Introduction
This essay discusses the case scenario of Mrs Margaret Jones, a 78-year-old woman recently admitted to aged care, using the first three steps of the clinical reasoning cycle as outlined by Levett-Jones (2013). The clinical reasoning cycle is a structured process that guides nurses in making informed decisions about patient care, promoting safe and effective practice. In this context, the essay is written from the perspective of a student nurse on my first interaction with Mrs Jones during a morning shift. The purpose is to review her situation, identify relevant cues, gather necessary information, and analyse the facts through interpretation, discrimination, relation, and inference. This approach ensures a holistic understanding of her needs, considering her age, medical history, and current symptoms. Key points include her confusion, reported heart racing, abdominal discomfort, and vital signs, all supported by literature to inform nursing practice. By applying these steps, the essay highlights the importance of evidence-based care in aged care settings, ultimately aiming to improve patient outcomes.
Step 1: Reviewing Mrs Jones’s Situation and Initial Impression
In the first step of the clinical reasoning cycle, the nurse considers the patient’s situation by gathering an initial impression based on the context, person, and overall circumstances (Levett-Jones, 2013). Mrs Jones is a 78-year-old woman who has been recently admitted to aged care after living with her daughter and son-in-law. Her past medical history includes chronic back pain and short-term memory loss, which mainly affects her orientation to time and place, though she can recognise familiar people. She has no known allergies, which is crucial for safe medication administration.
Upon entering her room, my initial impression as a student nurse is that Mrs Jones appears awake, alert, and cooperative. She is sitting upright in bed, smiling, and engaging in conversation, which suggests a level of responsiveness despite her confusion. However, she seems disoriented, questioning whether she is “at the club or a hotel” and unable to state the correct date or location. This indicates possible cognitive impairment, common in older adults, particularly those with memory loss (Alzheimer’s Society, 2020). She recognises me as a nurse and responds appropriately to questions, which is positive and facilitates care delivery.
Contextually, this is her recent admission to aged care, a significant transition that can exacerbate confusion and anxiety in elderly patients (NHS, 2021). The person-centred aspect reveals Mrs Jones as someone who is usually independent but now dependent on care, with symptoms like intermittent heart racing, feeling “a bit funny” and unsettled, without chest pain. She reports not opening her bowels for about three days, abdominal discomfort, and poor appetite, but no nausea or vomiting. Her vital signs are stable: heart rate 88 beats per minute, blood pressure 120/70 mmHg, respiratory rate 16 breaths per minute, oxygen saturation 99% on room air, temperature 36.4°C, and pain score 5/10 at rest. She remains calm, chats pleasantly, but repeats information and needs gentle redirection, pointing to mild cognitive challenges.
Overall, my initial impression is that Mrs Jones is stable but requires monitoring for potential complications related to her age, such as dehydration or constipation, which could link to her abdominal issues (NICE, 2019). This step sets the foundation for deeper analysis, emphasising the need for empathetic, person-centred care in nursing practice.
Step 2: Identifying Relevant Cues and Gathering Information
The second step involves collecting cues through review and recall, identifying what is relevant, and determining what additional information is needed (Levett-Jones, 2013). This process ensures that nursing decisions are based on comprehensive data, reducing the risk of oversight.
From the scenario, several relevant cues stand out. Firstly, Mrs Jones’s confusion about her location and the date, coupled with her short-term memory loss, is a key cue. This aligns with literature on dementia or mild cognitive impairment in older adults, where disorientation to time and place is common (Alzheimer’s Society, 2020). The rationale for this cue is its potential to affect her safety and compliance with care; for instance, confusion can lead to wandering or medication errors, as supported by studies showing increased fall risks in disoriented elderly patients (NHS, 2021).
Secondly, her report of heart racing on and off, feeling “funny” and unsettled, without chest pain, is significant. Despite her heart rate being 88 beats per minute (within normal limits for her age), this symptom could indicate arrhythmias like atrial fibrillation, prevalent in those over 75 (British Heart Foundation, 2022). The rationale is that early detection prevents complications such as stroke, with evidence from the NICE guidelines recommending electrocardiogram (ECG) monitoring for palpitations in the elderly (NICE, 2018).
Thirdly, her abdominal discomfort, poor appetite, and constipation (last bowel movement three days ago) are cues pointing to possible gastrointestinal issues. Constipation is a frequent concern in aged care, often due to reduced mobility, medication side effects (e.g., from pain relief for her chronic back pain), or dehydration (NHS, 2020). Literature supports this, noting that untreated constipation can lead to faecal impaction or bowel obstruction, particularly in older women (Rome Foundation, 2016). Her pain score of 5/10 at rest further relates to her back pain history, warranting assessment for exacerbation.
Additionally, her vital signs are cues of stability, with normal ranges for blood pressure, respiratory rate, oxygen saturation, and temperature, indicating no immediate acute distress (Resuscitation Council UK, 2021). However, her cooperative nature and need for redirection during conversation cue mild cognitive support needs.
