Case Study: Care of Mrs Zata Zata with the Use of Clinical Reasoning Cycle

 Case Study: Care of Mrs Zata Zata with the Use of Clinical Reasoning Cycle

Nursing care of patients follows a step-wise process which must be followed to the latter for effective patient care. There are several tools developed by different scholars that provide a framework for effective nursing care of patients (Stojan et al., 2017). One such important tool is the clinical reasoning cycle which has a sequence of steps that must be followed to offer the best care to the patient (Levett-Jones, 2018). All the subsequent steps will discuss the care of Mrs Zata Zata using the clinical reasoning cycle, from the first step until the end, with consideration of the ethical, legal and evidence-based practice on the holistic care of patients.

The first step in the clinical reasoning cycle is the understanding of the patient’s situation.  From the information in the case scenario, the patient is 45 years old and has been referred to the hospital for further care by her general medical practitioner. The patient had prior problems before the referral by her doctor. Apart from the complaints that the patient had before referral, the patient still has present complaints. Patient referral is an evidenced practice that is legally accepted. It provides the patient with the opportunity to seek further medical attention when the first or the previous mechanisms have been fully exhausted to no success (Vedsted & Olesen, 2015). That is the kind of patient that we have in question.

Collecting cues to understand the history of the patient. Data collection is the next single and most important step in the care of the patient. Patient information is obtained sequentially to aid in the admission, plan of care and further interventions not limited to discharge of the patient (Blanch et al., 2016). Proper data collection always determines the kind of attention given to the patient and the ultimate outcomes. For the case of Mrs Zata Zata, she has a past medical history of hypertension and hyperlipidemia. She is on an antihypertensive, Metropolol which she takes 25 milligrams after every 12 hours. She is also on anti-hyperlipidemic medications which she takes 20 milligrams daily. The patient has had surgery, appendectomy,  done at the age of 25 years. The patient’s father died of cancer at the age of 66 years. The patient is married with two children, but she is currently separated from her husband. Legally, the current situation of the patient must be established before going ahead to treat the patient further. Knowing the current status of the patient gives caregivers a clear trajectory to ongoing health problems. This makes the development of the plan of care a simple process.

Ideally, this patient was referred because she was experiencing severe cramping and passing bloody diarrhoea as well.  Investigations into the problem using a pathology biopsy show that the patient had infiltrating and poorly differentiated Adenocarcinoma.  This necessitates the development of a plan of care where the patient has to be treated with six cycles of chemotherapy to be followed by Radiotherapy. This plan of care is in consideration with the available evidence in the treatment of cancer patients. The first line of treatment of such patients is the administration of anti-cancer drugs, then followed by chemotherapy. If the cells do not respond to the first two lines, the surgical resection is always the third and final line of treatment (Kehoe et al., 2015). Skipping any of these steps has legal implications more, especially if this is done without the consent of the patient.

Identification of the nursing problems is what follows now. We have already seen that the patient has been medically diagnosed with poorly infiltrating and differentiated Adenocarcinoma. However, the patient has more complains.  She complains of severe pain with a score range of 8-10 more, especially at night. The patient further indicates that she has not emptied her stool for the duration of fur days, and she has not been sleeping very well at night. Anthropometric measurements in the hospital also indicate that Zata has lost five Kilogram for two weeks.  The patient is scheduled to stay in the hospital until her neutropenic state improves. However, she agrees, but later on, the nurse reports that the patient refused to get out of bed. The patient also refused to eat. This may be taken as a case of revenge against self. From the scenario, the patient was not willing and ready to remain in the hospital, as stated by the doctors. This scenario has legal implications if Zata decides to sue the hospital-based on forceful admission. Patients need to be admitted to the hospital out of their consent. If a patient refuses admission, the law provides that such a patient be allowed to sign the,’ going home against medical advice form’. This form binds the patient and the hospital, legally.

From the complaints that the patient presents with, few nursing concerns crop up. The America Nursing Association defines nursing as the protection, promotion and the optimization of health and abilities by means of preventing illnesses and injury, and by alleviating suffering through timely diagnosis and treatment of human responses.  This calls for the nurse to address the conditions of the patient with due regard to their feelings. This particular case presents the following priority nursing issues which should be addressed accordingly to promote patient care;

• Chronic pain
• Disturbed sleeping patterns.
• Disturbed thought process

If the patient undergoes treatment as stated without keen attention to these nursing issues, then patient recovery will take longer.  The principle of holistic care states that a holistic approach should involve relieving the symptoms of the patient and modifying all the contributing factors for purposes of helping the patient regain their well being and lead a comfortable life. This principle is held in high regards all the time for effective patient care and faster recovery.

