The science of nursing decision making
Identify a patient’s health problem symptom and assess it holistically from the biological, psychological and social aspects
Assessment Briefing: Case Study Students will select a case study patient from practice. In the case study students will discuss and critique the decision making processes required in the assessment and delivery of care for their selected patient (1,500 words +/- 10% excluding references). This critique will be on the care, intervention and treatment plan of the chosen patient with appropriate explanation. Summative Assessment Guidelines For this assessment you will need to select a patient/ service user from a recent placement. Identify one health problem symptom experienced by the patient/service user and explore the impact this will have using the Biopsychosocial Model. You will need to include a critique of the care given related to this need using evidence to support your views. This needs to focus on the decisions made by the care team, including any reasoning for interventions and treatment. From the evidence used, you need to offer recommendations for how this care could be enhanced or improved to ensure patient centred care. The nurse’s role will be an important focus but students will need to demonstrate that they understand the importance of shared decision making in the assessment, planning, implementation and evaluation of care. Although symptom management is an important area additional dimensions are to be considered which can influence how well individuals cope. This will involve addressing psychosocial factors as well as reflecting on how policy in terms of service delivery can promote client centred care. Module Learning Outcomes: Learning Outcome 5. Critique the care, intervention and treatment plan of a given patient across the lifespan with appropriate explanation. Assignment Guidelines: Case study structure 1. Introduction (150 words). Start with a brief introduction of your chosen patient using approximately 30 – 50 words. You will need to provide more information of the patient in the appendix. Present your introduction and ensure it answers these 3 questions: a. What? The introduction needs to clearly explain what this case study is about. This section needs to explain in your own words what is required in the assignment brief given above. b. How? The second part of the introduction need to outline how this case study is structured. You need to summarise the details given in the body. c. Why? An introduction needs to articulate why critiquing and evaluation of care is of significance to care delivery. 2. Body (1200 words) a. Briefly explain the Engel (1977) Biopsychosocial Model which you will use for your assessment. b. Identify a patient’s health problem symptom and assess it holistically from the biological, psychological and social aspects. Critique the care for that patient’s health problem symptom based on whether it meets all the biopsychosocial needs which arise from that patient’s health problem symptom, whether it is supported by evidence or not and then, recommend a better care plan. (For example, how would pain and stiffness in the joints affect the patient’s physical/psychological status/quality of life) You will need to support your critique and reasoning with evidence-based practice. c. From your critique, identify the recommendations that would be appropriate to introduce to the patient’s care plan, based on the latest evidence-based research / practice. 3. Conclusion (150 words) Summary: Put a short concluding statement of approximately 50 words then summarise the key learning points that have emerged from your critique. 4. References 20 Harvard references Use references such as NICE, NHS, Public health England, WHO 5. Appendices In a table, you will give more information on your patient/service user with the following information: • Presenting complaint /symptoms • Past medical history • Medication • Intervention/Treatment • The implemented care plan for the patient for the identified problem. Do ensure that all information identifying the patient and the Trust/ Service provider are anonymised. This is my Case study:
Please use this A 45 year old male with severe rheumatoid arthritis admitted with fall due to impaired physical mobility. He has a history of type 2 diabetes, anxiety, depression, was admitted in hospital two years ago due to UTI. He is obese, smoker, lives with his wife, has two young son and works in an office part time. Identified patient’s symptom: pain and stiffness in the joints. How has pain and stiffness in the joints affected the patient physically, psychologically and socially? Physically: restriction on movement, swollen joints, chronic pain. Psychologically: frustration, anxiety, depression, sleep disturbance. Socially: Unable to work, isolated, dependent on others, deterioration of relationships with family and friends. Policies and laws to support the plan NICE guidelines The Musculoskeletal Services Framework NHS Equality Act 2010 Care Act 2014 Health and Social Act 2012 Current care plan for the patient: Regular observation and monitor pain Administer anti-inflammatory medications as prescribed. Position with pillows. Provide joint support with splints, braces. Provide safety needs such as raised chairs and toilet seat, use of handrails in shower and toilet. Provide pressure relieving mattress Assist patient with walking using mobility aids such as walking frame Shared decision making in essay Offering the pt all information we have so pt can make the decision. Such as offering steroids Recommended care plan for the patient based on the aspects identified: Educate the patient about his medical condition link this evidence with guidelines Refer to psychiatrist link this evidence with guidelines Offer psychological treatments for pain such as cognitive behavioural therapy link this evidence with guidelines Encourage patient to follow a healthy diet link this evidence with guidelines. Offer steroid injections to reduce pain, stiffness and inflammation of the joints link this evidence with guidelines Offer biologic disease modifying anti rheumatic drug link this evidence with guidelines Refer to physiotherapist, occupational therapist, rheumatologist link this evidence with guidelines
