Clinical Decision-Making for a Patient
The case study that is the basis of this report is the case of Rupert, who is a 90-year-old patient admitted for a routine checkup with a diagnosis of UTI, prostate cancer, and heart failure, whose eyesight is also impaired. Recently, he has slipped and received a bruise on his leg, which he did not report to the medical staff or his at-home caregiver. Rupert’s case is concerning since this patient does not have close relatives who can help him self-manage, and his age and frailty impair his abilities to maintain proper hygiene and care for himself.
Brief Summary of the Clinical Decisions
The first clinical decision, in this case, was to examine Rupert’s bruise and assess potential causes, which is why the FY1 asked to take blood samples to review clotting and platelets. According to Urakov (2020), bruises are “are blood-stained areas of the skin that impair its aesthetic appearance” (p. 1). This particular type of injury is common and can be a result of everyday activities, especially for older people. However, as Urakov (2020) notes, bruises also occur when using medication that thins the blood, which is the case with Rupert. Although the bruise itself is not a medical emergency or a serious concern, the event that resulted in Rupert getting a bruise and his medication should be reviewed thoroughly to ensure that he is capable of self-manage and that his medication is not impairing his health.
Pathophysiology and Pharmacology
Rupert’s slip might be a result of him being confused due to his UTI pain. However, some evidence suggests that a confused mind, which might have caused the patient’s slip, is linked with an infection. The signs and symptoms of this include a persistent desire to urinate, a small amount of urine, sometimes blood, and a strong smell of discharge are also present. Older patients with UTI are also often subjected to delirium and confusion, which may cause additional problems when diagnosing and treating them (Dasgupta et al., 2017). According to Farooq et al. (2020), UTIs may cause confusion, which could have been the reason why Rupert fell. The potential link between confusion, UTIs, and Rupert’s fall is also his age, which accumulatively results in impaired abilities. Mayne et al. (2019) state that confusion remains to be a nonspecific symptom that helps identify a UTI in cases where there are no other indicators of an infection. This diagnostics approach is often used when working with elderly patients. Hence, Rupert’s UTI is another concern that requires specific attention, apart from his medication and proper hygiene.
Rupert takes Aspirin 300mg and Dalteparin 5000Iu as prescribed by his physician. The medication may have an effect on the development of the bruise that Rupert has. However, Urakov (2020) reports that bruising can be a result of blood-thinning medication, Winker et al. (2020) report that aspirin does not affect bruising. Dalteparin is an anticoagulant, and according to King (2017), it may affect the severity of the bruising. Hence, Rupert might have had a mild injury, but his medication caused the bruising to look more severe than it would without the prescription.
The bruising may be addressed by the medical personnel if it is Rupert’s concern. Essebag et al. (2019) note that concomitant antiplatelet therapy can be used to reduce the bruising in case it is a clinical concern for a patient, but this approach should be used with caution and considering the potential risk. In Rupert’s case, the bruising is not a serious concern as it only affects the aesthetic appearance of this skin. The patient himself did not pay attention to this injury, which suggests that the medical team should focus on the causes of the fall and potential interventions to ensure that Rupert can care for himself properly.
The medication was prescribed to address Rupert’s blood clots, which is why he has to take Dalteparine. It achieves its effect by blocking specific proteins in the body that is the cause of clotting (“Dalteparin, injectable solution,” 2018). This medication belongs to the low molecular weight heparin agents, which have a similar mechanism of action. After the admission, Daltaperine stops the protein from forming new clots, and the existing ones do not develop and worsen the patient’s state (Khorana et al., 2017; McBane et al., 2019). Next, aspirin is acetylating agent, which is a non-steroid drug against inflammation (“How aspirin works,” n.d.). Aspirin helps reduce pain and inflammation by blocking the enzyme responsible for the production of hormones that trigger inflammation. In essence, this medication helps the patient’s heart process blood more easily, which is vital for Rupert, who suffered heart failure and allowed to address pain and information from his UTI.
