NRSG370 Clinical Integration: Specialty Practice
Question:
The supplementary assessment will take the form of case study, in the field of medical-surgical nursing, which discusses the provision of ethical, legal, evidence-based, holistic person-centred care including the establishment of realistic and relevant goals through the theoretical examination of a particular nursing specialty case study using the Clinical Reasoning Cycle (Levett-Jones, 2013).
Case study instructions:
Utilise the Clinical Reasoning Cycle (Levett-Jones, 2013) (a clinical decision making
framework) to plan and evaluate person-centred care:
- Considering the person’s situation, collect, process and present related health information;
- Identify and prioritise at least three (3) nursing problems/issues based on the health assessment data that you have identified for the person at the centre of care;
- Establish goals for priority of nursing care as related to the nursing problem/issues identified;
- Discuss the nursing care of the person, link it to assessment data and history;
- Evaluate your nursing care strategies to justify the nursing care provided;
Reflect on the person’s outcomes.
Case Study Details – Melody King, 36, Peritonitis following ruptured :
Ms. Melody King presented to the Emergency department with 2-3 days of severe Right Lower Quadrant abdominal pain, which required emergency laparoscopic surgery for removal of a ruptured appendix. She has a past medical history of asthma and depression, with her current prescribed and compliant medications list which includes Ventolin, Seretide, Sertraline.
Melody’s observations were as follows:
- BP 95/45mmHg
- HR 120
- Temp 38.3°Celcius
- RR 22/min and shallow
- SpO2 95% on room air
She complained of increasing nausea and centralised abdominal pain 7-8 on a scale of 0 to10. Physical assessment showed a distended abdomen and generalised abdominal guarding. To investigate her condition further, pathology results reveal a raised white blood cell (WBC) count and CRP. You are the RN caring for Melody post-operatively on the surgical ward.
Answer:
Patient case study
Clinical reasoning cycle is the approach that helps nurses to collect clues, process the data or information, come to the knowledge of the patient issues or the situation, planning and implementing the interventions, evaluating the outcomes, and reflecting on and learning from the process (Levett-Jones, 2013). The patient in the given case study had severe right lower quadrant abdominal pain and has a medical history of depression and asthma. She was taking Seretide and Sertraline medicine. She was also suffering from increasing pain and nausea. Her investigations results revealed that she has increased levels of WBC count and CRP. The high WBC count may be associated with the Infections (Anaya, et al., 2005) inflammation, stress, trauma, certain disease and trauma (Vozarova, Weyer, Lindsay, Pratley, Bogardus, & Tataranni, 2002). It can also occur due to the adverse effects of a drug, bone marrow diseases and the impaired immune system that abnormally increases the WBC production (B Kul’chyns’kyi, Kyjenko, Zukow, & Popovych, 2017). The conditions like acute lymphocyte leukemia, chronic lymphocytic leukemia, myelofibrosis, polycythemia Vera, smoking, stress, tuberculosis, allergy, whooping cough, and chronic myelogenous leukemia stimulate the elevations of WBC production (Janz, & Hamilton, 2010).
Clinical reasoning is frequently mixed up with the words ‘clinical judgment’, ‘problem-solving’, decision making’ and ‘critical thinking’ (Lapkin, Levett-Jones, Bellchambers, & Fernandez, 2010). Although in some means these words are comparable to critical reasoning, clinical reasoning is the recurring procedure that frequently leads to a sequence or spiral of related clinical encounters” (Levett-Jones, 2013). It was originally proposed by Levett-Jones in 2013.
The vital signs of the patient suggested that she has 95/45 mmHg blood pressure 120 heart rate; temperature was 38.3-degree Celsius and RR of 22/min and shallow. Her vital sign reveals that she has 95/45 mmHg BP, 120 HR and 38.3 degrees Celcius body temperature, 22/min and shallow RR and 95 percent SpO2. By analyzing her vital signs it can be seen that she has lower blood pressure and increased heart rate. Her body temperature is also little higher than normal, elevated respiration rate than the usual range and her peripheral capillary oxygen saturation was normal.
The Melody’s pain might be associated with the adverse reaction of Seretide and the increase nausea issues may be caused due to the adverse reaction of Sertraline medicine (MyDr, 2017). The increased level of WBS diagnosed in her pathology results, this particular issue might be associated with the worsening of the insulin sensitivity and patient’s stress and trauma. The increased level of CRP is associated with various types of disease and health conditions. However According to Elliott et al. (2009) there is no association between the disease (coronary heart disease) and increase level of CRP.