The Science of Nursing Decision Making
The patient in this case study is a 45-year-old man with severe rheumatoid arthritis who was admitted with a fall due to physical mobility impairment. The patient has a history of type 2 diabetes, depression and anxiety, and was admitted to the hospital two years ago to treat a urinary tract infection. He is also overweight and a cigarette smoker. The purpose of this patient’s case study is to explore and evaluate the decision-making processes required when assessing and providing care for this patient. The impact of joint pain and stiffness on the patient from a biopsychosocial view will be explored, as will shared decision-making in assessing, planning, implementing, and evaluating therapy. The biopsychosocial model is first explained in the paper. The paper then reviews a Rheumatoid Arthritis patient’s pain and stiffness of joint symptoms holistically and evaluates the care provided to see if it satisfies the patient’s needs. The critique’s recommendations are then identified and suggested as ways to support evidence-based practice and patient-centred care. Evaluating and evaluating service delivery is critical because it encourages evidence-based practice.
Briefly Explain the Engel (1977) Biopsychosocial Model
The biopsychosocial model was developed as an alternative to the biomedical model in that it takes into consideration all factors that influence both patient hood and sickness. While several alternatives to the biomedical model exist, the biopsychosocial model is presently regarded as the most established. Engel and a growing number of others regard the biopsychosocial model as a systems model. A systems-analytic approach is taken when dealing with illnesses, as they are viewed as a defect in the system. This suggests that complex and non-linear interrelationships exist between many parameters and that while failures in individual components of the system can result in overall malfunction, the system can nevertheless malfunction without being solely attributable to faulty components. Additionally, the model emphasises that any key domain or component inside the system can be viewed as a separate system with its own set of components (Bolton & Gillet, 2019).
The biopsychosocial model focuses on the individual inhabiting the body, which is made up of numerous organs. Each individual has a unique personal context defined by their personality, views, experiences, and expectations. Additionally, there are temporal variables, such as the person’s life stage and the stage of their illness and there exists the goal-directed interaction of the individual with other people and items in his or her environment, which entails a variety of behaviours. The social environment encompasses both other individuals and the individual witnessing how others act, and it defines the roles that are now being enacted. The individual can then exercise choice over their activities, and their quality of life can be measured against different measures such as social status, interpersonal relationships or money (Frazier, 2020).
Identify a Patient’s Health Problem Symptom and assess it holistically from the Biological, Psychological and Social Aspects
Rheumatoid arthritis leads to inflammations that gradually destroy the joints, and it can also cause inflammation of the lungs and blood vessels. The biopsychosocial paradigm can be used to examine pain and stiffness holistically. Pain affects the patient physically or biologically by causing movement limits, swelling joints, and chronic pain. Psychologically, they experience depression, frustration, and anxiety, as well as sleep difficulties (American College of Rheumatology, 2021). The symptoms also have a social impact on the sufferer, who becomes lonely, unable to work, reliant on others, and whose interactions with friends and relatives deteriorate (Arthritis Foundation, 2021).
Critique the Care for that Patient’s Health Problem Symptom Based on whether it meets all the Biopsychosocial Needs
The patient’s current care plan comprises routine observation and monitoring of discomfort, the administration of anti-inflammatory drugs as prescribed, pillow posture, and the supply of joint supports such as splints and braces. Additionally, it entails meeting safety requirements such as elevating seats and chairs, utilising handrails, utilising a pressure-relieving mattress, and supporting the patient with walking by utilising movement aids such as a walking frame (American College of Rheumatology, 2021). The decision to examine and evaluate the patient’s pain frequently aims to maintain tight control of the disease and determine whether the symptoms improve. Patients should undergo monthly disease activity (DAS) and protein assessments, according to NICE guidelines. It is critical to be extra careful when administering anti-inflammatory medications since they are not always appropriate for everyone and can occasionally cause major side effects. This decision, however, does not take into account other forms of treatment advocated in treat-to-target plans (Center for Disease Control and Prevention, 2021).
