Care Management Decision Making in Practice - Essay Example

Care Management Decision Making in Practice: Collaborative Care with Healthcare and Social Care Professionals Introduction: Healthcare practice no longer is a process of empirical care delivered by healthcare professionals, such as, doctors and nurses by practice methods learnt from seniors in the field; it is an entirely evidence-based process of analysis of problem and a process of step-wise synthesis of decision making dependent on academic learning that involves implementation of care through collaborative means by the professionals. As a student nurse in my clinical placement, I have come across many patients where I had an opportunity to observe delivery of care to different patients with different clinical diagnoses (Croskerry, P., 2002). While reflecting on such care delivery, I found that evidence-base care is actually a scientific process of arriving at a decision regarding management strategy that involves academic theoretical learning and experiential training on the backdrop of a model of collaborative care that involves input from all the professionals involved in a particular patient's care. The synthesis of experience and academic learning happens in the course of decision making occurs in all the professionals. Due to the fact that I am a final year adult nursing student nurse, I would not be allowed to implement the care in the practice setting, but my mentor insisted that to be able to understand the actual implications and significance of collaborative care decision making process, I must get involved in one such clinical condition to be analyze the process of decision making drill to see how the principles of evidence-based care is implemented in the clinical setting. I took it as an opportunity to participate in the decision making process in the collaborative care model of healthcare practice nursing to be able to handle care better in my practice. In my opinion, the academic learning in the nursing courses become meaningful when a nurse student like me is given opportunity to actively participate in the care delivery process. This account will demonstrate the decision making process of a particular case of care delivery in the clinical setting by using Marquis and Hudson decision making model (Willan, A. R., 2007). Structural decision making in the healthcare field is an important part of all science-based professions where specialist professionals apply their knowledge in a given area to make informed decisions. This is thus a process involving psychological construct that imputes a cognitive process leading to selection of a course of action among alternatives to ultimately reach a final strategy that begins with a problem that demands action. In collaborative healthcare practice in the clinical setting, it can be an action dependent on opinions based on a process of reasoning that builds on academic learning (McCaughan, D., Thompson, C., Cullum, N., Sheldon, T., and Raynor, P., 2005). In the case that I participated in the process of decision making involves an elderly individual in his 60s who presented with acute urinary retention. This patient was a known patient with benign hyperplasia of the prostate on medical therapy. He was admitted for chronic obstructive pulmonary disease and was being treated in the hospital for that. He started to complain about lower abdominal pain and sensation of fullness in the bladder. He was encouraged to void, but in vain. Despite repeated attempts, he could not pass a drop of urine, and the lower abdominal pain was replaced by severe distress over time. The problem appeared to be the decision making regarding whether to catheterize this white male or not. My mentor suggested that I collaborate with her and other professionals involved in the care regarding the decision about the interventions for this particular patient. The problem evidently is acute retention of urine with severe discomfort apparent from the distressed look of the patient. The history revealed that the patient had a couple of beer just before this incident. It is not the first time that he is suffering from such problems. He had another episode of acute urinary retention just about three months ago when he was offered catheterization of the bladder to evacuate the urine, and he was suggested to attend followup with his general practitioner. Records revealed that he had an ultrasonography done that revealed grade 2 benign hyperplasia of the prostate with a residual urinary volume of about 100 mL (Robson, Wm., L.M., Leung, A.K.C., and Thomason, M.A., 2006). He had continued symptoms of hesitancy, dysuria, and dribbling on occasion, but he denied any history of proved urinary tract infection or hematuria. On closer questioning, it was evident that when the environmental temperature goes down or when he takes