Clinical Reasoning and Decision Making in Nursing Essay

Introduction

I have chosen to discuss case study 2 in this assignment as it appealed to me most. It is based on a woman who has been diagnosed with a condition and has many responsibilities. This case will enable me to explore different aspects of the service user’s life and how they all impact her well-being. I have an interest in healthy lifestyles and well-being. Part A of this assignment will include a detailed overview of the case, and information about the body system to which her case relates, as well as the nursing process. I am also going to look at health promotion and the choices that are presented in this case. Part B will consist of my reflection on the case study. In conclusion, I will summarise this case study.

Your patient (Part A)

Case study 2, presents a 54-year-old married woman. This service user has been suffering from Diabetes Mellitus Type 2 which was diagnosed 6 years ago. This condition is caused when the pancreas does not produce enough insulin causing level of glucose in the blood to become too high (diabetes.org.uk). They also have a BMI of 35 which is obese. According to NHS live-well, A BMI ranging from 18.5-24.9 is considered to be healthy. High BMIs such as 35 are caused by physical inactivity, overeating, frequency of eating, and other issues. (Medicinenet.com). In addition, she also suffers from stress incontinence due to the birth of her last born.

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The service users’ presenting complaint relates to the endocrine system, which is responsible for regulating bodily functions by secreting hormones into the bloodstream. These hormones dictate how cells and organs behave. This system consists of glands such as the hypothalamus, pituitary, pineal, adrenal, pancreas, and more. (healthline.co.uk) The pancreas regulates blood glucose levels by secreting insulin and glucagon. Type 2 Diabetes happens when insulin is not being used by the cells. This results in the body becoming insulin resistant which causes long-term issues such as damage to the pancreas, causing insufficient insulin to be produced and the person becoming hyperglycaemic. (diabetes.co.uk)

This individual, lives a very demanding life, being an informal carer for her husband who has a heart condition, and looking after their 4 children. This may suggest that this service user and her husband are both unemployed. Therefore, they may not have a source of income; this could mean that they rely on government funding such as benefits to fulfill their livelihoods. By having many responsibilities to deal with, the service user may be very susceptible to stress and may be unable to manage her well-being. REF about stress In addition, one of her children is being discharged from the hospital to come home which also adds to her responsibilities. It may be advised that she could get domiciliary carers to care for her husband. This will relieve the stress and manager to focus on her well-being and her son.

Nursing process (Part A)

Clinical decision-making is an important nursing process that occurs to achieve the best possible person-centered care for their patient. According to the NMC, nurses must make person-centered decisions, with evidence-based judgments and conclusions, in partnership with others to ensure high-quality care. In the process of decision-making, it is important that regardless of the outcome or end goal, the decision must be based on the patient’s needs and they must be involved throughout the process. The decision made will motivate the patient to adopt positive health behaviors. (highspeedtraining.co.uk)

One decision that was made regarding the service users’ care was to manage their diabetes and regulate their blood glucose levels. This was done to prevent the service user from becoming hyperglycaemic. Hyperglycaemia has life-threatening effects if action is not taken to get blood glucose levels back to normal. For example, a hyperosmolar hyperglycaemic state is severe dehydration due to the body's system’s attempt to get rid of excess sugars. (NHS, 2018)

Many factors must be considered in the process of making the decision. These factors are mostly patient-related. One example of a patient-related factor to be considered is age. As we age, our cognitive abilities and thinking processes begin to decline. This becomes an issue when presented with certain situations. (Sciencedaily.com). With age, the levels of hormones decrease, and the function of the endocrine system declines as the hormone receptors lose sensitivity. (msdmanuals.com) This shows that health professionals should consider age and the effect it has on the patient’s body system. This must be highlighted when forming decisions especially when prescribing medication.

Another factor that should be considered is the level of capacity. Capacity is the ability to obtain and understand the information to help form a decision. (NHS, 2019) If an individual lacks capacity, the healthcare professional and others involved with the care of the patient all come to common ground and decide on the best interest of the patient. In addition, clear communication is equally as important. Having good communication between the patient and nurse will help reduce any anxieties or worries that the patient may have. (RCNI, 2016) When delivering and discussing the decision made, it's important that the patient clearly understands. This is achieved by ensuring the language spoken is the same and by reassuring them that they understand the information they are presented with.

