Clinical Reasoning Cycle Case Study

This case study will demonstrate the care of MS. Melody by the nursing staff using the clinical reasoning cycle, to respond to her unstable clinical manifestation and ensure that there is a positive outcome for her as a patient, during her hospitalization in the surgical ward (Levett-Jones, 2013).

Consider patient situation.

Ms.Melody is a 36-year old female who presents herself to the emergency department (ED), after having 2-3 days of severe right lower quadrant abdominal pain which is diagnosed, and she is immediately taken to theatre for an acute appendicectomy. After the laparoscopic removal of her appendix, she develops peritonitis which is common to patients who have had a ruptured appendix and require immediate treatment (van Rossem, Schreinemacher, Treskes, van Hogezand & van Geloven, 2014).

Collect cues and information.

Ms.Melody has a relevant past medical history of asthma and depression. The staff should be aware of what triggers her asthma and consider how often she takes the Ventolin, Seretide for asthma and sertraline an antidepressant which is a selective serotonin reuptake inhibitors (SSRIs), (MIMS online, 2019). These are all her regular medications. she is coming to the ward for treatment of peritonitis which is an infection to the inner lining of the peritoneum and needs immediate medical intervention as it is life threatening (Horvath et al., 2016).

Ms. Melody’s vital signs given are not very stable as she is hypotensive with a blood pressure(BP) at 95/45, tachycardic at 120bpm and febrile 38.5, her respiration rate is 22 breaths per minute and shallow. She had nausea, but no vomiting is reported. Pain levels are reported to be 7-8/10 on a scale of 0-10. Physical assessment done show a distended abdomen which she was guarding. Pathology results show an elevated level of white blood cells and c-reactive protein. Drake & de C. Williams, (2017), describe acute pain as the fifth vital sign while Gélinas, (2016), explanation of pain as an uncomfortable sensory and emotional experience which is related to an actual or potential tissue damage (Gélinas, 2016). There is a deficit of information regarding Melody which should have been included to get a complete scenario of her situation and provide holistic care. This information includes her social status and whether she lives alone or has family who might depend on her during hospitalization. The obs given were not specific as no time line is given of when they were taken.

Process information.

For Melody to be considered stable, her vital signs must be within a certain acceptable range. According to Kuiken (2016), Vital signs (VS) are used to measure a body’s physiological functioning. According to Limbe, Currey & Considine, (2016), normal vital sign range is RR12-22 breaths per minute, oxygenation above 95%, systolic blood pressure 90-139mmHg, heart rate 60-100 beats per minute for an adult and a Glasgow coma scale of 15 to a patient who is conscious and orientated to time, place and person. The body core temperature should be between 35-37.8c (Lambe, Currey & Considine, 2016).

 Vital signs abnormalities can be a clear indication of a deterioration of Melody’s condition within minutes to hours (Mok, Wang, Cooper, Ang & Liaw, 2015). Considering Ms. Melody’s age,no past medical history of hypotension, is tachycardic and has an elevated white blood cell count and c-reactive protein, all these vital signs are abnormal and are clear markers of a patient who has sepsis and her body’s response to the infection (Hayden et al., 2016). Sepsis according to Cheung et al., (2015) is a clinical condition that results from a dysregulated inflammatory response to an infection (Cheung et al., 2015). For Melody to be considered as having sepsis, there must be two or more vital sign abnormalities present and a culture-proven or an identified site for infection. These include temperature above 38.3 C or below 36°C,heart rate above 90beats/minutes, a respiratory rate above 20breaths/minutes and an elevated white blood cell and c-reactive protein (Cheung et al., 2015).Kuiken (2016) recommends that the nursing staff in Melody’s care, should assess, identify, monitor and document her physiological status and report all vital signs abnormalities to the treating physician (Kuiken,2016).

The elevated White Blood Cells and C-reactive Protein are inflammatory markers (Gans et al., 2015).Melody’s pathology results are indicative of an acute abdomen infection and inflammatory response(Gans et al.,2015) ……. also argues that elevated levels of white blood cells and c-reactive protein are not very specific and their diagnostic precision for a specific diagnosis is low, but they are still used to triage patients who may require urgent imaging to determine cause for elevation(Gans et al., 2015).

Identify problems /issues.