To gather more information, I would review her medical records for recent admissions, medications, and full history, as this provides context for her symptoms (Levett-Jones, 2013). A rationale is that polypharmacy in the elderly can contribute to constipation or palpitations, with studies showing 40% of older adults experience adverse drug reactions (Gallagher et al., 2008). I would also perform a physical assessment, including abdominal palpation for distension and auscultation for bowel sounds, supported by nursing literature emphasising early intervention in constipation to prevent complications (NICE, 2019).
Furthermore, gathering a detailed history from her family (daughter and son-in-law) about her baseline cognition and bowel habits is essential, as family insights improve accuracy in dementia care (Alzheimer’s Society, 2020). An ECG would be needed to investigate heart racing, justified by guidelines for symptomatic patients (British Heart Foundation, 2022). Lastly, assessing her nutritional intake and hydration status through a food diary or fluid balance chart is crucial, given her poor appetite, to prevent malnutrition, which affects 1 in 10 older adults in care (BAPEN, 2018).
Step 3: Analysing the Facts
In the third step, the nurse processes the information by interpreting, discriminating, relating, and inferring, drawing on evidence to form hypotheses (Levett-Jones, 2013). This analytical phase bridges cues to potential nursing diagnoses.
Interpreting the cues, Mrs Jones’s disorientation and memory loss suggest mild cognitive impairment rather than acute delirium, as she is alert and recognises people, which discriminates it from more severe conditions like infection-induced confusion (NICE, 2021). Literature supports this interpretation, noting that chronic memory loss in the elderly often presents as stable disorientation without fluctuating consciousness (Alzheimer’s Society, 2020). However, her recent admission could relate to adjustment issues, inferring a need for environmental orientation strategies.
Relating her heart racing to vital signs, the heart rate of 88 bpm is elevated but not tachycardic; yet, her subjective “racing” feeling infers possible paroxysmal episodes, such as atrial fibrillation, common in older adults and linked to unsettle feelings (British Heart Foundation, 2022). Discriminating this from anxiety, her calm demeanour and lack of chest pain point more towards cardiac rather than psychological causes, though stress from admission could contribute. Evidence from studies indicates that untreated arrhythmias increase stroke risk by 5-fold in those over 75 (Wolf et al., 1991).
For her abdominal issues, interpreting the three-day constipation with discomfort and poor appetite infers potential impacted bowels, related to her age, reduced mobility from back pain, and possible opioid use for pain management (NICE, 2019). Discriminating this from acute abdomen (no vomiting or fever), it relates to chronic conditions, with inference that dehydration exacerbates it, as older adults have diminished thirst responses (BAPEN, 2018). Her pain score relates to both back and abdominal cues, inferring multifaceted pain needing holistic management.
Overall, relating all cues, I infer that Mrs Jones’s symptoms form a pattern of age-related vulnerabilities: cognitive, cardiac, and gastrointestinal, requiring multidisciplinary input. This analysis, supported by literature, guides prioritising assessments like ECG and bowel management to prevent deterioration.
Conclusion
In summary, applying the first three steps of the clinical reasoning cycle to Mrs Jones’s case reveals a stable yet vulnerable elderly patient with cognitive confusion, possible cardiac irregularity, and constipation. The initial review highlights her cooperative nature amid disorientation, while cue identification and information gathering emphasise the need for comprehensive assessments supported by literature on elderly care. Analysis through interpretation and inference underscores potential risks like arrhythmias or bowel complications, informing targeted interventions. This process demonstrates the cycle’s value in nursing, promoting safe, evidence-based practice. Implications include the need for ongoing monitoring and family involvement to enhance outcomes in aged care, ultimately improving quality of life for patients like Mrs Jones.
References
- Alzheimer’s Society (2020) Memory loss and dementia. Alzheimer’s Society.
- BAPEN (2018) Managing Adult Malnutrition in the Community. British Association for Parenteral and Enteral Nutrition.
- British Heart Foundation (2022) Atrial fibrillation. British Heart Foundation.
- Gallagher, P., Barry, P. and O’Mahony, D. (2008) ‘Inappropriate prescribing in the elderly’, Journal of Clinical Pharmacy and Therapeutics, 32(2), pp. 113-121.
- Levett-Jones, T. (2013) Clinical Reasoning: Learning to Think Like a Nurse. Pearson Australia.
- NHS (2020) Constipation. National Health Service.
- NHS (2021) Dementia. National Health Service.
- NICE (2018) Atrial fibrillation: diagnosis and management. National Institute for Health and Care Excellence.
- NICE (2019) Faecal incontinence in adults: management. National Institute for Health and Care Excellence.
- NICE (2021) Dementia: assessment, management and support for people living with dementia and their carers. National Institute for Health and Care Excellence.
- Resuscitation Council UK (2021) Adult basic life support guidelines. Resuscitation Council UK.
- Rome Foundation (2016) ‘Rome IV diagnostic criteria for irritable bowel syndrome’, Gastroenterology, 150(6), pp. 1393-1407.
- Wolf, P.A., Abbott, R.D. and Kannel, W.B. (1991) ‘Atrial fibrillation as an independent risk factor for stroke: the Framingham Study’, Stroke, 22(8), pp. 983-988.
