Clinical reasoning is defined as a process that involves application of knowledge and clinical expertise to a clinical situation to develop appropriate solution. Nurses are required to engage in clinical reasoning to provide safe and effective care to patient. To engage in clinical reasoning during care delivery, nurses need to use cognitive skills of analysis, explanation, information seeking and inference to make judgment about patient immediate care priorities. It also requires behavioural skills like open-mindedness and mental skills like creativity, curiosity and flexibility to engage in decision making process. With effective clinical reasoning skills, nurses can have a positive impact on patient outcomes (Carvalho et al., 2017). This essay utilizes the steps of the clinical reasoning cycle to analyse the case study of Mr. Peter Ling and develop appropriate plan of care for patient.
The first step of the clinical reasoning cycle is to consider the patient situation. It involves describing facts or context of a patient (Dalton, Gee & Levett-Jones, 2015). This essay deals with the case study of Mr. Peter Ling, a 67 year old man admitted to the surgical ward after an open mesh inguinal hernia repair. He presented to the ED with a 6 hour history of right non-inguinal mass post starting a new gym/weight lifting regimen. He was recovering well. However, on Day 2, post op he became agitated and confused and reported significant left calf pain.
To further understand the key problem for Mr. Peter, there is a need to collect cues related to patient history and current assessment data of patient. From his past medical history data, it has been found that he is an ex-smoker and obese man with a body mass index (BMI) of 30. The normal BMI range is 18.5 to 25. As Peter’s BMI is 30, he comes under the obese category (NHS, 2019). He has a history of mild congestive heart failure (CHF), hypertension and hyperlipidemia. His current symptom of concern is significant left calf pain and feelings of agitation and confusion. The review of his vital signs can give more idea about signs of deterioration or changes in his body system due to surgery. His vital signs included temperature of 39.3 degree Celsius, respiratory rate (HR) of 25, heart rate (HR) of 100, BP 170/90, Pain score 7/ 10 and GCS (Glasgow Coma Scale) 14/15. GCS is used to assess level of consciousness in patient and score of 13-15 is best score indicating mild brain injuries (Jain, Teasdale & Iverson, 2019). Peter’s body temperature is higher than normal body temperature indicating that current he is febrile. HR is within normal limit. However, BP value is high and RR value is abnormal as normal RR range is 12-20 bpm. His pain score is very high and these symptoms must be analysed well.
Apart from the review of vital signs data of Mr. Peter, physicals assessment was also done. He is found to be confused to time and place. He has no chest sounds on auscultation and skin is dry. However, surgical wound dressing has oozing green purulent discharge indicating signs of infection. Swelling is also seen in his left calf and the skin is warm to touch. Green purulent discharge is an abnormal finding as it indicates that the surgical site is not healing well and there is risk of infection. Green discharge is a sign that some infection is present and this might be the cause behind intense pain for patient. Butterworth and Payne (2017) explain that initiation of inflammatory response at wound site leads to intense pain. Another abnormal sign identified for Peter is swelling of the calf. Postoperative oedema occurs because of direct tissue injury. It is a common phenomenon post surgery. Vaughan-Shaw et al. (2013) supports that oedema can increase postoperative morbidity and mortality rates and this form of fluid accumulation lead to infective complications, delayed wound healing and lengthy hospital stay. Postoperative edema mostly occurs due to the cytokine response to surgical injury.
The review of Peter’s investigations revealed a haemoglobin value of 16.5 gm/dl. The value of haemoglobin is within normal limits 13.5 to 17.5 gm/dl. His WBC, neutrophils and CRP values are all elevated. This again indicates infection risk because acute stress or infection increases the number of WBC and neutrophils. Post surgical infection is regarded as the main cause behind current symptom of Peter (Wang et al., 2017).