1.pain-Gélinas (2016), describes pain as an unpleasant emotional and sensory experience which is associated with potential or actual tissue damage. Melody reports 7-8/10 pain levels using the 0-10 numerical pain assessment tool. The Royal Children’s Hospital(RCH)2015, concurs that, any changes in physiological indicators of any patient should be incorporated when assessing pain. These changes include an increase or a decrease in heart rate, changes in respiratory rate and pattern, observed work of breathing and shortness of breath. Melody is also observed to be guarding her abdomen which is a clear indication that she is in a lot of pain and the pain location. Different tools of pain assessment should be used to assess and reassess her pain levels to identify onset, duration, severity, location, quality, quantity and provocation so that there is accurate documentation and appropriate pain interventions given to Melody (Levett-Jones, 2013).

2.Nausea– Post-operative nausea and vomiting (PONV) is often the cause of anxiety and great distress to patient (Bhakta et al., 2016). Excessive post-operative nausea and vomiting (PONV) may lead to dehydration, electrolyte imbalance and feared complications such as pulmonary aspiration syndrome. Nausea and vomiting may have financial implications in that, day procedures may turn into hospitalization of a patient if nausea and vomiting is not resolved at the expected time of discharge (Brown & Edwards, 2013). A patient may express dissatisfaction with the surgical process in instances where there is prolonged nausea and vomiting after the surgical procedure (Brown & Edwards, 2013).Factors that predispose Ms. Melody to post-operative nausea and vomiting (PONV) include her gender, anesthetic agents used during the removal of her appendix, time she took during surgery and the location of the surgical incision which in her case is abdominal and any past history of having motion sickness or nausea and vomiting(Brown & Edwards, 2013).

3.sepsis-Melody is febrile, her abdomen appears distended, tachycardic and has ongoing nausea. These are clinical manifestations of a peritonitis which is fatal. Ms. Melody is being admitted because of peritonitis which is more than likely to have been caused by a ruptured appendix and releases harmful enzymes, bile and bacteria into the sterile peritoneum. The intestinal contents produce an immediate chemical peritonitis followed by a bacterial peritonitis in a few hours (Brown & Edwards, 2013).

Establish goals

Resolve the abdominal pain being experienced by Ms. Melody or at least ensure pain levels are minimized to a comfortable level so that she can resume and undertake activities of daily living without much discomfort as soon as possible.

Resolve nausea and vomiting episodes so that Ms. Melody can tolerate fluids intake to restore her blood pressure to normal parameters within an hour.

Treat the cause of the infection and inflammation as per the hospital sepsis protocol, ensure the white blood cell count and the c-reactive protein is back to the normal limits.

Take action

Poor acute pain management can lead to adverse consequences (Levett-Jones, 2013). These include postsurgical complications and prolonged hospital stays, which increase health care costs and patient suffering (Drake & de C. Williams, 2017).

As the primary nurse, the main role after receiving Ms. Melody back into the ward is to manage her abdominal pain levels and ensure that she is comfortable (Drake & de C. Williams, 2017). This will work if there is proper pain assessment and dispensing nurse-initiated analgesia (Levett-Jones, 2013).

Russo et al., (2016) advocates for continuous use of intravenous (IV) infusion of opioids for postoperative pain as the best pain relief option for a patient like Ms. Melody who is a high -risk patient and needs intensive postoperative care. The most commonly used drugs are fentanyl and morphine (Russo et al.,2016).

Nausea-antiemetics such as intravenous(IV)ondansetron may be prescribed by the physician and administered to prevent and resolve nausea and vomiting episodes (MIMS online, 2019). Fluids may be charted and given to Ms. Melody to replace any lost fluids through vomitus and resolve the hypotension (Bhakta et al., 2016). Nursing care should include, weaning her with sips of water and dry foods as much as she can tolerate (LeMone, 2014). Maintaining an accurate fluid balance chart to monitor fluid intake and output and then use it to establish the necessary fluid replacement therapy. Ms. Melody should be encouraged to do deep breathing exercises which assist in voluntary suppression of the vomiting reflex (LeMone, 2014).

