The Levett-Jones Clinical Reasoning Cycle

Discuss about the Nurse delivered lifestyle interventions in primary.
Nursing care delivered to the patients with chronic illness needs to address multiple factors. Chronic illnesses like obesity and diabetes are known to be multifactorial disease and are associated with various comorbidities. It thus greatly influences the patient health outcomes. It is important for the primary care nurse to prioritise the care based on patient and the clinical needs. It is the integral par of the daily nursing practice to prioritise the patient’s need of care. Nursing interventions can be effectively delivered when collaborating and intergrading the various aspects of the patient’s needs. It helps to maximise the care activities. This process requires nurses to have clinical reasoning and decision making skills (Gee, Dalton & Levitt-Jones, 2015). The essay deals with the case study of Peter Mitchell, 52 year old male with morbid obesity and type 2 diabetes. In regards to the case study the essay presents the priorities of care while applying the Levett-Jones clinical reasoning cycle.

Clinical reasoning cycle revered by Jones, is the tool to develop goal driven patient care through a systematic process of considering many contributing and predisposing factors. There are 8 stages in this cycle. The first stage involves considering the patient’s situation (Gee, Dalton & Levitt-Jones, 2015). In the given case study, Peter Mitchell is a 52 year old male was admitted to hospital with morbid obesity and type 2 diabetes. The patient was noted with obesity ventilation syndrome, sleeps apnoea and poorly controlled diabetes. He was referred by his GP after presenting the symptoms of diaphoresis, increased hunger, and symptoms of shakiness, high BGL levels and difficulty breathing whilst sleeping.   The second stage of the clinical reasoning cycle is collecting cues and information. It refers to reviewing the patient’s current medical history and collecting specific information on the present activity treatment (Gee, Dalton & Levitt-Jones, 2015). The history of the patient highlights Peter as smoker for past 30 years Peter was reviewed by physiotherapist and recommended light exercises His dietician recommended for low energy and high protein diet for weight loss. Medical history the patient includes depression diagnosed three months, hypertension, obesity, sleep apnoea, gastro oesophageal reflux disease. Social history of the patient reveals loss of job, significant weight gain and embarrassments due to weight gain. Social isolation, poor performing activities of daily living, may be associated with his illness and weight issue.

Case Study: Peter Mitchell

The third stage of the clinical reasoning cycle is processing information to recognise the changes related to past health condition, predict outcomes recognise need of immediate intervention (Gee, Dalton & Levitt-Jones, 2015). In case of Peter the fatigue may be associated with his high weight. Reduced physical activity may be due to unemployment. It increases risk for apnoea and other health conditions. Obesity and diabetes pose risk for cardiovascular disease as the patient also has hypertension. His social isolation and health deterioration may have increased the depression (Choi & DiNitto, 2014).    Nursing Care For Patients With Chronic Illness Case Study

The fourth stage of the clinical reasoning cycle is the identification of problems and issues. These processes require examining the fact and then establishing definitive goals (Gee, Dalton & Levitt-Jones, 2015). As per the case study Peter with height 170 cm and weight 145 kg indicate obese. Obesity is confirmed or diagnosed in a person when the BMI is more than 30. In case of patient the BMI is calculated to be 50.2 and is indicating very high obesity (Mark & Somers, 2016). The patient has presented in hospital with the ventilation syndrome and sleep apnoea. Both the symptoms exist together in the patients diagnosed with obesity. The ventilation syndrome is the breathing problem in obese patients resulting in low oxygen levels. It results in obstructive sleep apnoea, where an individual stops breathing for short intervals when sleeping. Sleep apnoea is caused by the obstruction to the upper airway that caused repetitive episode of shallow breathing (Heymsfield & Wadden, 2017). These conditions occur as the adipose tissue increase in excess amount in the obesity. It restricts the movement of the chest muscle and the diaphragm. Therefore, respiratory muscles are easily fatigued.  Excessive adipose tissue in the neck and head area, inhalation and exhalation is slowed. Hypertension also occurs with increase in heart rate due to increasing vascular resistance caused by excess fatty tissue (Mark & Somers, 2016). Observations on discharge highlighted an increase in respiratory rate and the blood pressure. Hypertension in the patient is evident, and is known to contribute to diabetes.

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Obesity increases the body’s ability to control glucose level by insulin production, and consequently results in diabetes. Uncontrolled diabetes is associated with the increase in appetite, diaphoresis, high blood glucose level and shakiness (Imamura et al., 2015). Unusual sweating is known as diaphoresis and is common in overweight individuals. Diabetes patients are also prone to excessive sweating and dehydration during low blood glucose level (Imamura et al., 2015). Hypertension is influenced by both obesity and uncontrolled diabetes in Peter. Therefore, all the symptoms observed in Peter has direct link with obesity and uncontrolled diabetes and thus are major health issues. These symptoms share a common pathway in fact interrelated, which justifies the clinical reasoning. The same is evident from the vital signs and symptoms presented by Peter.

Prioritizing Nursing Care

The fifth stage of the clinical reasoning cycle is the establishment of goals; this phase includes making realistic and comprehensive nursing care plan within timeframe (Gee, Dalton & Levitt-Jones, 2015). The first goal/priority is to reduce weight and control obesity symptoms. The second goal/priority is to reduce glucose level and control diabetes. The care plan will involve both pharmacological and non-pharmacological interventions.

