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Clinical Cases in Dietetics

296 pages
Learning how to deal with actual cases and developing the ability to arrive at a reasoned clinical judgement are important parts of a student's training.

This unique text presents a series of clinical cases of increasing complexity and range. Readers are taken through a structured way of thinking that facilitates clinical reasoning and the arrival of a justified treatment plan. Each case includes a commentary and opportunities for reflection on practice, and identifies key learning points.

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A casebook approach
The practice of dietetics is primarily concerned with the practitioner who is presented with personal, medical, biochemical, physical and other data or information from patients or clients, and who subsequently arrives at a rea-soned clinical judgement based on this information. This judgement can then be used as a basis for dietary intervention. The diverse nature of the client group, together with the range of presenting signs and symptoms and other clinical information pose for the student practitioner the challenges of using these data to inform the clinical decision-making process. This textbook takes the reader through the process of therapeutic think-ing, to result in considered solutions about practical clinical dietary interven-tion. The approach involves development of critical thinking and the skills of clinical detection. The reader is presented with a series of clinical cases of varying complexity and range. The text encourages the reader to consider each patient as a unique collection of data to be worked through. Each case includes a commentary (towards the end of the book), opportunities for reflection on practice and key learning points.
As the need for healthcare practitioners to demonstrate competence and meet standards of proficiency increases, making professional judgements based on clinical reasoning becomes crucial. The process of clinical reason-ing begins with the working through of clinical, social and other information so that judgements can be made in a systematic, logical and consistent manner to arrive at an informed position that can be used as the basis for therapeutic care or intervention strategy. Thus, delivery of advice to a patient or client is rooted in a process of investigational skills that considers fully the context in which the client is placed as opposed to a more tradi-tional approach – basing interventional practice merely on the knowledge of the patient or client’s medical condition. The formulation of dietary advice is therefore based on the outcome of examination of data presented by the client, which are elicited using a sys-tematic approach. This considered approach has many advantages: it allows full exploration of the client’s context and thus dietary advice can be indi-vidually tailored; it avoids the pitfall of delivering advice in a habitual, ritu-alistic and less meaningful way; it encourages development of systematic investigational technique by the student practitioner and promotes engage-ment with the subject, client and client contexts. Ultimately it will result in instinctive professional behaviour that is evidence based and applies to the client in question. The investigational approach in a student dietitian begins at an early stage in their learning career, where the student is first exposed to data and their
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management. As the student begins to apply knowledge and engage with clinical information, there is clearly a need to develop skills to manage these processes. In programmes of study involving placement of a student in a clinical learning environment, these processes need to begin early and be developed over time. Ideally, to effect good intervention practice, the student dietitian needs to have theseclinical skillsin place before firmly clinical exposure. It is the contention of the author that the process of effec-tive critical and clinical thinking, reasoning and decision-making begins early in the pre-registration programme, before practice placement, and that the process is assisted with the use of case studies that focus on problems or issues. It is the intention of this series of cases to assist the student of dietetics to engage more instinctively with clinical information. Dietetics is not an exact science; it has to deal with the vagaries of the human subject and the social and disease contexts, and draws on investigational attributes of the practitioner to effect good professional practice. The basis of this textbook rests on presenting the student with information, encouraging an investiga-tional approach in managing the information and developing interpreta-tional skills to arrive at a reasoned, professional judgement. Experience suggests that students of dietetics need to place dietetics in the holistic context of the practice field, bringing in ethical, political, social and clinical dimensions; rote learning is neither useful nor wise and students of dietetics need to demonstrate problem solving as one of theirclinical skillsprior to placement and in practice. It serves to encourage instinctive and evidence-based practice; if the process is cultured in a student practi-tioner, even if the knowledge base changes, the process encourages the student to deliver health care based on evidence and unique data presented by the client. Further, it assists the student in planning and prioritising care for a client. The cases presented in this textbook are predominantly taken from clinical experience and have been altered only to protect the confidentiality of the client or referral agent. The cases are therefore largely real, and represent accurately the scope and variety of questions posed in clinical practice. Each case has been subsequently worked through by both specialist practitioners and students; the resultant cases are thereforetried and tested examplesof the problems presented to the dietitian in clinical or primary care practice.