The above section gave idea about the key symptoms and signs of concern for Mr. Peter and the processing of information revealed risk of infection for patient. Based on analysis and processing of data related to vital signs, physical assessment and medical investigations, three priority nursing problem has been identified for Peter. Firstly, high pain score is a major nursing problem or issue because unless this is addressed, it can further increase agitation for patient. Peter had undergone a hernia repair using open mesh and the surgical procedure might be the major cause behind pain. The Lichenstein open repair using open mesh is one of types of hernia and this kind of repair is known to cause discomfort and pain to patient. In addition to the surgical procedure, tissue injury can also be a cause of pain (Andresen & Rosenberg, 2018). Hence, pain is a major nursing issue and identifying appropriate nursing care for this is critical for recovery of Peter.
The second high priority nursing problem identified for Mr. Peter is risk of infection evidenced by symptom of green purulent discharge from wound dressing and high level of WBC and neutrophils. Such discharge from dressing is a warning signal for infection in the surgical site. Purulent discharge from the wound along with pain is signs that indicate major wound infection (Sattar et al., 2019). There is a need to engage in immediate wound care and implement proper nursing interventions to reduce infection. As Mr. Peter has been operated by open mesh inguinal, this might be one of the reasons for wound infection. Salamone et al. (2017) gives the evidence that wound infections following hernia repair mostly occurs because of mesh infection and systemic complications. Hence, there is a need to consider different measures to control surgical site infection and prevent complications for patient. Appropriate wound care option will also be necessary to ensure that wound dressing is dry and the healing process continues in a normal manner.
The third high priority nursing problem is swelling of the red calf. Although of the surgical area is common after a hernia surgery, however it may create discomfort for patient during movement. Hence, some immediate interventions need to be identified that reduces swelling. This can reduce postoperative morbidity and accelerate recovery for Mr. Peter.
Based on the analysis of key problems found in Mr. Peter, the priority goal of care care is to accelerate wound healing and reduce surgical site infection, reduce pain score of patient and alleviate discomfort caused due to swelling of the left calf.
To achieve the above goals of care for Peter, addressing all the three nursing problem areas are important. To reduce pain score and provide relief to patient, it will be necessary to implement pharmacological intervention along with routine assessment and observation of patient. First line treatment options for pain can include administration of conventional analgesics, non-steroidal anti-inflammatory drugs (NSAIDs) and elective serotonin reuptake inhibitor (Andresen & Rosenberg, 2018). These medications can provide immediate relief from pain and provide comfort to patient. Pain in patients after hernia repair occurs due to neuropathic aetiology. Garimella and Cellini (2013) give the evidence that various pain modalities are available to treat hernia repair pain. NSAIDs and opioids are common analgesic therapies. Although opioid is associated with side-effects. However, NSAIDs has the potential to reduce the opioid side effects and provide relief to patient too. It can act by inhibiting the production of prostaglandins resulting in initiation of anti-inflammatory response. However, before deciding to use this drug for pain relief, the nurse should consider medical history of patient as there is risk of bleeding with NSAIDs drug. Proper collaboration with physical regarding appropriate drug is important.
Apart from pharmacological management of pain, the nurse should also focus on use of non-pharmacological techniques like cold packs and distractions to ease acute post surgical pain. Distractions like talking with patient or engaging them in activities of interest like music can provide benefit to patient. It is an evidence-based non-pharmacological strategy to manage pain (Komann et al., 2019). In addition, to address surgical site infection and delayed wound healing for patient, it is necessary to implement appropriate wound care regimen and provide antibiotic prophylaxis to Peter. As the patient is at risk of impaired skin integrity due to discharge from dressings and elevate temperature near the left calf, there is a need to initiate process the breaks the chain of infection. This involves use of aseptic method during dressing changes and care of the wound. The main rationale for using aseptic technique is to decrease the chance of transmission of infection due to contact with purulent discharge (Heal et al., 2016). To ensure that the wound is dry, selecting appropriate dressing is also important as it can enhance healing rate. Low-adherent transparent polyurethane film dressing can be used as it has the advantage of allowing for inspection of the wound, maintaining moist wound environment and maintain optimal wound temperature (Vowden & Vowden, 2017). Another important intervention is to initiate antibiotic prophylaxis to treat the possibility of infection due to mesh material (Narkhede et al., 2015). To treat the third priority problem of swelling or post surgical edema, it is necessary to apply ice pack. This can help to reduce edema and reduce undue pressure on incision site.
