M1918270_EPIC-RN_NNNS5807_CASE STUDY 1

A CASE STUDY OF MR. GEORGE USING

LEVETT-JONES CLINICAL REASONING CYCLE

Student name- Karuna Maghaiya

ID Number- M1918270

Unit code and title- NNNS5807 (Nursing Care in Australia)

Title of assignment- Case Study 1

Due date- 4th October, 2019

Word count- 1648

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Introduction

Clinical reasoning in healthcare is a need for the health care system. Nurses use knowledge of

clinical reasoning to gather information, generate, prioritise and evaluate the patient’s health

care needs (Thampy, Willert & Ramani, 2019). The use of the skills of clinical reasoning

helps nurses to make appropriate and effective patient-centered decisions and promote good

patient outcomes (Koharchik, Caputi, Robb, & Culleiton, 2015). This case study will discuss

the case scenario of CKD in an aboriginal patient named Mr. George using Levett –Jones

clinical reasoning cycle (Levett-Jones, 2013). The case study will gather and analyze

George’s health condition and evaluate disease condition and finally discuss two care

priorities for him to maintain optimal health and slow progression of the disease condition.

Levett –Jones clinical reasoning cycle

Considering Patient

This case study deals with Mr. George a 51-year-old aboriginal man diagnosed with stage 4

Chronic Kidney Disease (CKD) who has been to his general practitioner (GP) for a yearly

health check-up. Further assessment showed, his Blood Pressure (BP), cholesterol, albumin,

and weight is increased. He had been living with his wife and three children in their

residence. Financially, he is getting a disability pension and his wife is getting carer’s

payment.

Collection of Cues and Information

Mr. George had a stroke two years ago. He also had a history of smoking and a family history

of dialysis as well. Furthermore, he is gaining weight. During George’s last visit, his BP was

153/93 mm of Hg. His lab findings were deranged; serum creatinine level was abnormal with

calculated eGFR (Glomerular Filtration Rate) - 27 mL/min/1.73 m2. The lab value of eGFR

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between (15-29) is regarded as severely reduced kidney function (Persson & Rossing, 2018).

Besides, his most recent HbA1c was 78 mmol/mol (9.3%). Moreover, urine analysis found

the urine albumin level of 30 mg/mmol, which is also associated with the decline in kidney

function (Persson & Rossing, 2018).

Regarding medication, Mr George has been prescribed with the medications such as

perindopril and lercanidipine (angiotensin-converting enzyme inhibitor and calcium channel

blocker) for control of hypertension (Yang, 2015), Atorvastatin for lowering cholesterol,

Metformin for lowering blood glucose level, sodium bicarbonate to correct metabolic

acidosis and vitamin D for bone and increase calcium absorption (Dhondup & Qian, 2017).

However, he does not know about the medication, its uses, and its effectiveness.

Process Information

The prevalence of the CKD among aboriginal is found to be higher than non-indigenous

Australian resulting from the various associated risk factors of chronic illnesses such as

obesity, diabetes, hypertension, and smoking (AIHW, 2019). It is also found that CKD

among the aboriginals is high due to the other factors such as low birth weight, metabolic

syndrome, post-streptococcal glomerulonephritis, and genetics (Hoy, Mott & McDonald,

2019). Mr. George being an aboriginal male is already in the risk of CKD. Therefore,

preventive strategies should be taken to decrease the prevalence of chronic illnesses and

CKD.

Furthermore, in the case of the obese patients, kidneys have to filter more blood to meet the

metabolic need of the increasing weight (glomerular hyperfiltration), which increases the

kidney function and impair the kidney (Kidney Health Australia, 2017). The good glycaemic

control might reduce the further progression of CKD by slowing glomerular filtration rate

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loss (MacIsaac, Jerums, & Ekinci, 2017). Furthermore, increasing weight interferes with BP

and glycaemic control. Similarly, increasing cholesterol level in the body effects on the

kidney functions, and make the symptoms more prominent (Bulbul et al., 2018).

Identify problems

There are several problems and issues in the case of Mr. George;

 Increased BP and blood glucose level

 Increasing weight

 Increased albumin level

 Lack of knowledge about consultation with Aboriginal and Torres Strait Islander

health peak bodies.

 Lack of education regarding disease condition, its management including dialysis.

 Financial Hardship

Establish goals

There are a few goals that Mr. George will be followed to bring positive outcomes in his

health and improve his quality of life.

 He will demonstrate the understanding of lifestyle modification to prevent chronic

illnesses.

