Introduction
Maria Demetriou is a widowed woman in her seventies who has been diagnosed with osteoarthritis after a fall accident. She is currently in the period of recovery, which involves using pain relievers, vitamin and mineral supplements, and walking aids. The Clinical Reasoning Cycle (CRC) and the Roper-Logan-Tierney (R-L-T) nursing model can be instrumental in evaluating Maria’s holistic well-being, identifying the areas of concern, and conducting an individual-level assessment of the activities of living. To address Maria’s case, this paper uses the introductory section, the application of the first four phases of the CRC, the discussion of the R-L-T model’s implications for the scenario and concluding remarks.
Stage 1 of the CRC: Considering the Patient’s Situation
The CRC seeks to anatomize the clinical reasoning process and foster systematic transitions between the eight separate decision-making stages. The first step centers the initial encounters with clinical cases and documenting the client’s health status and reasons for referral (Huang et al., 2018). Accompanied by her younger family members, Maria Demetriou presents to a multidisciplinary primary healthcare clinic in order to get her yearly influenza immunization.
The client reports that she is seventy-four years old and wishes to get an injection. She uses a walking stick to move, which implies the existence of visual impairments, chronic musculoskeletal disorders, dizziness, or joint injuries in her medical history (Ohara et al., 2021; Rhodius-Meester et al., 2021). Based on the initial case presentation, the key issue at this stage of analysis refers to collecting further information regarding the underlying causes of the patient’s inability to move effortlessly without any walking aids. Non-life-threatening injuries or diseases of the skeletal system do not represent contraindications to administering injectable influenza vaccines. Nevertheless, this information would enable the nurse to produce a comprehensive plan of care and conduct a patient education session.
Stage 2 of the CRC: Collecting Information or Cues
The next stage of the CRC should involve considering Maria’s medical history, the history of complaints, treatments, and similar details. This information will then help the practitioner in establishing relevant cues and proceeding with the analysis at an individual level. Using questions to establish the client’s social and family history, the provider finds out that Maria has four children and is currently a widow. One issue of interest is that Maria moved to her son’s house after her husband’s death. It can be linked with a sense of loneliness, her fear of being alone while losing functional independence, or even financial constraints (Hurek, 2020). It has been eight years since her spouse’s death from cancer, but it is possible that she still suffers and needs more social interaction.
The second issue of interest is the client’s physical health and treatment regimens. From the patient’s history, the provider can learn that Maria fell at home three months ago and received a diagnosis of osteoarthritis. Her history suggests that the patient did not sustain bone fractures or serious strains requiring surgical interventions. As per her provider’s recommendation, she has been using anti-inflammatory pain relievers and a walking cane since the incident. Anti-inflammatory drugs have been shown to produce pain reductions in knee osteoarthritis and walking function within two weeks, but these effects are likely to fade over time (Osani et al., 2020). The client uses vitamin D supplementation, which is supposed to improve osteoarthritis patients’ pain scores (J. E. Thomas et al., 2019). Calcium supplementation finds use in Maria’s self-care measures, which might potentially increase a person’s risk for pseudogout (Al-Omari & Hill, 2020). Overall, the information reveals the patient’s adequate compliance with treatment recommendations.
The third issue to collect information on refers to any contraindications for inactivated influenza vaccination. From the client’s available information, Maria has no history of allergic reactions to the components of influenza vaccines, immunodeficiency disorders, cochlear implants use, or Guillain-Barre syndrome in the post-vaccination period (Armstrong, 2020). Osteoarthritis is not regarded as a contraindication, which reveals the absence of obvious barriers to getting the vaccine as planned.
