clinical Reasoning (Case Study Sample)

CLINICAL REASONING
Patient context
Mr. Wong is an 81 year old man who presents to my facility feeble and fragile. A quick general examination depicts a very sick looking elderly man incapable of taking care of himself. He is brought in by the daughter assisted to walk on a walking frame. He seems not to have a lot of energy to even explain himself. The daughter quickly explains to me that she will fly out of the country to China to visit the family over the holiday. She has been his primary carer; therefore, when she is away the old man would need some care, reason why she brought him to my facility. On examination, he looks thin, frail and seems to have lost a lot of weight. Upon weight measurements, he is found to weigh a paltry 50 kilograms. Definitely he is underweight as per his age. He cannot remember the most basic information and appears to be in the early stages of dementia. This would be very frightening for him when he is moved to a new environment. I notice that he does not eat nor drink that much. He appears uncomfortable and an examination reveals a soiled trouser with a urine smell. His gait depicts one in a lot of pain from the pelvic region. A snapshot impression tells that Mr. Wong needs urgent and special care.
Collect cues/information
I would need to know about his past diet and if he has any dietician. If not I would for a dietician that would attend to him and adjust his meals and nutritional requirements in the most appropriate way. The reason is he appears not taking adequate amount of food and drink. I would like to know if he had a dentist who attended to his oral health. Elderly individuals are less likely to take care of their oral health as compared to the younger population (Peterson & Yamamoto 2005, p. 89). Besides, very old men may have lost a few teeth (Kaye et al. 2010, p. 715). I would like to have some information on how he manages the sore genitalia. Does he take any systemic medications? Does he apply some topical creams? If yes, which ones? Systemic medications treat systemic diseases while topical creams are used for the management of localized infections (Chalmot 2012, p. 1436). I would like to know of if there have been any nursing or medical assessment that have been done previous. An example is rectal examination and its findings. Rectal examination is a medical assessment to determine any abnormalities in the size and the contour of the prostate gland (Parsons, Evans & Wright 2009, p. 329). I would then take an assessment of Mr. Wong for further information. I would begin with a general examination then a local examination specific to the systems affected. I will assess for pallor, jaundice, signs of shock and hydration status. If there had been a metastasis, the kidneys would be compromised that would lead to anemia and consequent body weakness. Jaundice will relate to liver compromise, while shock signs and the hydration status will be significant in prioritizing care (Saladin 2014, p. 680). I would examine the genitalia and note any ulceration, redness, swelling on any discharge. He could be having a urinary tract infection.
Process information
From the information provided and the additional information that I would like to know, there are possible relations to the pathology surrounding Mr. Wong’s clinical presentation. The weight loss could be a result of a cancerous process going on. Elderly people are at risk of developing cancerous growths (Fatma et al. 2012, p. 65). Mr. Wong has an unstable gait. It means that he is at an increased risk for falls if he is admitted in an aged care facility (Rubenstein 2006, p. 35). He has a thin skin and seems underweight. He is; therefore, at risk of skin tears and would need skin care. Urinary incontinence would mean that Mr. Wong would soil himself quite often. Urine irritates the skin; therefore, he will need a continence nurse. In Mr. Wong’s case, a medical history would suffice. I would need to know his past medical history, if he has ever suffered from a major medical illness that would warrant a hospital admission. The reason is it could be a relapse of a past illness (Redelmeier 2001, p. 810). Significantly, I would like to know about a history of a chronic illness either him or one that is in the family. Similar symptoms in a member of a family depict a genetic condition (Thompson 2008, p. 490). It is of importance that we get to know the duration of the weight loss. Elderly patients are at risk of developing cancer which presents with cachexia as one of the symptoms (Tisdale 2009, p. 392). In particular, elderly men above 60 years are predisposed to developing cancer of the prostate (Stangelberger 2008, p. 113). I would as well need to know Mr. Wong’s medication charts if he has been on any medication. Medication taken for a long time or to treat a chronic illness could have effects that would present with some symptoms of Mr. Wong. One of the side effects of drugs is reduced appetite and abdominal discomforts (Ahmed 2010, p. 213). I would like to know if there had been any investigations that had been done before. And if there had been any investigations undertaken, what were the results? Case in point is PSA (prostate specific antigen) levels. High levels of PSA are consistent with benign prostatic hyperplasia and cancer of the prostate (Downing 2003, p. 139). Elsewhere, I would need to know if there had been any radiological investigations that had been undertaken. Bone x-rays radiographic films or any pelvic ultrasound would suffice as an investigation into the cause of the urinary incontinence. Metastasis of cancer cells to the vertebra would compress on the nerve roots that are responsible for the control of bladder sphincter that would result in its loss of function and hence the incontinence (Parsons, Evans & Wright 2009, p. 325).
Identify problems
Mr. Wong is an elderly sick patient who needs special care with regards to his clinical presentation at the facility. He is underweight or has lost weight. He is fragile and feeble with an unstable gait. He needs to be supported and is at risk of falls. He does not take adequate amounts of food and drink therefore he is undernutritioned and dehydrated. He often has sore genitalia and soils himself occasionally due to urinary incontinence.
Conclusion
Mr. Wong definitely needs specialized care. However, some additional information needs to be extracted to maximize care (Levett-Jones 2013, p. 54). As described above, a few investigations need to be done, such as the PSA levels as he is an elderly patient at risk for the development of cancer. The findings would definitely influence the kind of nursing care that he would receive. In terms of care relevant to the pres...