Clinical Reasoning Client Report
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Clinical reasoning, which also referred to as “thinking like a nurse,” is the process through which clinicians and nurses collect clues, process this information to understand the situation or problem of patients and come up with possible solutions. Based on the outcome of the performed solution, one is able to perform evaluations of the outcomes, reflect on them and possibly learn something new at the end of it all. It is, therefore, important that nurses understand this to handle patients with care and generate the necessary information needed for their treatment. This report discusses patient context, which is the initial impression of a patient’s situation perceived by a clinician. To expand on this, it outlines the different cues discovered on a patient and the processing of this information to make conclusions. From this information, it also identifies probable problems that arise and are in relation with the information collected earlier.
The client in this report is Mr. Wong, who has had a recent fall in his home before going for his scheduled respite care. The client in question is in-home respite care services recommended by his family and the doctor in charge because of a condition that he might be having. From his appearance, he always requires demanding caregiving, which his family finds it difficult to meet. It is also possible that Mr. Wong is a patient with dementia, and the respite care seems helpful in coping with his condition while participating in activities that seem to match his needs and abilities. Mr. Wong is an elderly man who seems to be older than 60 years. It seems that Mr. Wong faces difficulty when it comes to remembering conversations and events that are recent and even names of people around him. From his symptoms, most probably Mr. Wong is in the complex stages of dementia. In most cases, dementia depicts by impaired judgment, communication, and difficulty in engaging in physical activities.
From the information presented, it is apparent that Mr. Wong is a patient scheduled for respite care and has had a recent fall. His most common signs are a temperature of 37.7oC, a blood pressure of 110 for systolic and 110/65 for diastolic. His heart rate is at 84 bits per minute. In the cultural context, Mr. Wong was born in China, speaks Mandarin as his first language and English as the second. For his feeding habits, the client in question prefers Chinese Cuisine, which includes noodles, rice, meat or fish and vegetables. Health wise, it is known that Mr. Wong has dementia, which is characterized by his impaired functional capacity, impaired cognitive capacity and the lack of ability to reason. He has poor hygiene practices and always needs assistance when eating.
With the information available, most likely Mr. Wong suffers from a type of dementia characterized by some of the information available. Mr. Wong has a normal body temperature of 37.70C, which qualifies him to have good health. Other vital signs apart from the body temperature like the pulse rate and blood pressure also seem to be normal for a person of his age. These factors are always important when it comes to monitoring and detecting existing medical problems. The impaired functional and cognitive capacities in Mr. Wong prove memory loss, which is always an early and noticeable symptom. Apart from the information provided, it was necessary to find out how the client hands his moods and whether he is in a state of depression, agitation or aggression. Other common behavioural symptoms that are non-cognitive in nature and mentioned include withdrawal, apathy, irritability and anxiety. These secondary symptoms tend to be beneficial when it comes to providing medical attention.
From the processing of information available, it now clear that Mr. Wong has Alzheimer’s disease: a type of dementia. This common type accounts for over 50% of demeentia cases. The decline of Mr. Wong’s cognitive and functional abilities proves this. His memory is slowly declining and, therefore, bringing about a lack of insight and no knowledge of his physical needs. Others include memory loss, inability to perform daily activities such as eating in the case of Mr. Wong and impaired judgments. In order to attain appropriate medical care, the family decided to seek the help of experienced caregivers that are experts at handling this condition.
With this information, a nurse or clinician must set priority in enduring that Mr. Wong gets back to his normal condition before the fall occurred. Records of Mr. Wong show that there have not been any recent fall assessments. This would be the first step as a nurse obtains the other patient history from his family. The fact that Mr. Wong’s fall may affect his mobility is a key to ensuring proper medical attention from a clinician. From my knowledge as a nurse, increased falls is a proof of Alzheimer disease. To perform a fall assessment, it would be important to identify its major causes, which are impaired processing of the mind, balance disorders, impaired vision and possibly environmental hazards. Other causes may be use of strong medications such as sedatives and alterations in the wake-sleep cycle. The other assessment I would conduct is the PPA (Physiological Profile Assessment) that will help to predict future falls that may be recurrent. It will also identify the different causes of the fall such as muscle strength and reaction time that also guide on the mode of treatment for the patient. Once complete, a nurse will communicate to Mr. Wong’s families on the identified reasons, and on how to prevent occurrence of similar incident. While administering the medication, the possible side effects and their impacts to the personal health of the patient will remain pertinent. The prescription of drugs in Mr. Wong’s case will depend on the stage of the dementia.
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