NRS82005 Transformative Clinical Practices Assignment Sample

Part 1: Collecting the Clues

Introduction to Transformative Clinical Practices 

Clinical reasoning is the foundational component of clinical competency that has been utilized in to encounter from simple to complex presentations of the patient (Thampy, Willert & Ramani, 2019). It has been considered as a perpetual focus of the medical education, performing the assessment, and study. The whole process of clinical reasoning includes the integration of the clinical knowledge with the patient’s initial information in order to structure a case representation of the patient’s medical issue (Gruppen, 2017). This assessment task will be based on the clinical reasoning process for exploring the case of a deteriorating patient in clinical placement named Mr. X, who is 79-year-old who is being treated for malignant tumour on his right mandible.

Consider the Patient

Patient X is of 79 years of age and he has been living in the aged care along with his wife for the past 5 years. His past medical history has revealed that he has diabetes; dysphasia, and often encounters anxiety. He has two sons who come and visit them occasionally. He has been diagnosed with malignant tumour on his right mandible and has been receiving radiation therapy for the same. In radiation therapy, high-energy x-rays will be bombarded on patient’s right mandible in order to destroy the malignant tumour cells or to slower their growth rate and then eradicate them completely (Huang & O’Sullivan, 2013). The patient has been smoking and using tobacco for a very long time that has led to malignant tumour on his right mandible. Chewing tobacco or smoking is directly linked with more than 50% risk of developing cancer in the jaw line and gums (Park et al., 2018). On the first day of his therapy his vitals showed 37.9⁰C temperature, 100/65 mmHg blood pressure, and 78 Spo2. He is on medications that have Morphine, Insulin, Vitamin D, Magnesium, and Paracetamol medicines.

Collect Cues

The patient was admitted to the hospital settings when he encountered painful sores in his mouth. On account of this he revealed that certain red or white colour patches has been developing in his mouth since past few months. His gums bleed whenever he tries to eat something; he has pain and swelling inside his mouth near the jaw and finds it difficult to open his mouth. And, as he said that he used to consume tobacco & smoke a lot, the evidences from the study presented by Kumar & Manjutha (2013), and from gathering all these cues, the clinicians found that there might be chances of tumour in mandible. The confirmation of this was done by physical examination followed by the endoscopy and biopsy. Later on, the differential diagnosis for the inflammatory and the reactive lesions were done (Kumar & Manjutha, 2013). Patient’s consumption of tobacco, his blood sugar level, and often getting anxiety attacks are the factors of his deteriorating health.

Process the Information

The Cancer care team at the hospital that includes other health care professionals such as oncology nurses, physician assistants, pharmacists, social workers, dieticians, counsellors, and others collaboratively started processing the information. It is enormously vital for the whole team to generate an inclusive treatment plan prior to the treatment process. As the patient has a medical history of diabetes and anxiety, his blood sugar level has been assessed and maintained prior to the treatment and he should be informed regarding his treatment to avoid any stress during the treatment. The patient’s right mandible will get exposed to the high-energy x-rays with the goal to destroy the malignant tumour cells (Cabrera-Rodriguez, 2016). The treatment will be given for 5 days a week up to 6 to 7 weeks. On the first day of his therapy his vitals showed 37.9⁰ C temperature, 100/65 mmHg blood pressure, and 78 Spo2. In order to reduce any related side-effect risk, appropriate doses are given and the beam is focused accurately to hit the tumour cells only.

Understanding the Patient’s Problem

Identification as well as intervening on the clinical deterioration of the patient plays a vital role in the patient setting. It is established by the vibrant behavior of the patients' health conditions during the phase of hospitalisation. The clinical deterioration helps in enabling the professional in identifying the clinically modifiable risk factors as well as the accompanying interventions in order to prevent the patient from clinical deterioration (Padilla & Mayo, 2018). Important issues identified in patient after the radiation therapy is the changes in skin such as burns in the treated area, hoarseness, even pain in the mouth and throat, and loss of sense of taste (Chang, Goldstein & Dharmarajan, 2017). As the patient is an elderly patient of 79 years of age these factors can prominently lead to his clinical deterioration as he will be unable to eat and he already has a history of anxiety and this may also lead to re-emerge the mental stress and anxiety that can potentially results in his health deterioration.

Part 2: Planning Care and Evaluating Outcomes

Plan and Implement Interventions

The Registered nurses play a vital role in the provision of patient-centred care prior to the radiation therapy, during the radiation therapy, and post-radiation therapy in case of malignant tumour on mandible in an elderly patient. Management of his nutrition and diet must be taken care of as the patient would not be able to eat. As patient is of old age nutrition plays a vital role for him and other related risk factors could be generated because of this that could lead to deterioration of patient’s health (Fleming & Haney, 2013). The radiation therapy of mandible often results in high energy as well as nutrient needs for the healing of the wound and this depends on the place as well as extent of the trauma; this is the reason a proper nutrition support is needed in this case. If removal of malignant cells is done, a liquid diet would be necessarily needed by the patient until the jaw of the patient is healed, a more diverse diet would be desirable. Blending of the cooked food, appropriate uniformity with the water, milk, juice, or broth to be added as a thinner later on strained in order to remove the food fibres for preventing the problems related with the oral hygiene should be done (Giridhar, 2016). In addition to this, it is very important for the registered nurse to inform patient’s wife who lives with the patient in aged care along with their sons who occasionally visit them regarding the therapy as well as his diet care and shared decision making must be done (Dworsky & Russell, 2019). Along with this, as per the Nursing and Midwifery Board of Australia (NMBA) standard for registered nurse standard two, patient’s autonomy regarding the decision for care must be respected and acknowledged (NMBA, 2018a). 

