Clinical Decision Making Promoting Health in Extended Care

Question: Discuss about the Clinical Decision Making for Promoting Health in Extended Care. Answer: Introduction: Clinical reasoning can be alternatively called as clinical conclusion, trouble shooting, decision making and critical thinking. Clinical reasoning is a way of thinking of clinicians and nurses in the management of patients. In clinical reasoning two very important points to be considered are clinical conclusion to identify exact problem of the patient and clinical decision making to give appropriate treatment to the patient. In this case application of clinical reasoning by the nurses in two priority areas like impact on ADL performance and increased fall and injury risk in Johann Silvermann are discussed (Thompson and Dowding, 2002; Elstein and Bordage 1991; Levett-Jones et al., 2010). Impact on ADL performance: First care priority identified was potential impact on ADL performance. Johann Silvermann has tremors in hands. This leads to the disturbance in performing day to day activities like cooking, tea making, doing buttons of shirt and shoe laces. This is common in elderly patients and moreover is suffered with Parkinson's disease which is also responsible for the tremors. In this situation there are both the possibilities like negative and positive functional consequences. In negative, he can get affected psychologically due to inability to do work and on positive side, he can become determined to perform the tasks with all odds (Kozak-Campbell and Hughes, 1996). In this scenario action taken by the purposeful intervention by the nurse can definitely help Johann to boost physically and psychologically to improve his performance (Tanner, 2006; Dalton et al., 2015; Levett-Jones et al., 2010; Levett-Jones et al., 2010). Nurse should keep in mind that Johann is staying alone and moreover, he is not willing to stay with his brother. He is not financially sound to keep an assistant for his help for daily activities. Nurse should know about Johanns disease and routine activities. This information should be collected from the observation and discussion with him. Nurse should know what are the difficulties and since how long he is facing difficulties in doing daily activities. Nurse also should know about, the way he wishs to have assistance in doing his daily activities. So that he should feel more comfortable during nursing care. While helping him in his daily activities nurse should make sure that he should not feel completely dependent on the nurs e, otherwise there is the possibility that it can hurt his self-respect. From the collected information nurse should interpret type of daily activities in which he need support, most important activity for him, sequences of activities he required, is there any other better way to perform his activities, what difference would be there in his earlier activities and planned activities, whether it would really give advantage, relief and satisfaction to him by assisting him in his daily activities. Nurse should discuss this plan with Johann and understand his view on this plan. This discussion would help to make conclusions of exact requirement of the Johann in his daily activities and possibility to amend and improve the plan according his comfort without affecting his dignity. Nurse should set some definitive goal for Johann for his ADL performance (Brnnstrm et al., 1991; Carpenter et al., 2006; Ciro, 2014). This goal should be for making him comfortable in daily activities by physical ly helping him, giving him moral boost to perform activities, so that he can build his self-confidence and time plan should be set in stepwise manner like there should be his satisfaction, comfort and improvement in few activities in first week and others in month. Assistance was provided to Johann in terms of transfer within his home, dressing, eating, toilet use, and personal hygiene (Morris et al., 1999). These activities were divided into independent eating, supervision transfer within the home eating, limited assistance personal hygiene and extensive assistance toilet use and dressing. These activities were evaluated after set time points like one week and month. In case of transfer within the home and eating there was improvement in the one month as compared to the first week. At the end of the month, Johann didnt required supervision as nurse got confidence that he can move within the home and eat without assistance without any discomfort. There was also improvement in t he limited assistance task of personal hygiene. In first week, Johann required little assistance for brushing tooth and bathing. However, at the end of the month, he was able to it under supervision without assistance. Extensive assistance tasks such as toilet use and dressing didnt exhibited improvement in at the end of one month (Charles et al., 2007). I was thrilled and excited to assist Johann in his daily activities. I learned that management of patient in terms of non-medicine management is more challenging than management of patients with medicine management. I understood that, in the management of patient with non-medicine management like to assist in ADL is not completely textbook and academic dependent, however it was more related to experience and understanding skills about others conditions and problems. In this case, I got more confidence about my capability of handling non-medicine management of the patient. Fall and injury risk: Second care priority identified was increased fall and injury risk. Johann Silvermann is 77 years old having Parkinson's disease and he is staying alone in his two- storey home. Old people are more prone to fall due to their physical and psychological conditions. Johann has to perform all his activities on his own and in recent times he is not comfortable of doing routine work also. Moreover, as he is staying in two-storey home there is the possibility of fall. Fall and injury of Johann can have both negative and positive impacts. In terms of negative impacts due to the fall, he can have serious injuries and as he is staying alone, there is possibility that his fall remains unnoticed and proper management of injuries is not possible in time. On the other hand, fall can have positive impact also. Johann can learn from the fall and he can be more careful to prevent the fall (Kozak-Campbell and Hughes, 1996). Nursing management can be the best choice for the management of fall and injury of Johann (Tanner, 2006; Dalton et al., 2015; Levett-Jones et al., 2010; Levett-Jones et al., 2010). Nurse should understand that Johann is old, staying alone and he is having difficulties in doing his routine work. To know more about the fall condition of the Johann, nurse should collect information from him about his fall, she should go through all his previous reports to find out information about fall, and nurse should check previous medications for fall. After collecting the information, nurse should interpret his condition and understands the reasons for his fall. Nurse should avoid irrelevant information like fall due to the performing task beyond the capabilities. Nurse should relate fall during normal task and fall during performing task beyond the capabilities. Nurse should evaluate fall risk of Johann through shingle leg stance test and timed up and (TUG) test (Whitney et al., 2005; Deandrea et al., 2010; Phelan et al., 2015). Nurse should make inferences from the current situation and the previous evidence that fall during the normal task or daily activities is a serious problem in case of Johann. Nurse should set goals of one month to prevent fall of Johann. Nurse should plan for exercise, administration of high dose of vitamin, withdrawal or reduced frequency of medications for Parkinson's disease and use of body protectors. Nurse should assign exercise for Johann daily for 15 minutes to maintain balance of the body. Nurse should start administering high dose of vitamin D for one month. Frequency of administration of medications for Parkinson's disease to the Johann should be reduced for one month. Johann should be provided with body protectors like hip, elbow protectors while doing daily activities and at the time of toilet use. After the completion of each task, nurse should evaluate the outcome. In case of exercise, after initiating exercise fall frequency was evalu ated after one week and it was observed that there was no fall within this week. During the administration of vitamin D for the period of one month, there were two falls occurred in the first 15 days, however there was no fall in the next 15 days of vitamin D administration. In case of withdrawal of medications of Parkinson's disease also three falls happen in the first 15 days of medicine withdrawal and in next 15 days there was no fall. After the body protector use, there was no injury observed for Johann in one month period (Hill et al., 2008; Bell et al., 2012). In this case of fall and injury management of Johann, I learned to manage both medicine and non-medicine management of the patient in same case. I understood that giving confidence to the patient is very important to see improvement in his condition. Conclusion: Clinical reasoning was applied in the two priority areas like impact on ADL performance and increased fall and injury risk in Johann Silvermann . While applying clinical reasoning, nurse made clinical conclusion by from information gathered, evidences available, made decisions based on instinct and pattern recognition. Nurse applied rational methodology by collecting cues, processing the information, making decision, planning and implementing the management strategy, evaluating the result and reflecting on the learning process. 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