The R-L-T Model and Stage 3 of the CRC: Processing the Patient’s Information
In stage three of the CRC, Maria’s information is to be processed critically, which will aid in establishing the core reasons behind the patient’s current issues. Firstly, Maria’s family status and its implications for physical and cognitive health deserve attention. Current research suggests that the experience of widowhood can accelerate the speed of cognitive decline in older adults, which suggests the need for further cognitive functioning assessments in Maria’s case (Shin et al., 2018). Secondly, there can be connections between the history of moving into her son’s two-level house and the fact of sustaining an injury from falling. Maria is the only elderly person in the household, so the family’s home is likely to be unsafe for the aging individual, including the absence of safety-enhancing equipment (Tzeng et al., 2020). The patient’s compliance with her treatment regimen does not present severe issues.
Maria has been using pain-relieving anti-inflammatory medications for osteoarthritis pain for the past three months and should proceed with the current medication regimen. Based on immune response research, in older adults, polypharmacy and the regular intake of pain relievers, including NSAIDs, cause reductions in the production of virus-neutralizing antibodies after receiving influenza vaccines (Agarwal et al., 2018). Although such reductions do not involve the absence of immune response to flu vaccines, Maria’s case might present a dilemma. On the one hand, postponing the yearly influenza injection would increase the risks of seasonal flu and its complications. Since older adults, especially frail ones, are at an increased risk of complicated flu and influenza-induced exacerbations of pre-existing chronic conditions, missed immunizations can be costly in Maria’s situation (Halpin & Reid, 2022; Keilman, 2019). On the other hand, to maximize the injection’s efficiency, the woman would need to refrain from taking pain relievers for some time, which would involve temporary reductions in life quality and having to tolerate joint pain. To provide the best possible solution to this issue, an in-depth inquiry into Maria’s subjective reports of joint pain could be pivotal.
The R-L-T nursing model could be applied to promote the individualization of nursing care in Maria’s case. The model centers patient assessment around the twelve activities of living (ALs) and the individual’s position on the independence/dependence scale (Tierney et al., 2020). As a common degenerative joint disease stemming from age-related changes in the musculoskeletal system, osteoarthritis contributes to AL-related restrictions, especially in those in their mid-eighties and older (Kutsal, 2019). Out of the twelve ALs, maintaining a safe environment and washing/dressing might limit Maria’s independence due to the presence of biological factors, including the diagnosis of osteoarthritis (Piadehkouhsar et al., 2019). Nursing interventions, for instance, home-based education on physical exercise and self-help in osteoarthritis, support elderly osteoarthritis patients’ health knowledge (Mohamed & Ali, 2019; Mohsen et al., 2021). Resolving Maria’s temporary deficits in independence might require concerted efforts with her family members to fall-proof the woman’s living environment.
Stage 4 of the CRC: Identification of Problems or Issues
The fourth stage of the CRC model of reasoning requires applying takeaways from the previous phases, in particular, the third one, to approach the determination of reasons behind the client’s current health state. From the analysis above, Maria’s compliance and health status linked with the safety of immunizations are not the most problematic aspects of the case. After proceeding with immunization, Maria’s risks of further falls and her current residence’s possible limited safety should be taken into account. The lack of balance training, including moderate-intensity resistance exercise, aerobic and stability training, or other measures, could have contributed to the fall and osteoarthritis development (E. Thomas et al., 2019). In persons diagnosed with osteoarthritis, the risks of falling are influenced by intrinsic factors, such as balance and pain levels, and extrinsic ones, including the absence of walking aids or safe environments (Manlapaz et al., 2019). Thus, aside from further health assessments, the patient’s living conditions, for instance, the presence of dangerous ladders, unstable furniture items, stepstools, and poor lighting, must be examined to provide fall prevention recommendations.
Conclusion
Finally, in the discussed case, Maria’s complex health needs do not constitute a crucial barrier to getting immunized, and her present health issues probably stem from insufficient home safety. The patient’s independence is partially limited while she is recovering from the fall. Assessing her living environment’s appropriateness for a person with a high risk of subsequent falls and proposing risk reduction strategies for her family to implement should be included in the care plan.
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