The reason for providing joint supports in the form of splints and braces is to facilitate self-care and minimise discomfort and joint stiffness, with guidelines indicating that they are helpful in this area and enhancing function. Additionally, it is recommended to give RA patients firm mattresses and appropriate elevation of bed linens such as pillows, as this alleviates pressure on sore and inflamed joints and thus improves sleep (Arthritis Foundation, 2021). The purpose of installing safety features such as raised toilet and chair seats, railings, and walking frames is to avoid unintentional injuries and falls. Young persons with rheumatoid arthritis, such as the patient in this example, have also been reported to exhibit muscle weakness due to pain, fear, or exhaustion from limited exercise, which can result in a high fall rate. Shared decision making was also incorporated into the present approach, which included sharing all pertinent information with the patient, particularly addressing the usage of drugs such as steroids in their treatment plan. It was, however, limited in scope due to the absence of patient education. NICE suggests that healthcare providers involve patients in decision-making regarding their healthcare by educating them and learning about their preferences and values (National Institute for Health and Care Excellence, 2021).
While the preceding treatment plan incorporates several recommended guidelines, it does not adhere to all of them because it solely addresses the physical needs of the RA patient. Referral guidelines for rheumatoid arthritis patients are not considered. Additionally, it fails to address patients’ dietary needs, and it makes no allowance for the psychological and social needs that affect and are affected by joint pain and stiffness (NHS, 2021). Numerous recommendations can be incorporated into the treatment plan to ensure that it is patient-centred and evidence-based. To begin, the patient should be educated on his or her medical condition. The Musculoskeletal Services Framework, released by the Department of Health, promotes health and self-care by educating patients and assisting them in interpreting and accessing pertinent information to build skills and an awareness of how to manage their condition. This enables him to comprehend how the symptoms affect him and how they can be alleviated (Arthritis Foundation, 2021).
From your Critique, Identify the Recommendations that would be Appropriate to Introduce to the Patient’s Care Plan, based on the Latest Evidence-based Research
The patient should be referred to a psychiatrist who can assist him in addressing his psychological requirements. NICE guidelines state that rheumatoid arthritis patients should have access to psychologists who can provide therapy such as stress management, relaxation, and cognitive coping skills to assist them in adapting to rheumatoid arthritis lifestyles (Fraenkel et al., 2021). Psychological treatments for pain, such as cognitive behavioural therapy, should also be made available to address his anxiety, frustration, despair, and sleep disturbance. The Care Act 2014 requires authorities to collaborate with their communities to locate people with care and support requirements and organise or provide a range of products to help those needs and assist them in regaining their independence. Additionally, the patient should be advised to maintain a nutritious diet (Köhler et al., 2019). The NHS and Health Education England commissioned the musculoskeletal core competencies framework, emphasising nutrition and food’s relevance on health. Patients must be persuaded to have healthy lifestyles that include a balanced diet, cessation of smoking, exercising regularly, and improved blood sugar control. The National Rheumatoid Arthritis Society encourages maintaining a healthy weight since it is critical for managing rheumatoid arthritis disease activity and maximising drug effectiveness (National Institute for Health and Care Excellence, 2021).
