Introduction
This essay explores the application of the Clinical Reasoning Cycle (CRC) and the Roper-Logan-Tierney (RLT) Model in the care of Mrs Rita Roy, an 88-year-old resident recently admitted to Bakersville Residential Aged Care Facility in Australia. Admitted following a fall at home, Rita presents with a history of falls, mild asthma, poor diet, and psychosocial challenges due to relocation. As a first-year Bachelor of Nursing student, this analysis aims to demonstrate a structured approach to clinical reasoning and person-centred care planning, addressing Rita’s immediate health priorities such as fall prevention, nutritional risks, and adjustment to her new environment. The essay is structured into key stages of the CRC, alongside the RLT model, to assess, interpret, and prioritise nursing interventions in line with Australian best practices.
Stage 1: Consider the Patient Situation (Who, What, When, Where, Why)
Mrs Rita Roy, an 88-year-old widow, was admitted to Bakersville Residential Aged Care Facility two days ago after a fall on her front porch. This incident is part of a pattern of multiple falls at home, leading her to feel unsafe living independently. She has a medical history of mild asthma, managed with a reliever inhaler during infections, limited GP visits, and a self-reported unbalanced diet. Rita’s husband passed away four years ago, and while her grown-up children supported her transition into care, she is struggling with the change, evident in her agitation over missing her usual walk to the local community centre for gardening classes. The situation demands immediate attention in a residential aged care setting to prevent further falls, address nutritional deficits, restore regular medical oversight, and support her psychosocial adaptation. This person-centred focus aligns with the initial phase of the Clinical Reasoning Cycle, ensuring safe, value-based care (Levett-Jones, 2018; Aged Care Quality and Safety Commission [ACQSC], 2021).
Stage 2: Collect Cues/Information (Current Information, New Information, Knowledge)
This stage involves reviewing existing data, gathering new information, and recalling relevant clinical knowledge to inform safe care planning (Levett-Jones, 2018). On admission, Rita’s vital signs were stable: respiratory rate 18 breaths per minute, clear lungs, radial pulse 75 bpm, blood pressure 136/85 mmHg, and temperature 36.5°C. She reported a mild headache (rated 2/10), attributing it to relocation stress, and had normal bowel and bladder function. No blood glucose reading was recorded. Additional cues include her history of falls, mild asthma, infrequent GP visits, and poor dietary intake. Her family is due to visit, which may influence her emotional state.
New information should be gathered using a structured, multifactorial approach as per Australian guidelines. Fall risk and mobility can be assessed with tools like the Timed Up and Go test (a score over 12 seconds indicates higher fall risk), the 30-Second Chair Stand test (lower scores suggest increased risk), and, if available, the Short Physical Performance Battery (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2021). Orthostatic blood pressure should be measured to detect hypotension, while continence patterns, cognition (via Mini-Cog), sensory function (vision and hearing checks), and environmental hazards (e.g., clutter, poor lighting) must be evaluated. A Residential Medication Management Review with a pharmacist and GP can identify fall-inducing medications and verify asthma management (Australian Government Department of Health and Aged Care, 2023). Nutritional status should be assessed using the Malnutrition Screening Tool (MST), with weekly weight and BMI checks, alongside food and fluid charts. Blood tests (e.g., vitamin D levels) and dietitian referral may be necessary if risks are identified (Serón-Arbeloa et al., 2022). Finally, screening for mood, loneliness, and cultural needs, with family input, will support psychosocial adjustment (ACQSC, 2021). This comprehensive data collection underpins evidence-based care planning.
Application of the Roper-Logan-Tierney (RLT) Model
The RLT Model provides a holistic framework for assessing a patient’s independence and dependence across activities of living, considering biological, psychological, sociocultural, environmental, and politico-economic factors (Holland & Jenkins, 2019). For Rita, two key activities stand out: maintaining a safe environment and eating and drinking. First, ensuring a safe environment is critical given her fall history and fear of further incidents. Using the RLT lens, nursing assessments should evaluate mobility, balance, continence, sensory impairments, and environmental risks. Interventions include orienting Rita to her surroundings, ensuring appropriate footwear and assistive devices, clearing pathways, optimising lighting, and facilitating short, supervised walks to rebuild confidence. Referrals to physiotherapy and medication reviews align with Australian best practices (ACSQHC, 2021; Menant et al., 2023).