Now, after the identification of the mentioned three priority nursing problems, goal setting is the hallmark of all the actions to be taken. The goals need to be specific, measurable, attainable, and realistic and time-bound. Each particular goal needs single or several activities for patient care to be very effective. The goals should, therefore, be considerate of the actions that will be taken. Some of the goals of care as per the nursing issues include;

Chronic pain

Goals

1. To reduce pain to a level of 3-4 on a scale of 0-10 within 24 hours of hospitalization.
2. To help the patient understand different relaxation and diversionary skills for pain management at the end of the hospitalization period.

Expected Outcomes

1. The patient reports pain at a level of 3-4 on the scale of 0-10.
2. The patient demonstrates the use of relaxation and diversionary skills in pain management.

Disturbed Sleeping Patterns

Goals

1. To improve the patients sleeping patterns from the period of hospitalization going forward
2. To relieve the symptoms which result in lack of sleep within 24 hours.

Expected outcomes

1. The patient reports an optimal balance of sleep at the end of the hospitalization period.
2. The patient verbalizes techniques on how to fall asleep and stay asleep.

Disturbed thought process

Goals

1. The patient should appropriately interact and with staff during the hospitalization period.

Expected outcome

1. Patient appropriately interacts and communicates with staff.

After goals and expected outcomes, it is now time to intervene and perform the activities which will promote the patient’s health. These activities should improve the wellbeing of the patient physically, mentally, morally and psychologically. For each single nursing issue, specific interventions will be done to meet the goals and the expected outcomes. The interventions will be as follows;

Chronic Pain

• Explore the need to administer the combination of the three classes of analgesics being the opioids, the non-opioids and the non-steroidal anti-inflammatory drugs. The use of the analgesic combinations speeds up pain relief.
• Implement non-pharmaceuticals techniques of pain management when pain is relatively low. This reduces the continuous dependence on drugs for pain relief.

Disturbed Sleeping patterns

• Create a conducive environment for the patient to sleep by minimizing noise and putting off lights at night. This enables the patient to sleep properly without any disturbance.
• Identification of symptoms such as pain that makes the patient not to sleep. Symptoms such as pain need to be treated effectively for the patient to sleep well.

Disturbed Thought Process

• Maintain a pleasant environment for the patient and address the patient with the utmost respect, slowly and calmly. This is because the patient may respond with anxiousness when startled. They may become overstimulated and demonstrate bizarre behaviour.

At this point, potential nursing activities have been done to help the patient recover quickly. The process does not stop here. Periodic reassessments need to be done to ascertain the effectiveness of the interventions given. This period reassessment forms the biggest part of the evaluation process. The health practitioner approaches the patient after a specified period and makes inquiries on the signs and symptoms that the patient presents with again. This provides an opportunity for them to know whether the interventions served the purpose or not. It also provides a chance for the nurse to know whether the patient has developed any other problem or the patient is doing perfectly well (CMEAC, 2016). If the issues persist, then other alternative interventions are implemented. Other new issues that may have cropped up again are also worked on.

Upon evaluation, a period of reflection comes in. At this point, you need to think of what you have done to Mrs Zata.  You ask yourself questions whether the activities are of benefit to the patient or not. Ideally, all the events are supposed to be of interest to the patient. In situations where the patient does not benefit, then there must be a problem. This problem needs to be identified for purposes of ensuring that it does not happen again. You also need to ask yourself whether you have gained anything in the course of attending to the patient.

In conclusion, clinical reasoning provides the best guideline for patient care. The framework is unambiguous and beneficial on both the part of the patient and the health practitioner. If followed well, patients will be treated based on the best available evidence that does not collide with the law.  The holistic approach of patient care is also realized since it caters for adequate medical and nursing management of a patient.

References

Stojan, J., Daniel, M., Morgan, H., Whitman, L., & Gruppen, L. (2017). A Randomized Cohort Study of Diagnostic and Therapeutic Thresholds in Medical Student Clinical Reasoning. Academic Medicine, 92, S43-S47.

Vedsted, P., & Olesen, F. (2015). A differentiated approach to referrals from general practice to support early cancer diagnosis – the Danish three-legged strategy. British Journal Of Cancer, 112(S1), S65-S69.

Blanch, L., Abillama, F., Amin, P., Christian, M., Joynt, G., & Myburgh, J. et al. (2016). Triage decisions for ICU admission: Report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine. Journal Of Critical Care, 36, 301-305.

Kehoe, S., Hook, J., Nankivell, M., Jayson, G., Kitchener, H., & Lopes, T. et al. (2015). Primary chemotherapy versus primary surgery for newly diagnosed advanced ovarian cancer (CHORUS): an open-label, randomized, controlled, non-inferiority trial. The Lancet, 386(9990), 249-257.

Comprehensive Medical Evaluation and Assessment of Comorbidities. (2016), 40(Supplement 1), S25-S32.