Ms. Melody vital signs are consistent to a patient who has sepsis and therefore a sepsis treatment protocol should be initiated as per the hospital policy as it is life threatening and a time-dependent process (Hayden et al., 2016). Van Rossem, Schreinemacher, van Geloven & Bemelman, (2015), describes the first 12hours as the most crucial in a patient like Melody who presents to the ED with the mentioned vital signs. She should have a very quick and accurate prognosis, diagnosis and then appropriate antimicrobial therapy commenced without delay.

The Antimicrobial Prescribing clinical guideline, (2018) warns that, if sepsis is detected too late, and there is delay in initiating antibiotic treatment, Ms. Melody’s condition may worsen and could lead to serious sepsis or even septic shock (The Antimicrobial Prescribing clinical guideline,2018). Hayden et al., (2016) recommends that antibiotics are to be administered within the first 30min postdiagnosis or within the first 9-12hours (Hayden et al., 2016). Hayden et al., (2016) expresses how sepsis causes high death rates in patients who present to the Emergency department. Flum (2015), explains how having a complicated laparoscopic appendectomy as Ms. Melody has had, is associated with an increased risk of surgical-site infection and a much slower recovery time(Flum,2015). Ms. Melody will be receiving a 3-5days course of antibiotics such as cephazolin and metronidazole (Hayden et al.,2016). Fluid resus is also recommended to resolve the hypotension which may be due to vomiting and fluid loss. If not resolved a peritoneal drainage is recommended to prevent further post-appendectomy infection and remove all the purulent fluid leakage from the peritoneum(Cho et al., 2016).

Evaluate outcomes

Melody should be assessed and reassessed on pain levels and until she reports comfortable pain levels which enable her to undertake her daily activities of living (Levett-Jones, 2013).Ms. Melody’s self-report on pain remains the best option to identify whether the pain has diminished but the nursing staff should also use behavioral pain scale and critical-care pain observation tool to evaluate outcome of analgesics, other therapeutic options used and establish effectiveness(Gélinas, 2016).

Repeat blood cultures to establish whether the infection has resolved by showing a normal reading to white blood cell count and the c-reactive protein. Recheck the vital signs which should be normalizing as the infection is resolved (Gans et al., 2015).

Ms. Melody should be reassessed for signs of nausea and vomiting which is subjective and continuous monitoring of fluid intake and output adhered. Abdomen distension should be reassessed to ensure it has gone back to normal as it is a common stimulus for nausea and more antiemetics administered if needed (Le Mone, 2014).

Reflection

Next time I will ensure that there is proper handover of the patient as there is missing information about Ms. Melody which is important in providing holistic care such as the other set of vital signs since her admission to the hospital.

I should have asked for all the necessary documentation related to her nursing care for referrals to the relevant multidisciplinary health team workers who should have been in her care.

In conclusion, I quite understand how as a graduate nurse, time management and timely interventions are important in an acute setting. Proper and accurate documentation, team nursing and proper communication would distinguish between life and death to a patient (Levett-Jones, 2013).

Clinical reasoning and critical thinking ensures that nurses will develop some positive attributes which ensures that patients are safe and provided with holistic care by nurses who are open minded and safe to practice (Levett-Jones, 2013).