Second, eating and drinking are prioritised due to Rita’s reported unbalanced diet, which could exacerbate frailty. Using the RLT model, malnutrition screening (via MST), weekly weight monitoring, and intake recording are essential. Interventions might include offering small, nutrient-dense meals, creating a social dining environment, addressing barriers like pain or constipation, and involving a dietitian for personalised planning (Serón-Arbeloa et al., 2022; ACQSC, 2021). This approach integrates person-centred care with evidence-based standards, reflecting the RLT emphasis on holistic assessment.
Stage 3: Process Information (Interpret, Discriminate, Relate, Infer, Match, Predict)
Processing information involves interpreting cues, prioritising issues, making connections, and predicting outcomes (Levett-Jones, 2018). Rita’s history of falls, new environment, and expressed fear suggest a high short-term fall risk. Although her admission vitals were stable, unassessed factors like orthostatic hypotension or deconditioning require targeted testing. Her mild headache may relate to stress, minor injury, or dehydration, while poor nutrition likely contributes to frailty (ACSQHC, 2021). Relating these cues, a vicious cycle emerges: reduced activity (from halted walking and gardening) weakens muscle strength, while fear and stress further limit mobility and appetite, increasing fall risk.
Prioritising fall risk and malnutrition, I infer potential issues such as lower-limb weakness, impaired balance, sensory deficits, and environmental hazards. Malnutrition may indicate early sarcopenia, requiring urgent intervention (Serón-Arbeloa et al., 2022). Matching this to common aged-care patterns, a multifactorial approach—encompassing exercise, environmental modifications, medication review, nutritional support, and confidence-building—offers the safest path (Menant et al., 2023). Predictions include environmental optimisation within 48 hours, medication and physiotherapy reviews within a week, improved mobility by week two, and stabilised nutrition (75% energy/protein intake) within two to four weeks (ACSQHC, 2021).
Stage 4: Identify Problems/Issues (Summarise/Synthesise Facts to Form a Nursing Diagnosis)
This stage synthesises information into nursing diagnoses to guide interventions (Levett-Jones, 2018). The primary diagnosis is ‘Risk for Falls’, linked to Rita’s fall history, new environment, probable balance deficits, possible orthostatic hypotension, sensory issues, and fear. Desired outcomes include no falls within 30 days, achieved through environmental adjustments (within 48 hours), medication review and physiotherapy (within a week), and improved mobility (by week two) (ACSQHC, 2021; Menant et al., 2023). The second diagnosis is ‘Imbalanced Nutrition: Less than Body Requirements’, stemming from poor dietary habits and relocation stress. Goals include completing MST within 24 hours, achieving 75% energy/protein intake within two weeks, stabilising or gaining weight (0.2-0.5kg if underweight), and improving MST scores within four weeks (Serón-Arbeloa et al., 2022). These diagnoses and time-bound targets align with Australian aged care standards, ensuring evidence-based care planning.
Conclusion
This case study of Mrs Rita Roy demonstrates the integration of the Clinical Reasoning Cycle and Roper-Logan-Tierney Model in addressing complex needs in aged care nursing. By systematically considering Rita’s situation, collecting and processing information, and identifying key diagnoses—Risk for Falls and Imbalanced Nutrition—I have outlined person-centred interventions grounded in Australian guidelines. These include fall prevention strategies, nutritional support, and psychosocial care, all aimed at enhancing Rita’s safety and well-being. This structured approach not only addresses immediate risks but also highlights the importance of holistic, evidence-based practice in nursing. As a student, this exercise underscores the value of critical thinking and clinical reasoning in delivering quality care.
References
- Aged Care Quality and Safety Commission. (2021). Quality Standards Fact Sheet. Australian Government.
- Australian Commission on Safety and Quality in Health Care. (2021). National Safety and Quality Health Service Standards. Australian Government.
- Australian Government Department of Health and Aged Care. (2023). Medication Management in Residential Aged Care. Australian Government.
- Holland, K., & Jenkins, J. (2019). Applying the Roper-Logan-Tierney Model in Practice (3rd ed.). Elsevier.
- Levett-Jones, T. (2018). Clinical Reasoning: Learning to Think Like a Nurse (2nd ed.). Pearson.
- Menant, J. C., Meinrath, D., & Sturnieks, D. L. (2023). Falls prevention strategies in residential aged care: A review. Australian Journal of Ageing, 42(1), 15-22.
- Serón-Arbeloa, C., Labarta-Monzón, L., & Puzo-Foncillas, J. (2022). Malnutrition screening tools in elderly care: A systematic review. Nutrients, 14(3), 678.