a little bit more of alcoholic beverages, he has a tendency to urinate frequently, and therefore risks himself for retention of urine (Kaplan, S.A. et al., 2006). My educational learning on this topic states that all cases of urinary retention may not need a catheterization to alleviate the symptoms. If the diagnosis is done appropriately and if the patient presents early in the course of illness, the most important step is to assure the patient. The patient evidently is distressed and therefore in extreme agony and pain due to gradual accumulation of urine in the bladder, and as the amount of urine increases over time, the distress aggravates. The pain was 7 out of 10 on a visual analog scale at presentation, and as time advanced, the pain became intolerable and excruciating in that it went up to 10 out of 10. The retention of urine from whatever cause should not be allowed to persist for long mainly due to the fact that the tense urinary bladder can create pressure on the ureters, thereby hampering the drainage from the kidneys leading to difficulty in renal clearance of urine. If renal clearance of urine is affected, this may very well lead to a situation where the patient may enter into a phase of renal failure that would be evident by increasing urea and creatinine concentration (Kassem, S. and Friedman, G., 2006). My mentor insisted that I participate in the decision making process for this patient. I expressed that although I am theoretically able to participate in this process, due to my student status I really cannot participate in the care and the treatment. My mentor expressed the opinion that decision making process through an analytical approach is also a significant part in the care process since actual and appropriate care happens through a correct decision. Then I analyzed the patient's data and came to the conclusion that even though the patient is a known case of urinary retention due to grade 2 benign hyperplasia of the prostate, it is pertinent to think that this patient may have a larger growth of the prostate gland since his last ultrasonography, the patient may have an incidental urinary tract infection, and most likely, the patient would have been having some compromise in the renal function. Considering these facts, therefore, it would be logical to refer the patient to a urologist who would assess this patient (Pearson, B. and Illing, R., 2006). Meanwhile, the other methods of inducing a urination could be taken recourse to for alleviating the pain. An antispasmodic analgesic and a mild sedative could help the patient while waiting for the most definitive management catheterization. A lukewarm cloth on the suprapubic region and sound of flowing water from a tap with enough privacy is known to induce micturition in many patients. While these alternatives are contemplated and attempted, apart from a urologist chekup, a routine examination of the urine and blood tests for urea and creatinine may prove helpful. In due course, it was found that this patient has absolutely no abnormality of renal function as indicated by serum urea and creatinine levels. The routine examination of urine showed no evidence suggestive of hematuria or infection (Thomsen, T.W. and Setnik, G.S., 2006). A plain x-ray was taken that revealed no radio-opaque stone in the urinary bladder. As per the urologist, a digital rectal examination cannot be done at this stage of his suffering, and an ultrasonography can be done after a catheterization. As a result, it was decided that the patient would be evacuated by catheterization, and preparation for catheterization was undertaken. I expressed my opinion that this is the most plausible solution to this problem since the other methods failed to solve the patient's problems. In course of my discussion with the mentor and the visiting doctor, I also arrived at the same decision mainly due to the fact that most cases of acute urinary retention due to benign hyperplasia of the prostate need cauterization due to the fact that the enlarged prostatic tissue compresses on the urethra to reduce its lumen almost to a chink (Thomsen, T.W. and Setnik, G.S., 2006). Added to that, the urinary load builds up quite quickly in such patients since there is already residual volume of urine. One might also consider the factor of prostatic congestion in such cases where prostatic venous plexus gets congested due to pressure of urine filled urinary bladder on the prostatic tissue. In this elderly white patient, a speedy relief is advisable due to his distress and painful nature of the condition. The alternative methods failed to produce any results, and waiting for things to happen may complicate the situation by compromising the renal function (Johnson, J.R., Kuskowski, M.A., and Wilt, T.J., 2006). This, clearly, thus involved a collaborative approach where everyone in the team