Clinical Integration Specialty Practice
Ms. M. reported to the Emergency Department following severe Right Lower Quadrant abdominal pain 2-3 days. Her treatment included with an emergency laparoscopic surgery to amputate her ruptured appendix. Her medical history revealed that she has asthma and depression. She is currently on Ventolin, Seretide and Sertraline to which she very compliant. On observation, M. presented with BP 95/45mmHg, HR 120, Temp 38.3°Celcius, RR 22/min and shallow and SpO2 95% on room air. She also reported nausea and centralised abdominal pain of 7-8 on a scale of 0 to10. The physical assessment indicated a bloated abdomen and general abdominal guarding. Further pathological examinations revealed elevated white blood cell (WBC) count and CRP.
Ms. M.’s nursing care will have to address her current medication as well as post-surgery medical needs. To ensure that is achieved, it is imperative that the nursing care provider makes use of Clinical Reasoning (CR) Cycle (Levett-Jones, 2013). Despite the lack of distinction among the eight steps of the CR cycle, they offer a valuable input in addressing nearly all the concerns of the patients. The CR cycle will confer various advantages to both the nurse and Ms. M.. To start with, it spells out ‘five rights’ of clinical reasoning which the nursing officer will use to gather the right cues necessary for appropriate nursing care at the right time anchored on correct interpretations (Levett-Jones et al., 2010).
Ms. M. belongs to a category of patients with complex health problems whose likelihood of becoming more seriously ill during hospitalization is higher. Nursing practitioners with a poor grasp of the CR skills are likely to fail in detecting imminent patient’s poor prognosis and likely to fail in rescuing them. It is imperative to prioritize these problems because addressing them all at once is tantamount to adverse patient outcomes. Management of pain secondary to the fall will take the first priority. The second priority will be given to addressing Ms. M.’s depression. The third priority will encompass guarding against complications through inter-disciplinary and multidisciplinary cooperation.
There are various post-operative goals that the nurse will need to focus on to enhance Ms. M.’s faster recovery as well as seal any possible loopholes for complications in the spirit of meeting the priorities aforementioned. These goals are outlined below:
i) Obtaining the right and relevant data, assess her general health; assess her health care needs during day one of hospitalization.
ii) Ms M.’s severe Right Lower Quadrant abdominal pain improves during the first week of hospitalization.
iii) Restore presence of bowel sounds within the first week of hospitalization
iv) Impart appropriate health teachings and more importantly undertake suitable nursing care in conjunction with Ms. M. ’s post-operative peritonitis following laparoscopic surgery for removal of a ruptured appendix.
The nurse will need to examine the pre-operative intravenous cannula to determine its suitability or lack thereof. A replacement of the cannula can be done to lessen the chances of infections during fluid replacement. Monitoring of vital signs and baseline investigations according to the first and second objectives would also follow. This also outlined in the second phase of CR cycle (Levett-Jones et al., 2009). It would include BP, HR 120, Temp, RR, and SpO2. Further, the pre-operative nasogastric tube is cleaned to ensure the nil per oral (NPO) (Ruffolo et al., 2013). A urinary input-output is monitored for determination of intravenous fluids needed. An enema will be avoided to avert the risk of intestinal perforations. Further, Ms. M. will be offered relief post-operative to ensure comfort. Non-steroidal antibiotics and opioids will be used by means of injections (Hinkle & Cheever, 2014).
One would expect that Ms. M. present with a lot of anxiety considering her history of depression. This will impede the execution of the CR cycle phases. The nurse will need to step and play a critical role in ensuring a decline in Ms. M.’s anxiety levels. The nurse can do this by reassuring and explaining to Ms. M. of the care plan and reminding them of the informed consent they signed earlier. The patient will remain positioned in a semi-Fowler posture to ensure tension and subsequent and pain are reduced. Opioid analgesic pain relievers are preferably accompanied by antibiotics geared at eliminating infections. The nurse will need to start preparing Ms. M. for discharge because with reduced discomfort and normalization of body temperatures, expected to occur in two days; discharge is permissible. Ms. M. would also need to be educated on wound care as well as steps to undertake to maintain skin integrity. The educational component may also include management of surgical appointments, cleaning the incisions as well return to normal tasks and duties in about four weeks after surgery (Vidal et al., 2010).
Ms. M. will also be put on NPO during the acute phase of peritonitis until presentence of power sounds has been confirmed (Lewis et al., 2016). Confirmation of the presence of bowel sounds will necessitate that Ms. M. transitions to a soft diet given orally. Dietary modifications will be accompanied by education centered on the appropriate balancing of diet, significance of fiber, up-regulation of fruit intake to facilitate wound healing and intake of enough water.
