Case Study Contextual Framework Assessment Answer

Introduction

The assignment provides a preliminary contextual framework for analysing the clinical health condition of a 74-year-old female, Mrs. Margaret Reynolds. She was admitted to the emergency department due to complaints of shortness of breath and a feeling of hot. The Clinical Reasoning Cycle (CRC) will be employed systematically within the analytical framework to examine her clinical situation. The CRC is a structured approach used by healthcare professionals to assess, analyse, and make informed decisions regarding patient care (Leoni‐Scheiber et al., 2019). The assignment will continue with a detailed assessment of her condition, identification of relevant health issues, formation of therapeutic goals, formulation of nursing interventions, and reflective insights gleaned from the case study.

CRC Stage (Situation, Cues, Process)

The initial stage,Situation  identifies her as a 74-year-old female patient who has shortness of breath and high body temperature, indicating significant discomfort and potential respiratory distress. Considering the importance of the respiratory system in overall health, an accurate and timely assessment is required to address her urgent requirements and provide effective care (Theobald & Ramsbotham, 2019). This phase emphasizes the importance of prioritizing patient concerns in order to provide a prompt and tailored response.

Transitioning to the " Cues " stage, it becomes apparent that Mrs. Reynolds bears a significant medical history marked by hypertension, osteoarthritis, and depression (Gruppen, 2017). These coexisting illnesses have the potential to have a significant impact on her current health status as well as her later reactions to treatment measures (Kuiper et al., 2017). In addition, essential contextual clues like her living situation, social support network, and ability to execute everyday activities emerge as critical elements in understanding her overall well-being. Moreover, her self-reported sensations of heightened temperature and sleep disturbances serve as valuable diagnostic cues (Yazdani et al., 2017). This underscores the possible presence of fever and discomfort in her medical history.

The assessment is carried out in a methodical manner throughout the " Process " stage. Mrs. Given Mrs. Reynolds' principal symptom of shortness of breath and fever, her respiratory system is thoroughly examined. This includes monitoring her respiratory rate (RR), oxygen saturation (SpO2), lung sounds, and assessing for any productive cough with sputum characteristics. The recorded respiratory rate (RR) of 24 breaths per minute and SpO2 of 93% on room air and 96% on 2L of O2 via nasal prongs indicate respiratory distress (Moore et al., 2017). Lung auscultation indicates bilateral crackles and reduced air entry in the lung bases, indicating the presence of pneumonia (Moore et al., 2017). The greenish-yellow sputum and wet productive cough are consistent with infectious processes (Chang et al., 2017).

Vital signs and overall appearance are also evaluated as part of the assessment. In particular, Mrs. Reynolds exhibits an elevated temperature of 37.9°C, indicative of potential underlying infection, and her hypertension with a blood pressure reading of 150/90 mmHg merits attention (Machin et al., 2021). Her outward impression of being nervous and exhausted reveals her evident discomfort. Her clinical presentation is further complicated by her confusion about the day and time, as well as by her reported symptoms of decreased appetite and nausea (He et al., 2023). This raises concerns about the integrity of her cognitive functions and gastrointestinal well-being (Zhou et al., 2020).

The rationale behind this comprehensive assessment is rooted in evidence-based practice. The focused assessments are conducted to identify patient issues accurately. By integrating evidence-based literature, the assessment findings are further validated, as exemplified by the presence of crackles and diminished air entry in Mrs. Reynolds'. A detailed understanding of Mrs. Reynolds' health situation is made possible by this thorough evaluation, which is guided by the Clinical Reasoning Cycle (CRC) (Yazdani et al., 2017). It also serves as the foundation for nursing intervention priority, ensuring a patient-centered care strategy customized to her immediate and projected health requirements (Leoni‐Scheiber et al., 2019).

CRC Stage: Identify the issue

The emphasis of CRC Stage 4 turns to identifying particular health problems that Mrs. Margaret Reynolds is now dealing with, as well as those she is at risk of developing during her inpatient stay.

Actual Health Problems

Pneumonia : Mrs. Reynolds possesses bilateral crackles, diminished airflow in the bases of her lungs, a moist productive cough, and greenish-yellow sputum indicating the presence of pneumonia (De Freitas et al., 2018). Pneumonia is an urgent medical issue, if left untreated, it can cause respiratory distress, hypoxemia, and sepsis (De Freitas et al., 2018). This condition is supported by clinical evidence, emphasizing the urgent necessity for intervention to maintain her respiratory status and prevent additional problems (Zhou et al., 2020).

Cognitive Impairment : Mrs. Reynolds' confusion regarding the date and time, as well as reports of decreased appetite and nausea, point to cognitive impairment or delirium, which is a serious health risk (Mitchell et al., 2018). Delirium can result in functional decline, prolonged hospital stays, and increased mortality rates. As per the works of Mitchell et al., (2018) it is understood that identifying and treating delirium in elderly hospital patients as soon as possible is essential in order to reduce adverse outcomes.

Potential Health Problems

Pressure Ulcers : Mrs. Reynolds is more likely to develop pressure ulcers during her inpatient stay due to her advanced age and prolonged periods of immobility caused by her sickness. Additionally, the possibility of cognitive impairment raises this risk (Jaul et al., 2018). As per the research works of Jaul et al., (2018) it is acknowledged that regular repositioning and skin assessment are some of the effective strategies which can be applied for Mrs. Reynolds so as to prevent the development of pressure ulcer.

