide in acute kidney injury: a pharmacokinetic/pharmacodynamic study. Critical Care Medicine, 44(10), 923-929.

Zaccardi, F., Webb, D. R., Yates, T., & Davies, M. J. (2016). Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgraduate Medical Journal, 92(1084), 63-69.


 

  1. Maintenance of blood glucose levels of the patient. 

  2. Treatment of second degree ulcer 

  3. Pain management 

  4. Patient education and successful care 

    1. Aseptic condition maintenance: The nursing care priority should be to keep the ulcerated site free from infections as the patient is diabetic; it is likely that the healing process will take longer and therefore the patient requires essential care where aseptic conditions are maintained and no secondary infections develop (Mervis & Phillips, 2019). 

    2. Blood glucose level monitoring: The nurse must essentially take care that the patient glucose level is maintained. This can be done by effective monitoring of the blood glucose levels of the patient and administering the insulin when required (Atalla, 2016). 

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