In order to fulfil the nursing goals the plan of care will be carried out which, is the sixth stage of the clinical reasoning cycle (Gee, Dalton & Levitt-Jones, 2015). In relation to controlling weight, a diet plan will be formulated upon collaborating with dieticians.  There is a need of decreasing the fat consumption and increase protein uptake.  Realistic weight loss plan will be set for Peter on a weekly basis. Further, an appetite reduction plan will be developed to track if signals of hunger are ignored or distorted (Sargent et al., 2012).  There are several benefits of weight reduction in obese patients. It will improve the overall quality of life. A weight loss of 10 kg can reduce the cholesterol and hypertension. It will help achieve the recommended target of blood pressure (Nanditha et al., 2016). The next strategy is the physical activity. It is the modest method to reduce the weight by 1 kg each month. It is helpful in increasing the metabolic rate and improves self esteem. Since the patient has type 2 diabetes, he will be supported to participate in 30 minutes of moderate physical activity. It can be gradually accumulated   if participated for five days in a week. These lifestyle interventions will also help reduce type 2 diabetes complications (Nanditha et al., 2016).

For the second goal, Peter will be educated to quit smoking and its adverse outcomes as it worsens breathing problems. It results in upper airway obstructions and inflation. It is beneficial in maintaing the blood glucose level. Hence, patient must be educated about its benefits. Nursing Care For Patients With Chronic Illness Case Study The patient will be referred to motivational therapy and nicotine replacement therapy, for smoking cessation (Pan et al., 2015). Motivational therapy will help adhere to physical activity and weight loos goals.  Education will help patient to adopt healthy behaviour and lead better lifestyle modification (Nanditha et al., 2016). Peter will be educated about maintaining healthy diet and nutrition so that he can sustain the weight loss intervention. Weight loss and smoking cessation leads to several mental health concerns. Therefore, self monitoring and stress management strategies are adopted from cognitive behavioural therapy. Self monitoring of glucose and blood pressure will help control diabetes (Levich, 2011). Further, pharmacological interventions to control glucose are use of anti-obesity medication as metformin, glycosidase inhibitors and insulin uptake leads to weight gain. The patient can be administered with Orlistat on consulting with physician as it prevents the absorption of dietary fat by 30%. It is an effective weight loss aid for BMI >28kg/m2. Simultaneously, metaformin will be continued to control blood glucose and Metoprolol will be administered to maintain blood pressure (Bedhiafi et al., 2018).

Establishing Goals And Developing A Care Plan

The seventh stage of the clinical reasoning cycle is the evaluation of patient outcomes, and eighth stage is reflection to track the changes in the health status (Gee, Dalton & Levitt-Jones, 2015). The weekly weight reduction plan and physical activity will be monitored for compliance. Weight and vital signs will monitor regularly. The side effects of all the medications will be monitored for its impact on vital signs. The patient is monitored to demonstrate change in eating pattern and display weight loss. The patient will be evaluated for overall disease awareness, adverse outcomes and benefits of the interventions (Eldredge et al., 2016). I will reflect on the barriers in implementing the care plan such as low self esteem of patient and address the challenges. In case of Peter the challenge is mainly with nutritional management. I will help patient by making him ware of the daily allowance of calories. I will refer to cognitive behavioural therapist for preventing binge eating (Brownell & Walsh, 2017).

In conclusion the essay enhanced personal critical thinking skills to identify and prioritise the patient health issues. Clinical reasoning cycle helps in decision making by systematically analysing the case study of Peter. Following each step correctly, leads to processing of health information and design appropriate nursing care plan. Two health priorities identified for Peter using the clinical reasoning cycle are control of weight and glucose level. The nursing strategies used are evidenced based and will help patient control both obesity and diabetes symptoms.

References

Bedhiafi, T., Charradi, K., Ben Azaiz, M., Mahmoudi, M., Msakni, I., Jebari, K., … & Aouani, E. (2018). Supplementation of grape seed and skin extract to orlistat therapy prevents high-fat diet-induced murine spleen lipotoxicity. Applied Physiology, Nutrition, and Metabolism, (ja).

Brownell, K. D., & Walsh, B. T. (Eds.). (2017). Eating disorders and obesity: A comprehensive handbook. Guilford Publications.

Choi, N. G., & DiNitto, D. M. (2014). Role of new diagnosis, social isolation, and depression in older adults’ smoking cessation. The Gerontologist, 55(5), 793-801.

Eldredge, L. K. B., Markham, C. M., Ruiter, R. A., Kok, G., & Parcel, G. S. (2016). Planning health promotion programs: an intervention mapping approach. John Wiley & Sons.

Gee, T., Dalton, L., & Levitt-Jones, T. (2015). Using Clinical Reasoning and Simulation based education to flip the enrolled nursing curriculum. In Sustainable Healthcare Transformation: International Conference on Health System Innovation.

Heymsfield, S. B., & Wadden, T. A. (2017). Mechanisms, pathophysiology, and management of obesity. New England Journal of Medicine, 376(3), 254-266.

Imamura, F., O’Connor, L., Ye, Z., Mursu, J., Hayashino, Y., Bhupathiraju, S. N., & Forouhi, N. G. (2015). Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. Bmj, 351, h3576.

Levich, B. R. (2011). Diabetes management: optimizing roles for nurses in insulin initiation. Journal of multidisciplinary healthcare, 4, 15.

Mark, A. L., & Somers, V. K. (2016). Obesity, hypoxemia, and hypertension: mechanistic insights and therapeutic implications. Hypertension, 68(1), 24-26.

Nanditha, A., Snehalatha, C., Ram, J., Selvam, S., Vijaya, L., Shetty, S. A., … & Ramachandran, A. (2016). Impact of lifestyle intervention in primary prevention of Type 2 diabetes did not differ by baseline age and BMI among Asian?Indian people with impaired glucose tolerance.