 He will be able to manage blood glucose and BP by modifying the lifestyle.

 He will further consult with the multidisciplinary team as well as aboriginals’ health

bodies to slow the progression of a disease condition.

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Action Plan and strategies

There are several care priorities to prevent further kidney damage and make his life better.

However, two main care priorities of Mr. George will be discussed in detail.

1. Lifestyle modification

Lifestyle management is a pivotal factor in the management of chronic illnesses in the

case of CKD. Despite taking the antihypertensive medication, Mr. George BP and

blood glucose is still high, which is common in many patients with CKD. Hence, Mr.

George should be focused on lifestyle modification also which includes dietary

modification, increasing physical activities, and health education.

Dietary modification: The main reason for maintaining good nutritional

status among CKD patients is to slow the progression of the diseases,

enhancing the effectiveness of the medications and managing any further

complications. Different clinical trials and epidemiological studies have found

the reducing sodium intake and decreasing potassium intake improve blood

pressure among patients with high BP among CKD patients. Thus, it is

recommended to limit the salt intake less than six grams per day (2.4 gm. of

sodium) (Kidney Health Australia, 2015). Besides, emphasis should be given

in consuming low-fat dairy products, omega-3, and omega-9 polyunsaturated

fatty acid, green vegetables, fibers, wholegrain, meat, and lean protein.

However, animal protein should be limited as it might results in elevated

albuminuria in patients with CKD (Goldstein-Fuchs & Kalantar-Zadeh, 2015).

Similarly, the diet should also be focused to lower blood glucose levels.

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Hence, Mr. George should be encouraged to have a healthy diet to prevent

further complications.

Physical activities: In the case of Mr George, during an assessment, it is

found that his mobility had declined as he had stroke two years back. It is

evident that encouraging physical exercises in CKD patients improves the

overall health of the patient and improves the quality of life. The patient with

the CKD should be encouraged to different kinds of simple exercises such as

walking, yoga, dancing, cycling aerobic exercises, and Tai Chi. However;

exercise stress tests should be recommended before starting vigorous exercise

(Howden, Coombes, Isbel, 2015). Thus, Mr George should be encouraged to

actively participate in physical activities to reduce the complication of chronic

illness and foster weight loss.

Educational programs play a vital role in bringing the change in the lifestyle. Kidney Health

Australia (KHA) provides essential resources, support, educational materials to the

Aboriginals suffering from CKD to maintain a healthy lifestyle and change behaviors

targeted towards “Close the Gap” outcomes (Kidney Health Australia, 2017). However, it is

also found that the educational materials used for providing health education were not

relevant to aboriginal culture, so emphasis should be given to the locally available resources

(Rix, Barclay, Stirling, Tong & Wilson, 2014). Therefore, George and family members

should get adequate information regarding the disease condition, prevention, treatment

modalities, and lifestyle modification. Also, George should be provided adequate information

regarding the use of the medication that he is taking to preventing chronic illnesses.

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Referral

Being George an aboriginal, referral should be made to Aboriginal and Torres Strait Islander

health peak bodies to understand the choices regarding culturally appropriate health care and

services. George had a stage 4 CKD, which might need the option of dialysis in near future;

however, to provide information regarding this critical issue, he must be referred to the

interpreter, and local Aboriginal liaison officer who can understand their cultural values,

beliefs and aids in better communication and decision making (Rix et al., 2014). Also,

George should be referred to as the secondary care nephrology service. Australian guidelines

in management in chronic kidney diseases recommend every patient with CKD stage 4 and

above with hypertension, diabetes, albuminuria should be referred to the nephrology

department to provide a further choice of the dialysis (NACCHO, 2018). Also, a

multidisciplinary team approach is an essential part to provide holistic care considering

culture, managing risk and availability of health care and services to George. This includes

his family (children and wife) as primary carers, aboriginal social workers, nurses,

consultants, pharmacists, and aboriginal health workers.

Evaluation

After the implementation of any action plan, it is important to evaluate whether all the health

care needs of George are met or not. Mr. George and his family will be assessed whether they

have understood the benefits of lifestyle modification, which was found to be satisfactory.

They have agreed to visit aboriginal liaison officers to discuss further management of CKD

and discuss a choice of dialysis. Also, George understood the importance of the medication to

prevent chronic illness. Furthermore, on the next visit, his BP was 130/80 mm of Hg and

blood glucose level of 35mmol/mol.