The second phase of CR cycle obligates the nursing practitioners to take appropriate action. Part of the appropriate action will include careful consideration by the nurse to avoid or lessen the severity of complications. Some of the actions that can be taken include constant monitoring and execution of preventive or palliation interventions for the identifiable complications. The nurse will be watchful and document any possible adverse reactions of Ventolin, Seretide, and Sertraline with the newly prescribed medication. With this information, the physician can make the necessary adjustments in respect to dosages in case any negative interactions are recorded.
Continuous assessment for abdominal tenderness, fever, vomiting, abdominal rigidity, and tachycardia are critical in peritonitis will ensure that reflecting on the process with a focus making adjustments as the need may arise (Allemann et al., 2011). Constant nasogastric suction out to be done during an acute phase. In addition, administration of intravenous fluids and antibiotic (which a continuation of pre-surgery continues; all these interventional protocols put in motion to prevent the occurrence of peritonitis.
It is also possible for Ms. M. to develop complication a pelvic abscess post-surgery. The nurse would need to do further evaluations with regards to anorexia, chills, fever as well as diaphoresis. Additionally, Ms. M. will be examined for diarrhea which is indicative of a pelvic abscess. In the event that the aforementioned signs and symptoms are portrayed by Ms. M., the nurse care will prepare her for rectal examination. Diagnosis of a pelvic abscess will necessitate her to undergo surgical drainage to foster faster recovery. It is also possible for her to experience a subphrenic abscess forming below the diaphragm secondary to a ruptured appendix. This will need assessment for chills, fever, and diaphoresis (Linton, 2015). The nurse will prepare Ms. M. for an abdominal and chest x-ray to affirm the diagnosis. A diagnostic confirmation of diaphoresis will necessitate a second surgical drainage of abscess. Further assessment for ileus complications will be determined by assessment for the absence of bowel sounds (Sadhuwong, Koraneekij & Natakuatoong, 2016). Intubation and suction will be done by gastric means. Fluids and electrolytes will be administered by intravenous means following the physician’s prescriptions. Ms. M. will be asked to be prepared surgery following a diagnosis of mechanical ileus. All this constitutes the inquisitiveness secondary evaluation required by the second last phase of the CR cycle. Without being inquisitive, many of the complications will go unaddressed necessitating a prolonged hospital stay.
It is essential for the nurse to explore how to work with the rest of the healthcare team to speed recovery and avoid complications. This is a pre-requisite to ensuring that quality services are given. In addition, it will also ensure patient-centered is underscored not to mention higher scores of Ms. M.’s satisfaction (Van et al., 2014). Some of the members who may constitute the health care team include medical professionals with varying education and abilities functioning together to realize a mutual outcome (Valentine, Nembhard & Edmondson, 2015). The rationale of interdisciplinary health care in the surgical field, in this case, is to help in minimising oversights, amplify efficiency, and guarantee excellent care. Prior training and training and unimpeded communication and a collaborative spirit are the crucial actualisations of set goals (Gausvik et al., 2015).
The team needs to be constituted and stay put before, during and after the operation. Each member needs to be aware of his or her role because they are all involved in the direct care of Ms. M.. Each will be required to uphold outstanding inter-professional working relationship with her while conducting evaluation aimed at determination of vital signs, wound healing, pain management and nutritional requirements and nutritional status. Working as a team will make it possible for analysis of the Ms. M.’s needs and necessitate possible both intra-disciplinary and interdisciplinary referrals (Valentine, Nembhard & Edmondson, 2015). The surgeon, despite having carried out laparoscopic surgery does not mean his or her work has ended; he will need to make follow-ups depending on Ms. M.’s prognosis as documented by the nurse. Physiotherapists will spearhead her timely. Nutritionists and dieticians will be tasked with the determination of Ms. M.’s nutritional requirements and offer appropriate technical advice (Valentine, Nembhard & Edmondson, 2015). Each and every healthcare member of the team will be expected to offer professional care with unwavering adherence to the duty of care, medical tenets, and high-quality care (Gausvik et al., 2015).
The reasons for utilization of CR cycle are multidimensional but encompass a huge bulk of the challenges that novice nurses face while distinguishing medical problems requiring immediate attention from less acute ones; and a propensity to commit medical errors in pressing circumstances where there is voluminous complex data to process. M.’s medical situation spans from pre-operation, the operation and pre-operative phases. Having members of different health care disciplines with different competencies affirms the need for a well-coordinated utilization of the CR cycle.
I belief the priorities and goals set truly address Ms. M.’ condition fully. Undertaking this task has taught me that patients’ care requires interdisciplinary and interdisciplinary efforts. The patient’s involvement is also critical to ensuring faster recovery and prevention of complications.
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- Quote paper
- Daudi Nyangaresi (Author), 2018, Clinical Reasoning (CR) Cycle by Levett-Jones, Munich, GRIN Verlag, https://www.grin.com/document/442886