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Clinical decision-making (CDM) is a dynamic activity in which the nurse builds a case in which hypotheses are accepted or rejected based on collected data, better defined by Barrows & Pickell (cited in Robinson 2002, p. 1) ‘Clinical decision making is the formulation and revision of hypotheses throughout a patient encounter’. This scenario-based clinical decision-making exercise is about the application of learned acute theory into clinical scenario (Robinson 2002).
The following case study outlines the possible nursing problems of our client, Mr Robbins who was diagnosed with advanced prostate cancer and was advised that the only treatment available for him was palliative following a transurethral resection of the prostate (TURP). After seeking a second opinion he was placed on a monthly hormone therapy subdermal transplant for two years and sub. At present, Mr Robbins prostate specific antigen (PSA) level is 12 and has been stable for 4 months.
Mr Robbins has a positive attitude towards his condition. He communicates with other sufferers and medical experts from other countries and has a regular contact with his specialist about options available for him. He also has a supportive partner and has very active life in the community that he lives in. His major concern is his osteoporosis and fracture incidence due to bone metastases of his prostate cancer. He had several falls but did not suffer any fractures. He takes Bisphosphonate medication for his bones and believes that his medication has his cancer under control. He recently been admitted in the hospital due to his chest infection and requires 4 hourly antibiotic intravenously and he is to be discharged the next day to Hospital in the home.
This brief outline offers a basis on which to plan and implement suitable nursing care for Mr. Robbins. By applying the concepts of CDM to this case will develop a coordinated care pathway for the patient from hospitalization to patient discharge and transition to home.
Prostate cancer is a malignant tumour of the prostate gland. The majority of tumours occur in the outer aspect of the prostate gland. Prostate cancer is usually slow growing. The tumour can spread to other parts of the body, particularly the lymph nodes and the bones. It is usually asymptomatic in the early stages but eventually the patients may have symptoms such as difficulty in urinating and erectile dysfunction. Other symptoms can potentially develop during later stages of the disease (Brown & Edwards 2008).
Treatment options for prostate cancer are surgery, radiation therapy, hormonal therapy, and chemotherapy. Treatment depends on the stage of the cancer and the overall health of the patient (Brown & Edwards 2008). Mr. Robbins prostate cancer was classified advance, which means that the cancer cells spread beyond the localized area of the prostate and in his case it metastasis into his bones.
Coordinated care pathway is structured multidisciplinary care plans which detail essential steps in the care of patients with a specific clinical problem. The aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources.
The nurse care coordinator will engage with Mr Robbins, and support him through the duration of his care plan. The RN will also organize the care and services identified in the care plan across social care and other agencies and he/she will also liaise with the other healthcare professionals in regards to implementation of Mr Robbins care plan. The nurse coordinator also monitor the progress of the care plan by collating information from agencies and individuals who provide particular elements of a care plan. The RN also act as a communicator between the patient and those providing elements of the care plan to ensure the appropriate passage of relevant information on progress and developments.
Mr. Hay appears to understand how to manage his health as he sought medical attention for his cough, and believes he copes at home despite no mention of services in place. An assessment should be conducted to gain insight into what he believes is normal for his age. This may incorporate questions regarding his dietary and fluid intake; utilizing a dietician or nutritionist if necessary. Further questions could be posed regarding his adherence to medications in reference to the antibiotics. He will also require close monitoring from his doctor in regards to his chest pain and may need a referral to a cardiologist and respiratory specialist in the future. Â
Mechanical and gas exchange alterations in the lungs that occur in normal aging, in conjunction with his respiratory complications and possible angina, would most likely reduce Mr. Hay’s ability to tolerate exercise (McCance & Huether 2006). His past #NOF may also be impairing mobility. Therefore, he may require assistance with self care activities and ambulation whilst admitted.
In the elderly malnutrition is a major concern, especially when they are suffering a chronic pulmonary disorder; due to increased energy expenditure and impaired oxygenation. Therefore maintenance of an acceptable and stable weight is important.
A diet high in energy density, frequent snacking, soft food, and frequent beverages is advisable. Discharge planning should involve assistance in this area such as shopping and meal preparation (Brown & Edwards, 2008)
His elimination pattern could be assessed by asking him about the frequency of bowel and bladder activity and seeking a description. He should also be asked if frequency or pain is experienced with defecating or urinating, if laxatives or enemas are used, results should also be noted. The skin should also be assessed in terms of excretory function if excessive perspiration, oedema, pruritus and/or redness are present (Brown & Edwards, 2008, p. 40).
Mr. Hay is able to express himself clearly as evidenced by his complaints of chest pain, and he is also able to recall past events by stating this had happened previously. Although hypoxia and fever could affect his mental state, as alluded to by the discrepancies in the data
Laying down results in sputum obstructing airways, whilst dyspnoea may lead to anxiety to further impede sleep. Monitoring is essential to avoid skin break down on his left side if pain determines he lays on that side exclusively, and likewise prevention of further breakdown should he continue to sleep on his right. Whilst the pyrexia could affect sleep as he may be experiencing night sweats or feeling too hot to sleep. Extrinsic factors such as the hospital environment can amplify sleep disturbances, as Mr. Hay may have to share a room with strangers and endure a noisy ward when he is accustomed to sleeping alone in his home. Not to mention his own anxiety as a natural reaction to being admitted to hospital.
Mr. Hay seems capable of self care activities and perhaps this is supported as he did make mention of visiting his doctor, which requires some level of cognitive and physical functioning. Yet without factual information regarding this visit, the focus still lies on the circumstances the led to this admission which paint a different picture.
Living alone, isolated from family with his neighbour only discovering him after time had elapsed, as well as the death of his wife; reveals Mr. Hay’s isolation and possible loneliness.
His prior injuries all seem to have coincided with the passing of his wife, as he sustained a #NOF and P.E. in the same year she died, and a year later he severely burnt his hand; perhaps evidence of his decline since becoming a widow.
Mr. Hay’s recent widowhood has meant he has been forced to re-establish himself as an individual after years of being part of an intimate relationship. The grief experienced by the remaining spouse due to the loss of closeness in sexual intimacy and overall companionship can manifest into serious health implications.
It could be taken at face value that Mr. Hay drinks a nightly scotch, yet alcohol consumption is linked with ineffective coping mechanisms, especially in men (Cooper et al. 1992). Mr. Hay stated that he is able to cope on his own, yet his past and current injuries say otherwise.
Mr. Hay’s optimistic responses in relation to his home situation and health imply he is independent. In actual situations this would prompt further questions to understand how the patient views their current situation and to anticipate how he might deal with the intrusion to his independence through closer monitoring by implementing services as home.
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