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Reflect on the process and new learning

Looking towards the George health condition, he could have screened timely and adopted a

healthy lifestyle to prevent chronic illnesses. Also, pre-dialysis information could be given to

George, so he won’t be in stress after. I also felt that establishing accessible health care

services, screening high-risk Aboriginal groups and educating Aboriginals for lifestyle

modification using local resources might prevent chronic illnesses among other aboriginals

like George. Importantly, George's children should also be given the education to prevent the

incidence of CKD.

Conclusion

A clinical reasoning skill is an important factor to bring positive impacts on patient health

outcomes and decision making. This case study has used Levitt-Jones’ clinical reasoning

cycle for assessment, development, and implementation of the best care priorities of Mr.

George. In the CKD patient, it is important to manage other chronic conditions such as

diabetes, hypertension, and obesity. Besides taking medications, lifestyle modification should

be emphasized. Importantly, the multidisciplinary team approach should be adopted for

optimum management and Mr. George should be referred to the nephrologist to discuss

further regarding the choice of dialysis.

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References

Australian Institute of Health and Welfare. (2019). Chronic kidney disease in Aboriginal and

Torres Strait Islander people. Retrieved from

[Link]

indigenous-australians/contents/summary

Bulbul, M., Dagel, T., Afsar, B., Ulusu, N., Kuwabara, M., Covic, A., & Kanbay, M. (2018).

Disorders of Lipid Metabolism in Chronic Kidney Disease. Blood Purification, 46(2),

144-152. doi: 10.1159/000488816

Dhondup, T., & Qian, Q. (2017). Electrolyte and Acid-Base Disorders in Chronic Kidney

Disease and End-Stage Kidney Failure. Blood Purification, 43(1-3), 179-188.

doi:10.1159/000452725

Goldstein-Fuchs, J., & Kalantar-Zadeh, K. (2015). Nutrition Intervention for Advanced

Stages of Diabetic Kidney Disease. Diabetes Spectrum, 28(3), 181-186. doi:

10.2337/diaspect.28.3.181

Howden, E. J., Coombes, J. S., & Isbel, N. M. (2015). The role of exercise training in the

management of chronic kidney disease. Current Opinion in Nephrology &

Hypertension, 24(6), 480–487. doi: 10.1097/MNH.0000000000000165

Hoy, W., Mott, S., & McDonald, S. (2019). An update on chronic kidney disease in

Aboriginal Australians. Clinical Nephrology. doi: 10.5414/cnp92s122

Kidney Health Australia. (2015). Chronic Kidney Disease Management in General Practice

(3rd Ed.). Retrieved from [Link]

[Link]

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Kidney Health Australia. (2017). Obesity and chronic kidney disease: the hidden impact.

Retrieved from [Link]

report-obesity-and-chronic-kidney-disease--the-hidden-impact_06.[Link]

Koharchik, L. , Caputi, L. , Robb, M. & Culleiton, A. L. (2015). Fostering Clinical Reasoning

in Nursing Students. AJN, American Journal of Nursing, 115(1), 58–61. doi:

10.1097/[Link].0000459638.68657.9b.

Levett-Jones, T. (2013). Clinical reasoning: Learning to think like a nurse (2nd Ed.). Sydney:

Pearson.

MacIsaac, R. J., Jerums, G., & Ekinci, E. I. (2017). Effects of glycaemic management on

diabetic kidney disease. World journal of diabetes, 8(5), 172–186.

doi:10.4239/wjd.v8.i5.172

NACCHO. (2018). National guide to a preventive health assessment for Aboriginal and

Torres Strait Islander people. Retrieved from

[Link]

rces/[Link]

Persson, F., & Rossing, P. (2018). Diagnosis of diabetic kidney disease: state of the art and

future perspective. Kidney international supplements, 8(1), 2–7.

doi:10.1016/[Link].2017.10.003

Rix, E., Barclay, L., Stirling, J., Tong, A., & Wilson, S. (2014). 'Beats the alternative but it

messes up your life': Aboriginal people's experience of haemodialysis in rural

Australia. BMJ Open, 4(9), e005945-e005945. doi: 10.1136/bmjopen-2014-005945

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Thampy, H., Willert, E., & Ramani, S. (2019). Assessing Clinical Reasoning: Targeting the

Higher Levels of the Pyramid. Journal Of General Internal Medicine, 34(8), 1631-

1636. doi: 10.1007/s11606-019-04953-4

Yang, Z. (2015). Efficacy and safety evaluation of perindopril-lercanidipine combined

therapy in patients with mild essential hypertension. Current Medical Research &

Opinion, 31(1), 183–186. doi:10.1185/03007995.2014.960072

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