The antibiotics were prescribed for Rupert’s UTIs, which help destroy the bacteria that cause the UTI. Notably, there are antibiotic-resistant bacterial UTIs since antibiotic resistance is becoming a global crisis (“About antibiotic-resistant urinary tract infections,” n.d.; Bebell, 2019). According to Bebell (2019), ‘trimethoprim/sulfamethoxazole (Bactrim) or ciprofloxacin (Cipro)’ are the two types of antibiotics, which are typically prescribed for UTIs. This information calls for a need to assess Rupert’s condition after his antibiotics treatment to ensure that his UTI is not antibiotic-resistant.
It is imperative to involve patients in the decision-making that concerns their health and well-being. The main concern with Rupert is that he may be unable to manage his self-care at home, despite having a caregiver due to his age and lack of family support. The bruise he received due to slipping supports the fact that Rupert’s health and well-being need more attention.
Shared decision-making is an approach that implies two-way communication between caregivers and patients to make health-related decisions that will benefit this patient and satisfy them (“What is shared decision-making?,” n.d.). The idea is that clinicians can make recommendations regarding the best course of action. However, patient’s desires do not always align with these recommendations, and through shared decision-making, both parties can reach a consensus. From an ethical perspective, this is the best approach to providing care because it considers the patient’s viewpoint. However, in Rupert’s case, as is with many other older adults, healthcare conditions and cognitive impairment may result in patients being unable to make sound decisions and assess the situation objectively. In such cases, healthcare professionals have to use social care policies and guidelines to ensure that patients are not harmed, but they can receive the optimal care.
The expert patient is a concept that described individuals who have a long-term health condition, for example, a chronic illness, and they have sufficient knowledge and expertise to care for themselves (Jackson et al., 2018). Being an expert patient is essential for people with chronic diseases because it allows them to maintain a good quality of life. In Rupert’s case, some red flags that point to his inability to maintain an expert patient approach are present. The first one is him refusing to maintain proper hygiene. With a UTI, it is imperative to clean the body and adhere to personal hygiene recommendations (“What can cause a urinary tract infection?” n.d.). As for his other conditions, he appears to take medication for his heart failure, which is a good sign. However, he did not report falling and injuring himself, which is another indicator that he is not an expert patient. Hence, health professionals caring for Rupert should consider his reluctance to take proper care of himself when making a decision about his future treatment plan. Notably, the NHS and Self-Management UK even provide training courses for patients with chronic illnesses to help them manage their care, reduce anxiety and boost their confidence (NHS, n.d.e). While it is possible to recommend one of this courses to Rupert, his age and physical capabilities are also an issue that would hinder self-care.
Finally, Benner’s novice to expert framework explains how both patients and medical professionals gain more knowledge about health and well-being over the course of education and practice (“From novice to expert,” n.d.). At the novice stages, the understanding of health concerns is limited, while an expert would be proficient in knowing the symptoms, management practices, as well as some non-medical factors that would affect care. Rupert clearly has a lot of experience due to his age, but considering that he refuses to be washed and did not report the slipping incident to his caregiver suggests that he cannot care for himself properly and that he is at the novice level. Moreover, Rupert has several comorbid conditions that complicate care, and his immobility also makes it more difficult for him to maintain proper hygiene, take medications and attend to his needs.
The relevant policy in this scenario relates to patient care and mental health since Rupert cannot care for himself adequately and has no caregivers to attend to his needs. The relevant healthcare policies relate to patient autonomy and their ability to care for themselves, which are assessed through their physical and mental capacity. The existing healthcare policies support the patient’s right to make health-related decisions if they have the physical and mental ability for it. According to the NHS (n.d.), “dementia is a growing challenge” (para. 1). The aging population is the leading cause of this concern since this mental condition impacts older adults the most. With Rupert, an assessment is necessary to ensure that he does have dementia, which might have caused him to fail to report his slipping incident. The NHS recognizes cognitive impairments as a concern and has a program that addresses dementia and diagnosing and care. Providing care to people who refuse it is challenging, both ethically and practically. For Rupert, more attention is clearly necessary because his age and health status do not allow him to care for himself. Here, medical professionals would have to partner with social services to assess Rupert’s state.
