Critical reasoning is an important skill required by nurse to process patients information and provide holistic care to patients. Clinical reasoning and judgment provides nurse with an opportunity to improve the quality of care and avoid adverse events in clinical setting (Kuiper, Pesut & Arms, 2016). This paper will provide an insight into the process of clinical reflection by using the clinical reasoning cycle and discuss the provision of providing holistic person centred care related to the case scenario of Candace Evans, a 42 year old woman with elective lower uterine caesarean section (LUCS). The paper will also identify three nursing problems and plan appropriate nursing care related to the three problem.
During one of my specialty placement, I was given the responsibility to take care of Candace Evans, a 42 year old woman who has undergone elective LUCS under spinal anaesthesia at 38 weeks gestation period. The main patient’s diagnosis was placenta previa and after being operated for LUCS, Candace arrived at the post anaesthetic recovery room (PACU) after birth of a male infant. On inspection of vaginal blood loss, the patient’s vaginal pad was found to be soaked with frank blood and clots.
In response to the problem of vaginal bleeding after LUCS, information was collected regarding patients medical history records, current vital signs, pain level and urine output. The main purpose of collecting medical history was to identify other risk factors that might have lead to post-partum haemorrhage. For example, apart from placenta previa, multiple gestation, advanced maternal age, large baby and rapid birth can also lead to contraction of the uterus and excessive vaginal bleeding (Sheldon et al., 2014). In case of Candace, her past medical history revealed that this was her second pregnancy and her first pregnancy occurred 5 years ago. She had suffered from gestational diabetes during her first pregnancy. Hence, gestational diabetes can be regarded as a risk factor of vaginal bleeding as gestational diabetes increase the risk of placental abruption (Gelaye et al., 2016). Her advancing age is also identified as a risk factor of vaginal bleeding.
To assess the severity of problem for Candace, assessment of vital signs was done. Her BP was 104/76, temperature was 36.9° Celsius, SpO2 97% and HR 88. All the vital signs were normal except her BP which is found to be low. This is seen because of blood loss. Vital sign assessment is necessary to quantify blood loss and identify signs of hypovolemic shock in Candace due to haemorrhage. Many signs and symptoms of restlessness, fatigue, tachycardia and weakness are also associated with blood loss (Diaz, Abalos & Carroli, 2014). Hence, vital signs assessment may guide fluid replacement therapy and estimate consequences of excessive blood loss. Pain assessment revealed no pain due to bleeding.
To determine the type of nursing intervention to be implemented for vaginal bleeding, it was also necessary to estimate the amount of blood after the birth of baby. After pregnancy, normal blood loss is 300-500 ml for pregnant women and postpartum haemorrhage is indicated when blood loss is greater than 1000 ml in the first 24 hours after a caesarean birth. Birth canal injury assessment and gravimetric measurement of perineal pad was done to estimate blood loss (Abdul?Kadir et al., 2014). Her blood loss was found to be 150 within the first 24 hours after the caesarean section. This indicated that blood loss was within normal limit. However, assessment of indwelling catheter showed that it contained 100 ml of rose coloured urine. Blood in the urine is an indication of hematuria and it occurs because of changes in the urinary tract induced by hormonal and mechanical factors of pregnancy (Karaosmano?lu et al., 2018). The source of bleeding was also examined. Bladder injury during caesarean section may also lead to hematuria.
Based on the collection of health assessment data for Mrs. Candace, the first major problem that has been identified in patient is presence of hematuria evidenced by in-dwelling catheter assessment. Developing appropriate nursing care plan to treat hematuria is important as delaying treatment may increase the risk of urinary tract infection in patient. Salman et al. (2017) explains that gross hematuria in the Foley catheter is an indication of bladder injury and use of appropriate antibiotics can prevent the condition. Another problem or issue that has been identified for Candace is risk of hypovolemic shock because of vaginal blood loss. Kerr et al. (2016) supports the fact that hypovolemic shock is subsequently seen in patients with severe haemorrhage and implementing appropriate therapy is essential to reduce chance of organ damage and death. Signs of hypovolemic shock may be identified by assessment of body temperature and blood pressure. Cool and clammy body and low blood pressure is an indication of hypovolemic shock in patient (Kalkwarf & Cotton, 2017). The vital sign assessment data revealed that Candace blood pressure was very low. This symptom was observed because of the effect of blood loss. Hence, low blood pressure is also identified as a problem or issue for patient that needs to be managed to prevent further complication for Candace.
In response to the issues identified in patient, three nursing goals have been identified for the health and recovery of Mrs. Candace. The first nursing goal is to reduce the risk of urinary tract infecting by treating hematuria. The second nursing goal is to reduce possibility of hypovolemic shock. The third nursing goal is to manage low blood pressure and educate patient regarding ways to identify and detect signs of deterioration and seek emergency help.
To address the issue of hematuria, it is planned to conduct urinary catheterization assessment to monitor for signs of urinary tract infection. Monitoring creating and WBC count in the urinary catheter can help to detect signs of complication. Indwelling catheterization is normally done before caesarean section to reduce the risk of intra-operative injury to the urinary system, assess urinary output and prevent post-operative urinary retention (Pandey et al., 2015). However, the practice increases the chance of urinary tract infection because of urinary colonization. Hence, assessment of catheterization may help to control risk of infection. To prevent any risk of infection, it is also planned to provide fluid replacement therapy to Candace. The main rational for maintaining proper fluid intake is that sufficient hydration increases urine output and prevents infection.