The evaluation of the effectiveness of the above nursing care strategies will be done by subsequent assessment of pain following analgesic therapy. Comprehensive pain assessment can be done by use of standard tools that gives idea on the severity, location and frequency of pain. Reduction in pain score will be an indication that the nursing care strategies are successful. In addition, no drainage from the surgical wound dressings and reduction in swelling will indicate reduction of infection and proper wound healing process.
On reflecting on the activity of developing care strategies for Mr. Peter using the clinical reasoning cycle, it has been learnt that surgical procedure and tissue injury during surgery increases pain related morbidity for patient. Preoperative assessment and management of surgical outcome is crucial to provide relief from pain due to mesh. In future nursing practice, antibiotic prophylaxis should be prioritized for patient with open mesh hernia repair.
Conclusion:
To conclude, the clinical reasoning cycle steps helps to systematically analyse patient information and identify key health concerns in the case study. Three major priority nursing problems identified for Mr. Peter included pain, risk of infection and postoperative oedema. Evidence based nursing care strategies were employed along with evaluation of major outcomes to support recovery and quick wound healing of patient.
References:
Andresen, K., & Rosenberg, J. (2018). Management of chronic pain after hernia repair. Journal of pain research, 11, 675.
Butterworth, M., & Payne, T. (2017). Surgical infections. In Complications in Foot and Ankle Surgery (pp. 69-87). Springer, Cham.
Carvalho, E. C. D., Oliveira-Kumakura, A. R. D. S., & Morais, S. C. R. V. (2017). Clinical reasoning in nursing: teaching strategies and assessment tools. Revista brasileira de enfermagem, 70(3), 662-668.
Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based education to’flip’the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, The, 33(2), 29.
Garimella, V., & Cellini, C. (2013). Postoperative pain control. Clinics in colon and rectal surgery, 26(03), 191-196.
Heal, C. F., Banks, J. L., Lepper, P. D., Kontopantelis, E., & van Driel, M. L. (2016). Topical antibiotics for preventing surgical site infection in wounds healing by primary intention. Cochrane Database of Systematic Reviews, (11).
Jain, S., Teasdale, G. M., & Iverson, L. M. (2019). Glasgow Coma Scale. In StatPearls [Internet]. StatPearls Publishing.
Komann, M., Weinmann, C., Schwenkglenks, M., & Meissner, W. (2019). Non-Pharmacological Methods and Post-Operative Pain Relief: An Observational Study. Anesthesiology and pain medicine, 9(2).
Narkhede, R., Shah, N. M., Dalal, P. R., Mangukia, C., & Dholaria, S. (2015). Postoperative mesh infection—still a concern in laparoscopic era. Indian journal of surgery, 77(4), 322-326.
NHS (2019). What is the body mass index (BMI)?Retrieved from: https://www.nhs.uk/common-health-questions/lifestyle/what-is-the-body-mass-index-bmi/
Salamone, G., Licari, L., Augello, G., Campanella, S., Falco, N., Tutino, R., … & Porrello, C. (2017). Deep SSI after mesh-mediated groin hernia repair: management and outcome in an Emergency Surgery Department. Il Giornale di chirurgia, 38(1), 41.
Sattar, F., Sattar, Z., Zaman, M., & Akbar, S. (2019). Frequency of Post-operative Surgical Site Infections in a Tertiary Care Hospital in Abbottabad, Pakistan. Cureus, 11(3).
Vaughan-Shaw, P. G., Saunders, J., Smith, T., King, A. T., & Stroud, M. A. (2013). Oedema is associated with clinical outcome following emergency abdominal surgery. The Annals of The Royal College of Surgeons of England, 95(6), 390-396.
Vowden, K., & Vowden, P. (2017). Wound dressings: principles and practice. Surgery (Oxford), 35(9), 489-494.
Wang, T., Wang, H., Yang, D. L., Jiang, L. Q., Zhang, L. J., & Ding, W. Y. (2017). Factors predicting surgical site infection after posterior lumbar surgery: a multicenter retrospective study. Medicine, 96(5).
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