      References

• Antimicrobial Prescribing clinical guideline. (2017). Retrieved from  https://www.sahealth.sa.gov.au/wps/wcm/connect/6bb523804358edbd883b9              ef2cadc00ab/Surgical+Antimicrobial+Prophylaxis_v2.0_23112017.pdf?MO              D=AJPERES&CACHEID=ROOTWORKSPACE-              6bb523804358edbd883b9ef2cadc00ab-msq.2DQ
• Bhakta, P., Ghosh, B., Singh, U., Govind, P., Gupta, A., & Kapoor, K. et al. (2016).               Incidence of postoperative nausea and vomiting following gynecological               laparoscopy: A comparison of standard anesthetic technique and propofol               infusion. Acta Anaesthesiologica Taiwanica, 54(4), 108-113. doi:               10.1016/j.aat.2016.10.002
• Brown, D., & Edwards, H. (2013). Lewis’s Medical Surgical Nursing (3rd ed.).               London: Elsevier Health Sciences APAC.
• Cheung, W., Chau, L., Mak, I., Wong, M., Wong, S., & Tiwari, A. (2015). Clinical               management for patients admitted to a critical care unit with severe sepsis or               septic shock. Intensive and Critical Care Nursing, 31(6), 359-365. doi:               10.1016/j.iccn.2015.04.005
• Cho, J., Park, I., Lee, D., Sung, K., Baek, J., & Lee, J. (2016). Antimicrobial               treatment after laparoscopic appendectomy for preventing a post-operative               intraabdominal abscess: A Prospective Cohort Study of 1817 patient.               International Journal of Surgery, 27, 142-146. doi:               10.1016/j.ijsu.2016.01.069
• Database of prescription and generic drugs, clinical guidelines | MIMS online.               (2019). Retrieved from https://www.mims.co.uk/
• Drake, G., & de C. Williams, A. (2017). Nursing Education Interventions for               Managing Acute Pain in Hospital Settings: A Systematic Review of Clinical               Outcomes and Teaching Methods. Pain Management Nursing, 18(1), 3-15.               doi: 10.1016/j.pmn.2016.11.001
• Flum, D. (2015). Acute Appendicitis — Appendectomy or the “Antibiotics First”               Strategy. New England Journal of Medicine, 372(20), 1937-1943. doi:               10.1056/nejmcp1215006
• Gans, S., Atema, J., Stoker, J., Toorenvliet, B., Laurell, H., & Boermeester, M.               (2015). C-Reactive Protein and White Blood Cell Count as Triage Test               Between Urgent and Nonurgent Conditions in 2961 Patients with Acute               Abdominal Pain. Medicine, 94(9), e569. doi:10.1097/md.0000000000000569
• Gélinas, C. (2016). Pain assessment in the critically ill adult: Recent evidence and               new trends. Intensive and Critical Care Nursing, 34, 1-11. doi:               10.1016/j.iccn.2016.03.001
• Hayden, G., Tuuri, R., Scott, R., Losek, J., Blackshaw, A., & Schoenling, A. et al.               (2016). Triage sepsis alert and sepsis protocol lower times to fluids and               antibiotics in the ED. The American Journal Of Emergency Medicine, 34(1),               1-9. doi: 10.1016/j.ajem.2015.08.039
• Horvath, P., Lange, J., Bachmann, R., Struller, F., Königsrainer, A., & Zdichavsky,               M. (2016). Comparison of clinical outcome of laparoscopic versus open               appendectomy for complicated appendicitis. Surgical Endoscopy, 31(1), 199-              205. doi: 10.1007/s00464-016-4957-z
• Lambe, K., Currey, J., & Considine, J. (2016). Frequency of vital sign assessment               and clinical deterioration in an Australian emergency department.               Australasian Emergency Nursing Journal, 19(4), 217-222. doi:               10.1016/j.aenj.2016.09.001
• LeMone, P. (2014). Medical-surgical nursing (2nd ed., pp. 686-688). Australia:               Pearson Australia.
• Levett-Jones, T. (2013). Clinical reasoning. Frenchs Forest, N.S.W.: Pearson               Australia.
• Mok, W., Wang, W., Cooper, S., Ang, E., & Liaw, S. (2015). Attitudes towards vital               signs monitoring in the detection of clinical deterioration: scale development               and survey of ward nurses. International Journal For Quality In Health Care,               27(3), 207-213. doi: 10.1093/intqhc/mzv019
• Russo, A., Grieco, D., Bevilacqua, F., Anzellotti, G., Scarano, A., & Scambia, G. et               al. (2016). Continuous intravenous analgesia with fentanyl or morphine after               gynecological surgery: a cohort study. Journal of Anesthesia, 31(1), 51-57.               doi: 10.1007/s00540-016-2268-0
• The Royal Children’s Hospital Melbourne. (2015). Clinical Guidelines (Nursing):               PainAssessmentandMeasurement.Retrievedfrom               https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pain_Asse              ssmen_and_Measurement
• van Rossem, C., Schreinemacher, M., Treskes, K., van Hogezand, R., & van               Geloven, A. (2014). Duration of antibiotic treatment after appendicectomy for               acute complicatedappendicitis.BritishJournalOfsurgery,101(6),715-719.doi:               10.1002/bjs.9481 van Rossem, C., Schreinemacher, M.,
• van Geloven, A., & Bemelman, W. (2015). Antibiotic Duration After Laparoscopic               Appendectomy for Acute Complicated Appendicitis. JAMA Surgery, 151(4),               323. doi: 10.1001/jamasurg.2015.4236