Ms. Melody has different issues that are noticeable and concerning, however, three of the most important nursing concerns are her depression, abdominal pain and increased level of WBC and CRP. As she mentioned before the surgery that she has a history of asthma and depression the depression related issue is a major concern that needs to be treated. Patients undergo surgery; often feel anxiety and stress that ultimately results in depression due to the long hospital stay (Wetsch et al., 2009). This might be a problem for nurses to deal with this kind of patient in the emergency department. Ms. Melody also suffering from the abdominal pain which she has reported at the time of hospital visit and it is increasing continually. This is the second most important nursing concern that should be dealt with immediately. The level of pain she has reported was about 7 to 8 on the scale of 10 which is considered high. This may become the major issues for the patient to cooperate in the treatment process and specifically problematic for the nurses. The third most important nursing problem is the increased level of white blood cells and c receptor protein.
The goals for the priority of nursing care can be established by using the nursing skills and knowledge. The goal establishment for the patient should include implementing the intervention that can help the ongoing treatment to decrease the pain. The other intervention like empathy, emotional support, and therapeutic relationship can be included in the goals. Assessment of pain and vital signs should be included in the goal setting. The interventions like analyzing the WBC and CRP levels and reporting of any implications should be included in the goal setting for the patient in order to achieve the health target for the patient.
The patient should be dealt with empathy and care in order to decrease the issues of depression and anxiety. The patient has been suffering from pain for a long time; therefore, the goals should be established according to that only. The emotional support is the key strategy that should be included in the goals set for the patient. This might help Ms. Melody to decrease the depression related issues (Pepys, & Hirschfield, 2003). The nursing care to deal with the pain related issues includes, regular assessment of pain to analyze the pain level, providing muscle relaxants or/and analgesics that are clinically appropriate, and assessment of bowel movement such as color, frequency and amount (Bell, & Duffy, 2009). She can also be proved with acetaminophen and healing pads to decrease the pain (Eryilmaz, & Ozdemir, 2009).
The intake and output should be reported in the patient health information sheet. The nurse should also assess the abdominal distension, and reporting the changes in the size and quality as appropriate. Patients suffering from abdominal pain might have a reduced craving, be NPO, or do not want to consume fluids (Schultes, Ernst, Wilms, Thurnheer, & Hallschmid, 2010). A nurse should Assess and endorse appropriate fluid stability, which may need notifying the provider of a reduced oral consumption and require for intravenous liquids to uphold fluid balance (Hastings, & Powers, 2011). To deal with the increased level of WBC and CRP the nursing interventions should include regularly examining the level of WBC and CRP and report to the physician (Malik, & Bari, 2009). The CRP tests and WBS tests should be performed in the presence of specialised and authorized health practices; it should be carried out regularly according to the doctor’s recommendation (Malik, & Bari, 2009). The nurses should report and record the results of the tests in the patient health information sheet in order to identify whether the levels of both elements balanced or not (Malik, & Bari, 2009). The nurses should also maintain the surrounding environment of the patient infections free as the health concerns might be worst in the case Melody got infected (Pepys, & Hirschfield, 2003). The registered nurse should also assess the body temperature of the patient every four hours and report to the doctor if any temperature high than 100.4 identified. They can also administer the prescribed antipyretics. These interventions might help in the treatment process to maintain the level of WBC and CRP. Maintain a record of the tests help to physicians to assess that is the treatment for the particular issue is working or not. Medicines like Anticonvulsants, Arsenicals (Kuepfer et al., 2011), Chlorpromazine, and Clozapine can be administered according to the doctor’s recommendations (Cohen, & Monden, 2013).
The nursing cares strategies are established to deal with the patients are highly linked with the interventions provided. The nursing strategies made for the patient was goal setting for patient depression. Using empathy, therapeutic relations and emotional support were the strategies can be well connected to the interventions that are provided. The assessment of vital sign helped in managing the symptoms and risks associated with the present condition of the patient. Analyzing the level of the pain was a good strategy to deal with the abdominal pain of the patient. The therapeutic relationship was the strategy that also helped in the care provided to the patient. Being in an emergency department for the patient, this might increase the anxiety and fear and issues of trust and faith in holistically care. Implementing the therapeutic relationship strategy in the care helped in gaining the co-orparairon of the patient in the treatment process. It also helps in making a good communication with the patient so that she can easily express her feelings about the pain, and health condition.