The NHS is concerned with addressing frailty rather than patient’s old age and associated health impairments (NHS, n.d.c). In accordance with this approach, when reviewing each patient’s case, it is necessary to focus on what hinders their care instead of assuming that old age would be an issue. More specifically, the NHS (n.d.d) defines frailty as a state “where someone is less able to cope and recover from accidents, physical illness or other stressful events” (para. 1). This is especially important since the population will continue to age, reaching unprecedented rates in the following twenty years (NHS, n.d.c). Gullette (2017) also argues that it is important to understand the potential ageism bias when developing healthcare policies and assessing the health status of older patients. Ageism is a common issue that implies that older individuals are incapable of caring for themselves correctly simply on the basis of their age.
The UK’s Center for Policies of Ageing (n.d.) advocated for active aging and lifelong learning, which means that patients have to learn how to care for themselves and how to age while maintaining good well-being. The basis of this approach is education and the proportion of self-care among older individuals. In Rupert’s case, this would mean referring him to an education course from NHS or CPA that addresses his conditions, briefing him about the steps that he can take to better care for himself, and assessing his feedback. Moreover, according to the “Personalised health and care 2020” policy developed in 2014, citizens should have better control over the care they receive and the decisions regarding their health (“Policy paper: Personalised health and care 2020,” 2014). From this perspective, Rupert should be given the right to decide whether he wants to move to a care facility, receive at-home support, or refuse any help. This policy is based on the patient-centered care approach, which is n important concept in modern healthcare.
Evidence Supporting the Clinical Decision
Evidently, Rupert’s case goes beyond the mere health-related problems such as UTIs and bruising and concerns the ability of the older people to care for themselves properly without assistance. Hence the decisions made by the healthcare team, in this case, are valid since bruising may be a result of medication but can also point to clotting and platelets, which are a severe concern (Kim et al., 2017). Next, the ethical issue is Rupert’s desire and right for autonomy in contrast to his physical and mental inability to care for himself properly. Moreover, professionalism and integrity when caring for older patients are vital. However, considering the effect of the decision, more steps have to be taken to address Rupert’s health adequately.
Evaluating the Effect of the Decision
In summary, the decision in the case of Rupert was not to file any additional forms but focus on assessing his current health state. In these cases, it is vital to comprehend the challenges, including mental health ones, that older adults face when receiving care or refusing to engage in self-care and receiving help from caregivers—the existing NHS policies prompt health professionals to empower patients and address frailty as the primary concern.
The FY1 has asked to review Rupert’s blood samples to see the signs of platelets and clotting, which is reasonable considering Rupert’s medication intake and his bruise, which is adequate considering his heart failure. Another critical decision, in this case, is sending a patient safety incident report, which is supposed to inform the other staff members about Rupert’s incident. According to the NHS (n.d. b), one should report “any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare” (para. 1). The purpose of this reporting is twofold: it helps record an incident to inform future care for Rupert, and it helps the NHS to collect data (“Learning from patient safety,” 2017). Hence, in this case, the decision not to file a report about Rupert slipping violated the NHS’s policies on patient safety incidents reporting.
Rupert’s case is complex, and it is further complicated by the patient’s frailty, the combination of diseases, and the medication he takes, which is why it is essential to use the nursing process to monitor his well-being. This approach is a strategy for a consistent evaluation of the patient’s health through five steps: assessing, diagnosing, planning, implementing, and evaluating (ANA, n.d.; Ead, 2019; Toney-Butler & Thayer, 2020). In this scenario, only the first steps of the nursing process were applied, while the nurse would have to wait for the lab test results to perform other actions and create an intervention for Rupert. Moreover, this approach allows evaluating whether the plan was effective against the set measures. For example, if upon the evaluation the nurse would determine that the UTI caused Rupert to be confused, they would have to ensure that the prescribed antibiotics work to ensure that he does not fall in the future. Alternatively, if blood clots are a concern based on the lab results, Rupert would require different medications apart from Aspirin and Dalpatherin. Finally, one has to assess Rupert’s ability to self-care and, if necessary, refer him to an education program or a care facility, depending on his preference.
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