Evaluate Outcomes

The appropriate evaluation of all the vital signs and symptoms is done in order to determine how effective the nursing care interventions were. On the first day the vitals showed 37.9 temperature, 100/65 blood pressure, and 78 Spo2. After the nursing interventions patient’s temperature, blood pressure, and 78 Spo2 were addressed. The blood glucose level was also maintained and the diet and nutrition was properly taken care of. From the evaluation of these outcomes it can be said that the nursing interventions as well as the multidisciplinary managements that were used for the provision of patient-centered care were effective and appropriate. And, they were able to help the patient to recover from the malignant tumour of his jawline.

Reflect and Learn from the Process

I was quite nervous in the beginning as malignancy is a serious issue and the care it needs is extensive. The care for the patient should be highly specific. However, later as things went smooth and it has now been one of the best learning experiences of the clinical placement for me till now. I have learned a lot from the other registered nurses. I have learned how important communication is during the handovers between the multidisciplinary team and the registered nurses in treating the aged patient with the issue of malignancy of mandible. Working in a collaborative manner is the best way to achieve the patient related goals. I have learned the ways to address the issues of clinical deterioration with the help of effective nursing interventions that leads to patient centered care. I also understood the reason behind patient’s anxiety and excessive use of tobacco that are interrelated with him being living in the aged care for past five years even after having his own home. This stress and anxiety led him to the excessive use of tobacco that resulted in this severe illness of malignancy. Effective communication, patient advocacy, and patient-centered care are the three pillars that I have learned from this placement and will always work on the basis of them in my coming projects (NMBA, 2018b).

Conclusion on Transformative Clinical Practices 

Clinical reasoning is the basis of clinical competency that helps in encountering from simple to complex presentations of the patient. This assessment task has utilised the clinical reasoning process to explore the case of the patient X, who is 79-year-old who is being treated for malignant tumour on his right mandible. Comprehensive assessment regarding his problem was to focus on his vital signs, nutrition and diet and oral hygiene helped in addressing the patient’s deterioration. However, effective communication, patient advocacy, shared decision making, and patient-centered care are the important factors that will help the registered nurses to work appropriately in the clinical settings. 

References for Transformative Clinical Practices 

Cabrera-Rodriguez, J. J. (2016). The role of radiotherapy in the treatment of oral cavity cancer. Plastic and Aesthetic Research, 3, 158-166. http://dx.doi.org/10.20517/2347-9264.2016.1

Chang, S., Goldstein, N. E., & Dharmarajan, K. V. (2017). Managing an Older Adult with Cancer: Considerations for Radiation Oncologists. BioMed Research International, 1695101. https://doi.org/10.1155/2017/1695101

Dworsky, J. Q. & Russell, M. M. (2019). Surgical decision making for older adults. JAMA Patient Page, 321(7), 716. doi:10.1001/jama.2019.0283

Fleming, M. O., & Haney, T. T. (2013). An imperative: Patient-centered care for our aging population. The Ochsner Journal, 13(2), 190–193.

Giridhar V. U. (2016). Role of nutrition in oral and maxillofacial surgery patients. National Journal of Maxillofacial Surgery, 7(1), 3–9. https://doi.org/10.4103/0975-5950.196146

Gruppen L. D. (2017). Clinical reasoning: Defining it, teaching it, assessing it, studying it. The Western Journal of Emergency Medicine, 18(1), 4–7. https://doi.org/10.5811/westjem.2016.11.33191

Huang, S. H., & O'Sullivan, B. (2013). Oral cancer: Current role of radiotherapy and chemotherapy. Medicina Oral, Patologia Oral Y Cirugia Bucal, 18(2), e233–e240. https://doi.org/10.4317/medoral.18772

Kumar, G., & Manjunatha, B. (2013). Metastatic tumors to the jaws and oral cavity. Journal of Oral and Maxillofacial Pathology: JOMFP, 17(1), 71–75. https://doi.org/10.4103/0973-029X.110737

Nursing and Midwifery Board of Australia. (2018a). Registered nurse standard of practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/ codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

Nursing and Midwifery Board of Australia. (2018b). Code of conduct for nurses. Retrieved from https://www.nursingmidwiferyboard.gov.au/codesguide lines-statements/professional-standards.aspx

Padilla, R. M., & Mayo, A. M. (2018). Clinical deterioration: A concept analysis. Journal of Clinical Nursing, 27(7-8), 1360–1368. https://doi.org/10.1111/jocn.14238

Park, H. K., Kim, T. S., Geum, D. H., Yoon, S. Y., Song, J. M., Hwang, D. S., Cho, Y. C., & Kim, U. K. (2015). Mandibular intraosseous squamous cell carcinoma lesion associated with odontogenic keratocyst: A case report. Journal of the Korean Association of Oral and Maxillofacial Surgeons, 41(2), 78–83. https://doi.org/10.5125/jkaoms.2015.41.2.78

Thampy, H., Willert, E. & Ramani, S. (2019). Assessing clinical reasoning: Targeting the higher levels of the pyramid. Journal of General Internal Medicine, 34, 1631–1636 (2019). https://doi.org/10.1007/s11606-019-04953-4

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