Another nursing intervention that has been planned in response to risk of hypovolemic shock is to provide uterine massage to patient. The effectiveness of uterine massage has been proved by Saccone et al. (2018) which revealed that uterine massage can promote contraction of the uterus and stimulating the uterus by massage the area reduces volume of blood loss. As part of ethical practice, Mrs. Candace will be informed regarding the reason for the massage and other interventions provided to her. This will also promote cooperation of patient during the implementation of the intervention and increase patient’s satisfaction with care. Patient’s dignity and other concerns will be addressed while providing the above intervention.
As Mrs. Candace is at risk of hypovolemic shock due to bleeding post LUCS, it is planned to provide her non-pneumatic anti-shock garment (NASG) to treat hypovolemic shock. It is an effective initial intervention to prevent hypovolemic shock and its usefulness has been proved by recent research evidence. Escobar et al. (2017) explains that prioritising prevention of hypovolemic shock is important in patient with obstetric haemorrhage to reduce the likelihood of maternal mortality. Prolonged shock may increase fluid loss from the blood vessels. Hence, as hypovolemic shock is an urgent clinical situation, NASG is an effective treatment option before blood transfusion or other therapy is provided. NASG is a light weight first-aid device that is wrapped around legs, pelvis and abdomen to provide uterine compression. It is a part of resuscitation measure to control bleeding (Penn, Beam & Azman, 2015).
While collecting vital signs data for Mrs. Candace, it was found that she had a low blood pressure. This may indicate deficit in fluid volume of patient because of blood loss. In accordance with the holistic care provision, the main nursing goal is to maintain blood pressure at 100/60 mm Hg. To maintain the normal blood pressure, it is planned to monitor blood pressure of Mrs. Candace regularly and provide fluid replacement therapy to maintain normal blood pressure and prevent the likelihood of blood pressure (Asfar et al., 2014). While providing all the interventions, it is planned to provide all information to patient regarding the rational for treatment, its possible outcome and any precautions needed. This process would help to engage in informed decision making and promote rights of clients during treatment planning and recovery.
To evaluate the effectiveness of the intervention, the possibility of achieving desired outcome from each nursing care plan will be judged. In response to the intervention for hematuria, inspection of indwelling catherization is considered an effective step to identify possibility of catheter related infection. Other secondary measures such as fluid replacement are is likely to stabilize patient’s condition and prevent any possibility of serious complications like hypovolemic shock and low blood pressure. Use of uterine massage is also an effective care option as it has the potential to provide immediate intervention when main interventions like blood transfusion or surgery cannot be given immediately. Certain cultural values may act as a barrier in delivering such treatment. However, this can be controlled by engaging in informed decision making with Mrs. Candace and actively informing and educating her regarding each intervention.
Conclusion:
The essay summarized the process of developing holistic and person centred care plan for Mrs. Candace Evans, a 42 years old patient by the use of clinical reasoning cycle. By engaging in the process of collecting cues to identify patient’s issue, it was found that hematuria was a major issue for her because of postpartum haemorrhage due to placenta previa. Other two issues identified for Candace were risk of hypovolemic shock and low blood pressure. Three relevant interventions were planned with support from evidence based research to promote recovery of patient and stabilize her condition. Consideration of ethical and legal aspects of care provision helped to encourage patient’s engagement in the treatment process.
References:
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Asfar, P., Meziani, F., Hamel, J. F., Grelon, F., Megarbane, B., Anguel, N., … & Legay, F. (2014). High versus low blood-pressure target in patients with septic shock. New England Journal of Medicine, 370(17), 1583-1593.
Diaz, V., Abalos, E., & Carroli, G. (2014). Methods for blood loss estimation after vaginal birth. Cochrane Database of Systematic Reviews, (2). Retrieved from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010980/full
Escobar, M. F., Füchtner, C. E., Carvajal, J. A., Nieto, A. J., Messa, A., Escobar, S. S., … & Miller, S. (2017). Experience in the use of non-pneumatic anti-shock garment (NASG) in the management of postpartum haemorrhage with hypovolemic shock in the Fundación Valle Del Lili, Cali, Colombia. Reproductive health, 14(1), 58.
Gelaye, B., Sumner, S. J., McRitchie, S., Carlson, J. E., Ananth, C. V., Enquobahrie, D. A., … & Williams, M. A. (2016). Maternal early pregnancy serum metabolomics profile and abnormal vaginal bleeding as predictors of placental abruption: a prospective study. PloS one, 11(6), e0156755.
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Karaosmano?lu, A. D., Güne?, A., Özmen, M. N., & Akata, D. (2018). Anterior uterine wall: normal and abnormal CT and MRI findings after cesarean section. Diagnostic and Interventional Radiology, 24(3), 135.
Kerr, R., Eckert, L. O., Winikoff, B., Durocher, J., Meher, S., Fawcus, S., … & Wandwabwa, J. (2016). Postpartum haemorrhage: Case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine, 34(49), 6102. doi: 10.1016/j.vaccine.2016.03.039
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Pandey, D., Mehta, S., Grover, A., & Goel, N. (2015). Indwelling Catheterization in Caesarean Section: Time To Retire It! Journal of Clinical and Diagnostic Research?: JCDR, 9(9), QC01–QC04. https://doi.org/10.7860/JCDR/2015/13495.6415
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