Physical Assessment Of Cholecystitis Patient Using Clinical Reasoning Cycle

Clinical Presentation and Examination

The following assignment will utilize the elements of the Clinical Reasoning Cycle to carry out the physical assessment of the condition of a patient who has been admitted to the emergency department in a hospital setting with cholecystitis. All the steps in the cycle encompassing the consideration of the patient information, collecting cues relevant to the patient condition, processing of information will be carried out in due course. Further upon identification of the problems, the subsequent steps related to the establishment of goals, taking actions and evaluation of the outcomes will be undertaken through detailed assessment. In the final step reflection of the process and experience of new learning will be addressed as well (Levett-Jones & Hoffman, 2013). Thus by virtue of using a clinical patient scenario, exploration of physical assessment will be facilitated. Additionally information regarding focused assessment, normal and abnormal parameters along with health history will be incorporated.

In the chosen scenario, the patient has been suffering from cholecystitis, a condition in which inflammation of the gall bladder occurs due to obstruction of the cystic duct because of cholelithiasis or gallstones arising from the gall bladder. As per the given scenario, Mr. Kasim Al-Mutar, a 49 years old male has been presented with the symptoms of right upper quadrant (RUQ) abdominal pain, fever and vomiting for the past two days. With the advancement of age, the propensity of encountering cholecystitis is increased in the general population. However women are more prone to develop this condition in contrast to men. Having gallstones has been accounted as the major risk factor for developing cholecystitis. Tumor formation at the gall bladder or bile duct blockage have been attributed as ancillary causes that may lead to cholecystitis. Complications that are largely associated with cholecystitis include infection within the gallbladder, necrosis and tearing of the gall bladder tissue. The presented symptoms in the give case matched with the symptoms that typically refer to cholecystitis with the prominent ones being severe pain in the upper right quadrant, fever and vomiting. Recurrence of cholecystitis symptoms have also been noted in research findings (Karaköse et al., 2015). Therefore the complaint as registered with Mr. Kasim, though is not typical for his gender, but may be linked with his progressive age. Attainment of a considerable age rather than being young increases the chances of harboring cholecystitis condition.

Review of the handover information from the previous attending nurse, it was revealed that Mr. Kasim was exhibiting impaired responses to the vital signs parameters.  His cardiovascular fitness indicators as depicted in the form of heart rate and blood pressure were found to be 126 and 100/45 mm of Hg respectively while his body temperature was recorded as 38.8°C. Moreover he was also reported of being afflicted by severe RUQ pain with the last episode of vomiting taking place 2 hours ago. Additional reporting of symptoms as stated by the nurse showed that the patient appeared pale with dry mucous membranes and he also requested for a drink of water. His shoulder tip pain was documented to be 7/10 that may be considered quite high in terms of the severity of its perception. Kasim was reported of being accompanied by his 12 years old daughter during his admission to the emergency department within the hospital setting. The clinical presentation of the patient condition although seems to be nearly complete, but additional information and data regarding the type of pain experienced and knowledge gained from other physical assessments are missing. Physical examination to assess the tenderness in the upper right abdomen needs to be done to indicate palpable gallbladder that is considered as an important marker of cholecystitis. Information related to the timing and type of the excruciating pain is also incomplete. The duration of pain and the timing whether aggravates after a meal or while taking a deep breath must be noted to address the issue and recommend further interventions accordingly. Further information relevant to the weight of the patient is required apart from data related to height to assess his BMI that acts as an important marker of obesity or overweight. Obesity adversely impacts the development of cholecystitis by acting as a facilitator (Gutt et al., 2013).

Processing the Information

Processing the information retrieved from the clinical presentation it is evident that his vital signs are deteriorating and he is experiencing grimacing pain. The elevated heart rate shows that he is suffering from tachycardia at the moment. Diminished blood pressure indicates that he is facing hypotension presently that in turn may lead to unconsciousness due to sudden crash fall in blood pressure if not intervened timely. Moreover the elevated body temperature is a harbinger of the fact that he is having hyperthermia or fever. Pain radiating from the upper right quadrant of the abdomen to the shoulder tip is another indicator of his grimacing pain in such condition. All the symptoms are suggestive of the fact that he is suffering from acute type of cholecystitis that may be further confirmed through an ultrasound or a routine blood examination (Lawrence, 2015). Abdominal ultrasounds will be used as an imaging technique for correct diagnosis of cholecystitis. Laboratory test findings with leucocytosis and elevated liver functioning enzymes might also indicate the gravity of the cholecystitis to steer effective treatment modalities. Therefore performance of these common and reliable tests will explicitly indicate the extent of the disease thereby allowing the prescription, administration and recommendation of suitable therapeutic medications and treatments (Bosch, Schmidt & Kendall, 2016). Moreover, further harm to the patients might be mitigated by virtue of conducting the tests that are considered valid for the assessments of the severity of the disease.