Additionally, steroid injections should be administered to alleviate joint stiffness, discomfort, and inflammation. Steroids are powerful medications that can be used to provide temporary relief while other medications take action or during flare-ups. However, the NHS advises that they should only be used for a brief period, given the serious negative effects of long-term use. NICE guidelines state that steroids should be explored after all other therapies have been exhausted and the patient has been adequately informed about the long-term risks (National Institute for Health and Care Excellence, 2021). Additionally, disease disease-modifying antirheumatic medications should be available. NICE recommendations advocate their usage when standard DMARDs plus therapy prove insufficient. Finally, physiotherapists, occupational therapists, and rheumatologists should be consulted. According to NICE guidelines, rheumatoid arthritis sufferers should have access to expert physiotherapy services to learn how to exercise and maintain muscular strength and joint mobility and pain management approaches. Occupational therapists should assist them with daily chores. They can assist the patient in developing methods for social interaction, interpersonal relationships, and balancing work and life in their condition (NHS, 2021). Referrals to rheumatologists should also be made when more testing or specialist treatment are required since they can recommend various treatment programs tailored to the individual’s condition (Gentry et al., 2018).
The patient’s adjustment to RA needs to be addressed holistically to account for multiple aspects that can influence coping methods, physical health, and therapeutic responses in the long and short term. This is made possible by the biopsychosocial model, which may be used as a framework for assessing, organising, and planning treatment. The article demonstrated how chronic pain and stiffness in joints could be evaluated biologically, psychologically, and socially. In each of these circumstances, numerous guidelines based on evidence have been developed for dealing with rheumatoid arthritis, and care must be administered per these recommendations. The debate demonstrates that planning for a chronic condition such as rheumatoid arthritis should be patient-centred, taking into account the patient’s autonomy in decision-making and tailoring treatment plans to the patient’s medical, psychological, and social needs in a multidisciplinary manner.
American College of Rheumatology, (2021) Rheumatoid Arthritis. Retrieved from: https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis
Arthritis Foundation, (2021) New Guidelines for Rheumatoid Arthritis Treatments Retrieved from: https://www.arthritis.org/diseases/more-about/rheumatoid-arthritis-treatment-guidelines
Arthritis Foundation, (2021) Rheumatoid Arthritis: Causes, Symptoms, Treatments and More Retrieved from: https://www.arthritis.org/diseases/rheumatoid-arthritis
Bolton, D., & Gillett, G. (2019). The biopsychosocial model 40 years on. In The biopsychosocial model of health and disease (pp. 1-43). Palgrave Pivot, Cham. https://link.springer.com/chapter/10.1007/978-3-030-11899-0_1
Center for Disease Control and Prevention, (2021) Rheumatoid Arthritis (RA) Retrieved from: https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html
Frazier, L. D. (2020). The past, present, and future of the biopsychosocial model: A review of The Biopsychosocial Model of Health and Disease: New philosophical and scientific developments by Derek Bolton and Grant Gillett. New Ideas in Psychology, 57, 100755. https://www.sciencedirect.com/science/article/abs/pii/S0732118X19301448
Fraenkel, L., Bathon, J. M., England, B. R., St. Clair, E. W., Arayssi, T., Carandang, K., … & Akl, E. A. (2021). 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis & Rheumatology. https://onlinelibrary.wiley.com/doi/full/10.1002/art.41752
Gentry, K., Snyder, K., Barstow, B., & Hamson-Utley, J. (2018). The biopsychosocial model: Application to occupational therapy practice. The Open Journal of Occupational Therapy, 6(4), 12. https://scholarworks.wmich.edu/ojot/vol6/iss4/12/
Köhler, B. M., Günther, J., Kaudewitz, D., & Lorenz, H. M. (2019). Current therapeutic options in the treatment of rheumatoid arthritis. Journal of clinical medicine, 8(7), 938. https://www.mdpi.com/2077-0383/8/7/938
Larice, S., Ghiggia, A., Di Tella, M., Romeo, A., Gasparetto, E., Fusaro, E., … & Tesio, V. (2020). Pain appraisal and quality of life in 108 outpatients with rheumatoid arthritis. Scandinavian journal of psychology, 61(2), 271-280. https://onlinelibrary.wiley.com/doi/full/10.1111/sjop.12592
National Institute for Health and Care Excellence, (2021) Rheumatoid arthritis in adults: management NICE guideline [NG100] Published: 11 July 2018 Last updated: 12 October 2020, Retrieved from: https://www.nice.org.uk/guidance/ng100
NHS, (2021) Rheumatoid arthritis Retrieved from: https://www.nhs.uk/conditions/rheumatoid-arthritis/