An important aspect to be considered when forming the decision in this presenting case specifically is the clients’ family medical history. This is because family members share not just only genetic material but similar environments, lifestyles, cultures, and habits. (ncbi.nlm.gov, genetic alliance 2008) Therefore by accessing such information, the nurse and the patient will be able to discuss and adapt to positive lifestyle behaviours to help manage the diabetes, which may have also helped the relatives. By adapting to healthier habits, it will reduce the risk of developing other diseases. (ncbi.nlm.gov, 2008) Another aspect that was considered was the service users’ diet. According to Diabetes UK, when altering your diet, it is important to choose food with healthier carbohydrates. This is because carbohydrates increase blood glucose levels, therefore healthier carbohydrates such as whole grains, brown rice, fruits, and vegetables should be incorporated into the diet. This will help to maintain a normal level of glucose. It is also recommended to be aware of salt intake, limiting yourself to 6g of salt a day is ideal. Salt increases the risk of hypertension, especially in diabetic patients (diabetes.org.uk). Furthermore, it is important to take into consideration how easily accessible the supermarkets are and the price of food. This is because as mentioned earlier, the couple may not be employed therefore they may experience financial challenges with accessing the supermarkets depending on their locations. When managing diabetes, physical activity and being mindful of weight is also important. Exercising increases the amount of glucose being used by the muscles which means the glucose in the blood is being reduced and insulin will be used more efficiently to help regulate the blood glucose levels. (diabetes.org.uk)

The process of clinical decision-making can be defined as a process of choosing between alternative options (Thompson & Dowing, 2002) It is a complex process compared to day-to-day decision-making. According to Johansen and O’Brien 2016, clinical decision-making requires nurses to use their knowledge, experiences, clinical setting, patient information, unique characteristics, and other aspects. Another aspect to be considered is shared decision-making, healthcare professionals and patients discuss and share the evidence available when making decisions. Patients are supported by healthcare professionals to consider the options available to achieve the best care and decision. (Elwyn G et al, 2010)

Evidence-based practice allows nurses to enhance their knowledge of clinical training as well as experiences with updated research. (Kessenich CR, 1997) This ensures that their practice is safe, contemporary, and advanced as it is based on validated research. This practice involves being able to access and apply information from literature research to help form clinical decisions when required There are mainly three theories that have different approaches when to clinical decision making, which are the information processing theory, intuitive theory, and the cognitive continuum theory.

The information processing theory is a theory that supports and is most suitable for this case study. It is also termed a hypothetico-deductive approach. The principles of this approach involve the use of hypotheses generation and evaluation, cue recognition, and cue interpretation in stages (Tanner et al., 1987) Upon the first encounter between the nurse and patient, they will assess and obtain information about their patient for example, reason for admission, signs, and symptoms, etc. This stage is known as the cue recognition. In this case study, the nurse collects information about the service users’ history of blood glucose levels or BMI over the past 6 years. This information can be derived from medical notes or the service users themselves. The next stage to follow is the formation of a hypothesis, which is when the information provided is used to generate a hypothesis. The nurse may have recognized that the blood glucose levels require close monitoring through diet and physical activity which may have been further validated by the doctor. Cue interpretation follows, this is when the cues (information gathered at the beginning) will be analyzed to help conclude to either accept or reject the original hypothesis. The nurse will use their judgement and analysis to help form a suitable decision taking into consideration all patient-related and non-patient-related factors. Then the information collected will be evaluated with advantages and disadvantages, which is the final stage. (Banning M, 2010) Advantages and disadvantages will be evaluated by judging against other alternatives to the decision.

In comparison to other theories for example the intuitive theory (also known as the humanist theory), which does not take a scientific approach, does not support this case study. This is because decisions are based on ‘rational’ and ‘intuition’. (Dijkstra KA, 2012) Intuition is the human ability to know something or do something without thought or knowing (Thompson VA, 2014). In this case, it is not ideal to do so because the decision needs to be based on evidence which will be the service users, history of the glucose levels. This cannot simply be guessed without knowing exactly what the issue is.

Health Promotion (PART A)

The main contributing factors to Diabetes Mellitus Type 2 are being overweight and inactive. The complications of diabetes are life-threatening if the blood glucose levels are not regulated. Diseases such as kidney damage, heart and blood vessel disease, eye damage, and other complications may occur. (mayoclinic.org,2019)

The lifestyle choice that the service user makes that puts them at a health risk is their eating regime. The client recognizes and states that she is overweight and has been attempting to stick to a healthy eating plan, but she is finding it difficult to do. Excessive consumption of fats and carbohydrates, sugar, and salt within one’s diet all contribute to the development of diabetes by excessive weight gain leading to obesity (rcn.org.uk,2020). Foods such as processed red meat for example bacon, and deli meats should be avoided when one is diagnosed with diabetes, this is because they have a high source of sodium and nitrites. In addition, other foods such as unhealthy and trans fats which are found in butter, milk, and cheese increase cholesterol levels which is not ideal. Carbohydrates are an important source of energy, but however, highly processed carbohydrates are not advised. This includes cakes, white bread, white rice, etc. When these foods are processed the fibre and other important vitamins are removed causing their digestion when consumed to be different as a lot more glucose is released in the blood causing a rise in the blood glucose levels. Lastly, beverages that have a high sugar content, include teas, coffees, and carbonated drinks such as coke, and energy drinks, which all lead to weight gain and increase blood glucose levels. (healthline.com, 2018) The consumption of these foods may have contributed to the issue even more as the service users’ BMI remained at 35 which is classed as obese. Failure to alter and be mindful of what you consume especially when diagnosed with diabetes type 2 will lead to further complications and other diseases, placing the individual at an extremely high health risk.