involved in the care of this patient contributed to the decision making process about the treatment of the patient. The care plan originating from such process was discussed with the patient and the family, and all were in agreement with the plan. Male catheterization is comparatively a difficult process due to a tortuous anatomy of the male urethra. The male urethra starts from the base of the bladder, passes through the prostate lobes to be known as prostatic urethra, enters into the membrane as membranous urethra, becomes bulbous as bulbous urethra, continues through the shaft of the penis as penile urethra, dilates into glanular urethra in the glans penis, continues into the tip of the penis as meatus until it opens outside. One staff specially trained in male catheterization would be able to negotiate the catheter through the complex anatomy, and it was jointly decided that a catheterization nurse would insert the catheter (Siderias, J., Guadio, F., and Singer, A.J., 2004). I observed that patient was placed on the table, and the catheterization nurse washed her hands thoroughly with soap and water, dried it up, and then wore a pair of sterile gloves. I knew that this is important since a dirty and infected hand of the caregiver in such an hyperacute clinical situation is enough to precipitate a urinary tract infection. Then the nurse cleaned the penis and glans penis with soap followed by povidone iodine on a sterile swab. She then introduced 2% lidocaine jelly into the urethra, about 5 mL and held the meatus tight for about 5 minutes. After 5 minutes of waiting, she took out a 18 French Foley catheter from its package and introduced the catheter gently along the urethra. It was easy to introduce until the tip of the catheter reached the prostate gland where with gentle strong push, she could advance the tip of the catheter in to the bladder. Urine started flowing in jet and filled the kidney dish, and the measured amount of urine was almost 1 L. The patient stopped screaming, and the agony was over. The catheter was taken out, and the patient was advised to attend his general practitioner the next morning (Vaughan, M., Paton, E.A., Bush, A., and Pershad, J., 2005). This decision making process is an unique opportunity for a student nurse like me to revisit the academic training on urinary retention, and the opportunity to participate in such a process in the clinical setting is actually a learning exercise that would benefit anyone who has a future in the clinical practice in the live setting. The gap between the academic learning and practical approach to a problem can be reduced, especially in nursing practice, when a student is allowed to participate actively in the decision making process. Moreover, it is also an excellent opportunity to experience collaborative care in the clinical area that would actually advance professional practice in nursing. References Croskerry, P.,(2002). Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias. Academy of Emergency Medicine; 9: pp. 1184 - 1204. Johnson, J.R., Kuskowski, M.A., and Wilt, T.J., (2006). Systematic Review: Antimicrobial Urinary Catheters To Prevent Catheter-Associated Urinary Tract Infection in Hospitalized Patients. Annals of Internal Medicine; 144: pp. 116 - 126. Kaplan, S.A. et al., (2006). Tolterodine and Tamsulosin for Treatment of Men With Lower Urinary Tract Symptoms and Overactive Bladder: A Randomized Controlled Trial. JAMA; 296: pp. 2319 - 2328. Kassem, S. and Friedman, G., (2006). Subacute Urinary Retention. New England Journal of Medicine; 354: e5. McCaughan, D., Thompson, C., Cullum, N., Sheldon, T., and Raynor, P., (2005). Nurse Practitioner And Practice Nurses' Use Of Research Information In Clinical Decision Making: Findings From An Exploratory Study. Family Practice; 22: pp. 490 - 497. Pearson, B. and Illing, R., (2006). When Going Into Urinary Retention, Call A... Vet BMJ; 333: 379. Robson, Wm., L.M., Leung, A.K.C., and Thomason, M.A., (2006). Catheterization of the Bladder in Infants and Children. Clinical Pediatrics; 45: pp. 795 - 800. Siderias, J., Guadio, F., and Singer, A.J., (2004). Comparison of Topical Anesthetics and Lubricants Prior to Urethral Catheterization in Males: A Randomized Controlled Trial. Academic Emergency Medicine; 11: pp. 703 - 706. Thomsen, T.W. and Setnik, G.S., (2006). Male Urethral Catheterization. New England Journal of Medicine; 354: e22. Thomsen, T.W. and Setnik, G.S., (2006). Male Urethral Catheterization. New England Journal of Medicine; 354: e22. Vaughan, M., Paton, E.A., Bush, A., and Pershad, J., (2005). Does Lidocaine Gel Alleviate the Pain of Bladder Catheterization in Young Children A Randomized, Controlled Trial. Pediatrics; 116: pp. 917 - 920. Willan, A. R., (2007). Clinical Decision Making And The Expected Value Of Information. Clinical Trials; 4: pp. 279 - 285. Read More