The cases presented in this textbook represent the scope and level of prob-lems met in community and clinical practice of the dietitian. The cases chal-lenge the student with ‘virtual’ or simulated situations intended to closely match issues that occur in routine professional practice. In the learning centre or university, student practitioners are guided by academic theory
How to use this book
essentially involving class work where there is a greater or lesser degree of student independence. Theoretical grounding is the basis of learning as a prelude to clinical life; case study work supports formal instruction by providing illustrations to which theory can be applied. Indeed, some medical schools now use case study illustration as the core method of instruction – theoretical underpin-ning guided by acquisition of knowledge on aneeds to knowbasis as the medical student engages with cases. Understanding, as opposed to knowl-edge acquisition, is more easily demonstrated in applied learning situations, an example of which is the case study. It encourages the process of critical thinking and clinical reasoning and therefore fosters the problem-solving approach. The approach taken in this textbook is to encourage the student how to think(a skill) and notwhat to think(a knowledge base); these con-cepts stimulate the process of systematic enquiry resulting in better-informed clinical judgements. The intention is that students need tousethis book. Case studies, by their very nature, are activities and involve the student in processing information in a logical sequence of steps. Case studies need to be used alongside theory which may be delivered formally as part of a lecture programme or the cases themselves can stimulate the learner to seek the theoretical underpinning. Active learning is about engaging the student in issues and fostering a questioning attitude. This textbook assists, therefore, in the development of a clinical detective.
How to use this book
The cases are presented in many ways and different formats, but essentially there is a piece of prose (the stem of the case) that takes the form of a whole case, a letter of referral or the patient history. The stem or ‘story’ sets the scene and begins to unfold issues that the student has to deal with, such as the client’s social and socio-economic background and signifi cant history (clinical and physical information). Following the ‘story’ or scenario, the student is guided by a series of questions to extract relevant pieces of the story that may be significant in generating solutions or solving issues. The book has several uses: it may be used for self-study when the student wishes to work through the cases unassisted; it may assist the student’s formal learning if the tutor uses the cases to extend theoretical aspects of learning into practical areas. It may be used as the stimulus for learning and form the spine of a practical course in which theory may be guided by the problems. In addition, the cases can be used by individual students or as part of group working, where small syndicates of students may work through the problems. Some cases may be suitable for assessing students formatively or summatively; some may be useful for formal course-work assignments. Whilst one of the intentions is to use this textbook as a self-study frame-work, it is always useful to come together with either the tutor or peers to
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discuss findings. Others’ interpretations of problems are always useful in clarifying or fine-tuning the detail of the case or the outcomes generated. In addition, this encourages a student to engage in critical debate and foster group-working skills. Each case or problem is accompanied by an explanatory commentary (potential answers) that attempts to provide a framework or learning skele-ton for the ‘answers’ or solutions (see below for a fuller explanation). The discussions in the commentaries are by no means exhaustive and other important issues or questions may be examined; some issues and perspec-tives may not be mentioned or examined in any depth.
Making the most of the cases
Each case presents the student with information that may or may not pose issues or problems. This stimulates the student to move from baseline infor-mation through a series of logical steps to arrive at a judgement (solution or answer). Arriving at a clinical judgement involves using a combination of clinical and social information and placing this into the therapeutic context of the client or patient by relating this to evidence-based published clinical guidelines. This sequence of events utilises the process of clinical reasoning (Figure 1).
Gathering baseline information
Forming a therapeutic judgement
Delivering intervention
Achieving change
Clinical information Social information
Clinical decision
Therapeutic information or advice
Desired clinical outcome
Clinical guidelines (NICE, SIGN, disease specific guidelines)
Figure 1 Process of clinical reasoning. NICE, National Institute for Health and Clinical Excellence; SIGN, Scottish Intercollegiate Guidelines Network.
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