As stated previously, this service user has a highly demanding life filled with the responsibilities of caring for her husband every day, as well as her 4 children. Having no help, caring for her husband and her son who is to be discharged may become increasingly exhausting. This may cause her to be very susceptible to stress and potentially anxiety. One coping mechanism that she may have adopted could have been over-eating over-sleeping or not sleeping at all. When an individual is stressed, the glands release the cortisol hormone into the bloodstream, this cortisol may increase and expand one’s appetite causing cravings as a way to deal with the stress. (medicalnewstoday.com, 2018) Over-eating is not ideal in this case due to her diabetes, this will cause complications which may add more stress. Therefore, it is important to note that she may require additional help to relieve her of her stress. It will allow her to become more self-aware as she will be able to care for her well-being

This service user may have been advised in the past to prepare diet plans and healthy meal ideas to help tackle her weight and lower her BMI, alongside the help of other healthcare professionals. Patients are advised to eat a healthy balanced diet including a sufficient fluid intake of at least 6 to 8 glasses of water (NHS,2019)However due to her responsibilities of caring for her husband, she may have struggled to adhere to this plan to help manage her diet. The client recognizes that she is overweight therefore this may be affecting her self-esteem and may trigger low self-awareness and anxiety. Shame, rejection, and low self-esteem are all feelings that are common in obese adults. Loneliness can come into effect also; these emotional effects may affect and reduce one’s lifespan. (everydayhealth.com, 2010)

Reflection and Future Recommendations (PART B)

It is important to take into consideration positive lifestyle changes to improve the quality of life of this service user and reduce any further health complications. Many positive benefits can be gained from making small changes to one’s life, this will benefit their mental well-being, their family, and the community.

One positive lifestyle recommendation is stress management. Effective stress management allows the individual to be happier and live a healthier life. (helpguide.org, 2019). One way the service user could cope with stress is by creating some leisure time. This time could be used to do some activities such as reading books, going to the park, knitting, or spending quality time with the family, by carrying out such activities the individual will be at ease and will be happy. Sleep is also equally important with stress management, according to the National Sleep Foundation (2020), it is advised to sleep 7 to 9 hours per night. That is required to remain healthy. Another recommendation to consider is regular physical activity. Physical activity is important as it lowers risks of heart diseases and nerve damage and helps with the controlling of blood glucose levels. By being active the body will make your body more sensitive to insulin (cdc.gov, 2018). This physical activity could be simply jogging around the neighborhood or local park, taking part in local gym classes if possible, dancing, or playing any type of sport to help keep the muscles active. The service user could take part in any of these activities. Having an active lifestyle will have a huge impact on blood glucose levels, easing stress and reducing body weight. (webmd.com, 2019) One particularly important recommendation is altering the diet and monitoring blood glucose levels constantly. It is recommended that diabetic patients have a goal of limiting saturated fat and dietary cholesterol in their diet. (Vaughan, L et al., 2004) Healthier fats such as seeds, avocado, oily fish, etc are recommended instead of red and processed meat fats, butter, and cakes. Including when cooking, grilling, or steaming food is a better, healthier option than frying. Choosing healthier carbohydrates as mentioned before is crucial as well as salt intake. Healthier snacking between meals is ideal, sugary snacks and sweets can be exchanged for healthier sugars such as fruits, nuts, or seeds (diabetes.org.uk?) The service user could be recommended to have regular checkups with their local general practitioner or nurse for their regular 3-month blood glucose monitoring and checks (HbA1C test) (NHS. uk, 2017)

This case study has allowed me to gain a better in-depth understanding of the importance of nursing processes and clinical decision making which is a huge part of a nurse’s day-to-day practice. I have also managed to apply the theory model in nursing to this specific and compared the models. I have learned that nurses must make decisions regarding the patient to be person-centered and backed up with evidence rather than intuition. When I return to practice, I will be aware that all decisions made regarding a patient will be based on evidence from research or literature as it is a requirement. Failure to do so will result in consequences. In the future, if I were provided with a case study assignment, I would ensure to include all information about the patient and do further research.

In summary, this assessment involved a detailed overview of the service user and their presenting complaint of diabetes. The decision made by the healthcare professionals was explained and supported by the information processing theory to show that the decision made was supported by evidence-based research. Positive lifestyle recommendations were considered to improve and manage their lifestyle and live a happy and healthy life.