Clinical Reasoning Cycle For Post-Surgical Patient Care: A Case Study

Clinical Reasoning Cycle Steps: Care Cues and Data Collection

In clinical practice the nursing professionals are required to take a series of clinical decision and judgments regarding the care of the patient and how the care intervention are going to be implemented for the patient (Hunter & Arthur, 2016).  Critical analytical thinking skills and scientific reasoning are a part of the mandatory or essential skills that the nursing professionals must have to be able to provide safe and effective care. The clinical reasoning cycle provides the nurse with the opportunity to assess the patient, discover and then prioritize the care needs, establish care goals and the implement person centred care interventions with the aid of the evidence based practice (Gee, Dalton & Levitt-Jones, 2015). This essay will attempt to explore and implement the steps of the clinical reasoning cycle taking the assistance of a case study.

The patient representing in the case is named Melody King who had presented to the care facility with the peritonitis following ruptured appendix. The patient has been suffering from severe right lower quadrant abdominal pain due to which the patient needed to undergo an emergency laparoscopic surgery to remove the ruptured appendix. Her presenting health issues or complaints that the patient had been exhibiting includes increasing nausea and centralized abdominal pain which has been scored as 7-8 out of 10.

The second step of the clinical reasoning cycle is here the nurse is required to collect different care cues that are present in the scenario of the patient and process the information to arrive at a set of care needs for the patient (Dalton, Gee & Levett-Jones, 2015). The information that needs to be collected for the patient includes past medical history, medication list, handover reports, and nursing notes. In this case, the past medical history of the patient includes asthma and depression, asthma might lead to respiratory distress in the post-operative scenario and hence the nurse needs to take into consideration. The continual medication that Melody has been prescribed includes ventolin, Seretide, and Sertraline. The vital signs include 95/45mmHg blood pressure, 120 bpm heart rate, and 22/min respiratory rate of the patient. Along with that the pain score of Melody is 7-8/10 which is a grave concern for the patient, which needs to be addressed while providing the interventions (Litz et al., 2018). Other pressing complaints that the patient had made includes nausea. The physical assessment for the assignment for Melody revealed that she had a distended abdomen and generalised abdominal guarding. Her path lab tests revealed high levels of WBC and CRP which also can be concerning for heamodynamic stability in the patient.

Processing the information that has been collected, Melody had a ruptured appendix for which led for the patient to undergo a surgical removal of the appendix. As per authors, any blockage or obstruction in the appendix can lead to inflammation and infection of the appendix. On a more elaborative note, due to the blockage, a variety of different pathogens build up near the region of the inflammation and the infection starts to spread (Litz et al., 2018). In case adequate treatment interventions are not taken for the patient, it leads to rupturing of the appendix spilling the microbes to the abdominal parts infecting the abdomen in turn as well; leading to peritonitis which is the case for the patient in the case study. The pain that she is suffering from along with the distended abdomen is caused by the infection only as evidenced by the high WBC count of the patients which is a normal defense mechanism of the body against any infection. The blood pressure of the patient is low which might have led to symptoms of nausea and dizziness, which could have been the result of the anesthesia from the surgery. Along with that the patient also had shallow breathing which is indicative of the impending respiratory distress in the patient for her asthma (Kermani et al., 2014). Hence, Melody ill require an extensive person centred care to manage the symptoms that she had been suffering from.

Analyzing the Care Needs: Prioritization and Addressing Nursing Problems

Identify and prioritize at least three nursing problems:

The next step of the clinical reasoning cycle is focused on discovering the care needs that the patient had been suffering from and prioritizing the care needs exhibited by the patient. It has to be mentioned that the patient had been suffering from acute pain with a pain score of 7-8/10 which is due to the peritonitis. Hence, the patient will require the aid of the care interventions to manage the pain properly (Vennix et al., 2015). Along with that, the infection which has led to distended or enlarged abdomen is another very important care priority for Melody. It has to be mentioned that the infection that is caused due to peritonitis can easily spread drastically to the rest of the body and as a result it is necessary for the patient to get care interventions for the infection management. The third and final care priority for the patient in this case is the irregular vital signs of the patient (Grelpois et al., 2016).