Malnutrition : Mrs. Reynolds' complaints of nausea and low appetite, combined with her medical problems, put her at risk of malnutrition during her hospitalization. Malnutrition is a potential issue that can lead to delayed wound healing, increased susceptibility to infections, and prolonged hospitalization (Kiesswetter et al., 2020). Her nutritional needs can be addressed through appropriate assessments and interventions, such as dietary evaluations and nutritional support measures like dietary supplements or modified diets if required.

CRC Stage: Establish goals

Managing Pneumonia: The primary goal is to effectively treat the pneumonia, aiming to improve her respiratory function, alleviate discomfort, and promote a speedy recovery. The major goal is to treat the pneumonia properly, with the goal of improving her respiratory function, alleviating discomfort, and promoting a quick recovery (De Freitas et al., 2018).

Cognitive Function Stabilization Goal: The goal is to stabilize and potentially enhance Mrs. Reynolds' mental clarity and orientation. Enhancing cognitive function such as like minimizing environmental stressors improves patient engagement and decision-making, facilitating better self-care and health outcomes (Mitchell et al., 2018).CRC Stage: Take action

Pneumonia

The nursing intervention is to administer antibiotics as prescribed and evaluate respiratory condition on a frequent basis, including monitoring oxygen saturation. Timely antibiotic therapy is critical for efficiently targeting the underlying infection (Dhaese et al., 2020). Regular respiratory assessments ensure that any worsening in oxygenation is detected quickly, allowing for appropriate management to prevent respiratory distress and maintain adequate oxygen levels (Zhou et al., 2020).

Cognitive Impairment

One intervention is to implement strategies for the prevention of delirium like minimizing environmental stressors, maintaining consistent routine, and encouraging family involvement (Kotfis et al., 2022). By reducing noise, maintaining proper lighting, and promoting a calm atmosphere, stressors that could exacerbate confusion or agitation are minimized. In addition, a structured daily routine helps in orienting the patient to time and place (Mitchell et al., 2018). Moreover, family involvement provides emotional support and aids in Mrs. Reynolds' orientation, lowering the likelihood of delirium-related problems (Lange et al., 2022).

Pressure Ulcers

Implementing a pressure ulcer prevention protocol like regular repositioning, skin assessments and using pressure-relieving devices is one such nursing intervention (Jaul et al., 2018). By redistributing pressure on the skin's sensitive regions, repositioning lowers the possibility of tissue damage. In addition, regular skin examinations assist in identifying early signs of damage caused by pressure, enabling prompt action (Jaul et al., 2018). Special mattresses or cushions that relieve pressure on pressure-sensitive areas reduce the risk of developing pressure ulcers (Alwasel et al., 2021).

Malnutrition

One intervention is to collaborate with a dietician to design a personalized nutrition plan prioritizing high-calorie, high-protein foods and the supply of nutritional supplements when necessary. This intervention addresses malnutrition by tailoring the diet to Mrs. Reynolds' specific needs, promoting optimal nutritional intake (Kiesswetter et al., 2020). Working with a dietitian ensures a balanced approach, with the goal of improving her nutritional status for improved health outcomes (Kiesswetter et al., 2020).

CRC Stage: Reflect

While completing this report, I have gained priceless learning experience that has expanded my knowledge regarding patient-centered care. My ability to conduct a thorough and systematic assessment of Mrs. Reynolds was one of my strengths in this case study. This enabled me to precisely identify her health conditions and appropriately prioritize care. I also used evidence-based guidelines to back up my findings, which is critical when it comes to providing high-quality care. Another area where I excelled was in communication. I made certain that Mrs. Reynolds and her family were fully aware of her illness and treatment options and also communicated well to provide empathy (Abbaszade et al., 2021). The process of writing this report inspired me to engage in reflective practice. I recognized the importance of self-assessment and critical thinking in clinical reasoning. This self-awareness is required for ongoing progress in nursing practice (Galutira, 2018). However, along with these strengths, I also came to acknowledge that there were certain areas that require improvement and which I think I lack in. Time management is one such area of my weakness where I struggled to balance the competing demands of patient care alongside meticulous documentation. My inability to manage time hampered the smooth delivery of care (Vizeshfar et al., 2022). Another weakness of mine was cultural competence. I discovered that I needed to improve my cultural competence in order to better meet the different requirements of my patients (Sharifi et al., 2019). The cultural background and beliefs of Mrs. Reynolds were not adequately incorporated into the care plan. Holistic care integration is also another such weakening area which I identified while working with this case (Fukada et al., 2018). In the case of Mrs. Reynolds, a holistic care approach was highly necessary as she has a past history of depression, her psychosocial and emotional needs are very necessary to be addressed. To address my time management weakness, I plan to undergo training and seek guidance from experienced colleagues on efficient time allocation for patient care and documentation (Vizeshfar et al., 2022). Additionally, I aim to participate in cultural competence training programs and workshops to enhance my ability to provide culturally sensitive care (Sharifi et al., 2019). Also, I intend to engage in regular mindfulness exercises to improve active listening which can be effective for addressing psychosocial and emotional needs of patients (Fukada et al., 2018).

Conclusion

Throughout this report, the application of the Clinical Reasoning Cycle (CRC) has been explored in order to deliver person-centered care to Mrs. Reynolds. It highlighted the significance of comprehensive assessment, goal setting, and successful interventions. Recognizing strengths and weaknesses in clinical practice has highlighted areas for improvement, ensuring the delivery of holistic and culturally sensitive care in the future.

References

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