Identification of the problems and issues relevant to the given case scenario is a crucial step in treating the condition in an effective manner. The degree of inflammation accounts for different prognosis in case of acute cholecystitis. Hence the success of the treatment essentially relies on the early detection and prompt operation during severe cholecystitis. Independent factors that need to be considered for assessment include old age, male gender, body mass index (BMI), serum leukocyte count, serum neutrophil fraction, serum platelet count, level of serum alanine tramsaminase (ALT) for detecting the severity of cholecystitis in the patient. Further radiologic features that corroborate with the pathological findings include thickenings of the gallbladder wall besides the presence of the cholecystic fluid collection. Depending upon the individual hazard rate of the measured variables, a standard risk assessment scale needs to be improvised to evaluate the risk thereby aiding in the management of cholecystitis. In conjunction with the diagnostic imaging techniques, these preoperative clinical variables need to be supplemented to enhance the diagnostic accuracy of the imaging like CT and ultrasound. The pain scores of the patient also need to be assessed on regular intervals to implement suitable therapeutic and non-therapeutic interventions in the form of drugs, exercise or surgical as appropriate to the scenarios (Kim et al., 2016).

Health assessment of the patient will comprise of recording his vital parameters such as heart rate, blood pressure, body temperature. Other assessments regarding the perception of pain will be recorded through definite pain score through use of appropriate scale. Based on the data obtained through physical assessments, antibiotic and other drug administration will be recommended. The patient is likely to show better outcomes on treatment intervention by showing decreased heart rate, shift of blood pressure and body temperature towards normal range along with lower pain score. Upper gastrointestinal endoscopy may be opted as a chosen mode of preventive intervention prior the elective surgical therapy in cholecystitis to abate the pain (Faisal et al., 2013). Percutaneous cholecystectomy consisting of the removal of gall bladder is the best possible solution to resolve the problem (Popowicz et al., 2015). Medications and other antibiotic administration must follow such surgical intervention and attended carefully to address the condition (Loozen et al., 2016). Howeve4r, the entire procedure must be carried out under the strict supervision and guidance of authorized personnel like the physician and the registered nurses to account for the effectiveness of the intervention provided. The effectiveness of the actions and outcomes needs to be evaluated correctly to harbor optimal results.

In connection to the given case scenario it may be said that by virtue of evaluating the case scenario from the perspective of the clinical reasoning cycle, necessary information pertaining to the clinical condition of cholecystitis may be acquired. The causes and risk factors that might account to the manifestations of symptoms related to cholecystitis are thus known. The diagnosis of such condition might account for deriving holistic benefits. Insight regarding the physical examinations, pathological recordings and pain assessments are provided from knowledge acquired in course of the case study. The treatment modalities that are available till date to effectively tackle the cholecystitis condition are thus highlighted with emphasis being put on the most appropriate one that is both convenient and feasible option of treatment for application in the given case. Further emancipation of knowledge in writing academic assignments through reviewing of relevant academic literatures is also provided in course of this assignment (Academic Skills Unit, 2013).

References:

Academic Skills Unit. (2013). ACU study guide: Skills for success (3rd ed.). Fitzroy: Australian Catholic University.

Bosch, D., Schmidt, J. N., & Kendall, J. (2016). Acute Cholecystitis Detected by Serial Emergency Department Focused Right Upper Quadrant Ultrasound. Journal of Medical Ultrasound, 24(2), 66-69.

Faisal, A. H. M. E. D., Gadallah, A. N., Omar, S. A., & Nagy, M. A. (2013). The role of upper gastrointestinal endoscopy in prevention of post-cholecystectomy pain prior the elective surgical therapy of chronic cholecystitis. Med J Cairo Univ, 81(1), 289-93.

Gutt, C. N., Encke, J., Köninger, J., Harnoss, J. C., Weigand, K., Kipfmüller, K., … & Klar, E. (2013). Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Annals of surgery, 258(3), 385-393.

Karaköse, O., Sabuncuo?lu, M. Z., Benzin, M. F., Çelik, G., Bülbül, M., & Pülat, H. (2015). Development of acute cholecystitis following laparoscopic partial cholecystectomy.

Kim, K. H., Kim, S. J., Lee, S. C., & Lee, S. K. (2016). Risk assessment scales and predictors for simple versus severe cholecystitis in performing laparoscopic cholecystectomy. Asian journal of surgery.

Lawrence, R. (2015). Acute Cholecystitis. S. R. Eachempati, & L. Reed (Eds.). Springer International Publishing.

Levett-Jones, T. & Hoffman, K. (2013). Clinical reasoning: What it is and why it matters. In: T. Levett-Jones (Ed.). Clinical Reasoning: Learning to think like a nurse. French’s Forest: Pearson.

Loozen, C. S., Oor, J. E., Kortram, K., van Geloven, A. W., van Duijvendijk, P., Nieuwegenhuijzen, G. A., … & Kelder, J. C. (2016). Postoperative antibiotic use in the treatment of acute cholecystitis: a randomized multicentre noninferiority trial. HPB, 18, e854-e855.

Popowicz, A., Lundell, L., Gerber, P., Gustafsson, U., Pieniowski, E., Sinabulya, H., … & Sandblom, G. (2015). Cholecystostomy as bridge to surgery and as definitive treatment or acute cholecystectomy in patients with acute cholecystitis. Gastroenterology research and practice, 2016.