This is the step of the cycle here the nurse is required to provide a clear understanding of the nursing problems that the patient is suffering from and be able to establish care objectives addressing the care needs of the patient. For the first care priority, the care goal for melody will need to be focused on both pharmacological and non-pharmacological pain management techniques for her. Hence, the care goal will be to minimize three pain that Melody is feeling and provide optimal levels of comfort to her (Binet et al., 2017). For the second care priority, the care goal for Melody will be to provide infection control mechanisms for her and antibiotic therapy so that the inflammation is visibly reduced. For the last care priority that Melody would require an intervention for is the low blood pressure which can be due to the infection, impact of the anesthesia and as leading to the nausea and dizziness as well along with high heart rate and respiratory rate. Hence, the care goal will be to raise her blood pressure and provide adequate nutrient or electrolyte therapy to eradicate the nausea she had been feeling, and reduce the heart rate and shallow breathing

For the pain management, the nurse ill need to focus highly on both pharmacological and non-pharmacological management of the pain that patient had been feeling. The pain that Melody has been experiencing had been both due to infection and the surgical procedure (Montravers et al., 2016). Hence, as pharmacological intervention the nurse might provide medications such as ibuprofen, celecoxib, ketorolac and naproxen. The nurse might also take the assistance of the non-pharmacological techniques of pain management such as acupuncture, meditation, massage therapy and yoga based mindfulness enhancing therapies to help melody better manage the pain (Litz et al., 2018).

For the infection control, the nurse ill require to provide antibiotic therapy for the patient> however, before administration of the antibiotics the nurse ill need to perform 5 R’s of medication administration to ensure avoiding the risk of adverse drug interaction or hypersensitivity. The Nurse ill also have to provide periodical surgical site cleaning following a thorough aseptic technique to ensure that the patient is at no risk for sepsis (Podda et al., 2017).

Conclusion

For the low blood pressure, the nurse will need to provide electrolyte therapy to enhance the blood pressure of the patient. Along with that, as the heart rate of the patient had also been extremely high heart rate, the nurse might need to provide antiarrhythmic drugs, along with that in order to enhance the oxygen saturation and reduce the breathing rate to normal, the nurse ill also need to administer the aid of external oxygen therapy. Lastly, in order to regain homeostasis in the patient, the nurse will need to provide a warm and comfortable environment to the patient which ill help in stabilizing the vital signs (Grelpois et al., 2016).

The care interventions that have been selected for the patient had been very successful which helped Melody attain a comfortable recovery. It has to be mentioned that the aid of both pharmacological and non-pharmacological interventions aided excellently in maintaining the pain of the patient. The antibiotic therapy as also successful in providing the patient relief from the infection and her abdominal distension as visibly reduced within 48 hours. Although, stabilizing the vital signs of the patient had been a challenging task for Melody however, the electrolyte therapy and external oxygen therapy had been successful in controlling the blood pressure and respiratory rate (Vennix et al., 2015).

This has been an excellent opportunity for me to learn how to implement the clinical reasoning cycle in the real world care scenario. This patient had presented in the health acre facility with peritonitis and ruptured appendix and had symptoms of pain, infection and enlargement of the abdomen, and irregular vital signs. This exercise helped me understand how to plan and implement care in such scenarios and help the patient attain recovery. On a concluding note, it can be hoped that the experience gained from this assignment activity will be a guidance in my future practice to provide safe and effective care to patients in post-operative care scenario.

References:

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Kermani, R., Staudenmayer, K., Gurney, J. M., & Spain, D. A. (2014). Appendicitis in the elderly patient population. Journal of the American College of Surgeons, 219(4), e15-e16.

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Litz, C. N., Stone, L., Alessi, R., Walford, N. E., Danielson, P. D., & Chandler, N. M. (2018). Impact of outpatient management following appendectomy for acute appendicitis: An ACS NSQIP-P analysis. Journal of pediatric surgery, 53(4), 625-628.

Montravers, P., Blot, S., Dimopoulos, G., Eckmann, C., Eggimann, P., Guirao, X., … & De Waele, J. (2016). Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive care medicine, 42(8), 1234-1247.

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Podda, M., Cillara, N., Di Saverio, S., Lai, A., Feroci, F., Luridiana, G., … & Vettoretto, N. (2017). Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics. the surgeon, 15(5), 303-314.

Vennix, S., Musters, G. D., Mulder, I. M., Swank, H. A., Consten, E. C., Belgers, E. H., … & Hoofwijk, A. G. (2015). Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. The Lancet, 386(10000), 1269-1277.