The goals or aims of the health that are already set for the patient are well achieved successfully by implementing the strategies and care. The temperature has been reduced to 37.5-degree centigrade and issues related to depression and anxiety was decreased. The patient is feeling anxiety and stress very less. Maintaining the surrounding environment of the patient infection free, helped the person to maintain the WBC and CRP levels on the normal range. The levels of WBC and CRP has been decreased to the normal range within 20 hours as we used the strategy like administration of medicines like Anticonvulsants, Arsenicals, and Chlorpromazine, regular check-ups for the levels of WBC and CRP. The abdominal pain which was the main concerns of nursing care is reduced by using strategies like pain assessment, healing pain, and acetaminophen. The paint has been evaluated for the pain after the successful implementation if the care interventions and the results are good. The pain levels were checked by using the Numeric rating scale and found to be reduced to 2 to 3 which was previously recorded 7 to 8. Analyzing the outcomes of the patient it can be concluded that by using the strategies and care the health goals are achieved successfully.
References
Anaya, D. A., Mcmahon, K., Nathens, A. B., Sullivan, S. R., Foy, H., & Bulger, E. (2005). Predictors of mortality and limb loss in necrotizing soft tissue infections. Archives of Surgery, 140(2), 151-157.
B Kul’chyns’kyi, A., Kyjenko, V. M., Zukow, W., & Popovych, I. L. (2017). Causal neuro-immune relationships at patients with chronic pyelonephritis and cholecystitis. correlations between parameters EEG, HRV and white blood cell count. Open Medicine, 12(1), 201-213.
Bell, L., & Duffy, A. (2009). Pain assessment and management in surgical nursing: a literature review. British Journal of Nursing, 18(3), 153-156.
Cohen, D., & Monden, M. (2013). White blood cell monitoring during long-term clozapine treatment. American Journal of Psychiatry, 170(4), 366-369.
Elliott, P., Chambers, J. C., Zhang, W., Clarke, R., Hopewell, J. C., Peden, J. F., & Coin, L. (2009). Genetic loci associated with C-reactive protein levels and risk of coronary heart disease. Jama, 302(1), 37-48.
Eryilmaz, G., & Ozdemir, F. (2009). Evaluation of menstrual pain management approaches by Northeastern Anatolian adolescents. Pain Management Nursing, 10(1), 40-47.
Hastings, R. S., & Powers, R. D. (2011). Abdominal pain in the ED: a 35-year retrospective. The American journal of emergency medicine, 29(7), 711-716.
Janz, T. G., & Hamilton, G. C. (2010). Anemia, polycythemia, and white blood cell disorders. Rosen’s emergency medicine: concepts and clinical practice, 1586-605.
Kuepfer, I., Hhary, E. P., Allan, M., Edielu, A., Burri, C., & Blum, J. A. (2011). Clinical presentation of Tb rhodesiense sleeping sickness in second stage patients from Tanzania and Uganda. PLoS neglected tropical diseases, 5(3), e968.
Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. (2010). Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical simulation in Nursing, 6(6), e207-e222.
Levett-Jones, T., (2013). Clinical reasoning (1st ed.). Australia: Pearson Education Australia.
Malik, A. A., & Bari, S. U. (2009). RETRACTED ARTICLE: Conservative Management of Acute Appendicitis. Journal of gastrointestinal surgery, 13(5), 966-970.
MyDr (2017). Seretide. Retrieved from: https://www.mydr.com.au/medicines/cmis/seretide
Schultes, B., Ernst, B., Wilms, B., Thurnheer, M., & Hallschmid, M. (2010). Hedonic hunger is increased in severely obese patients and is reduced after gastric bypass surgery–. The American journal of clinical nutrition, 92(2), 277-283.
Vozarova, B., Weyer, C., Lindsay, R. S., Pratley, R. E., Bogardus, C., & Tataranni, P. A. (2002). High white blood cell count is associated with a worsening of insulin sensitivity and predicts the development of type 2 diabetes. Diabetes, 51(2), 455-461.
Wetsch, W. A., Pircher, I., Lederer, W., Kinzl, J. F., Traweger, C., Heinz-Erian, P., & Benzer, A. (2009). Preoperative stress and anxiety in day-care patients and inpatients undergoing fast-track surgery. British journal of anaesthesia, 103(2), 199-205.
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