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Clinical Reasoning Cycle for Melody

NRSG370 - Clinical Integration - Speciality Practice

Assessment: Case Study Outline- Information For Students

Assessment 2: Case Study - North Sydney

Students will complete a case study 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). Students must select and respond to the case study question that reflects their allocated clinical placement specialty.   

The Clinical Reasoning Cycle 

Student are expected to use the Clinical Reasoning Cycle (Levett-Jones, 2018) as a framework to plan and evaluate person-centred care. You are being asked to think through the case scenario and then discuss how data was collected and the type of data collected, identify problems and nursing issues, identify and state the objectives and discuss how care was provided in order to address the issues and evaluate the interventions carried out: (analyse and identify a nursing issues/problems/needs, set objectives, discuss the nursing interventions and evaluate the interventions of care carried out). As per lecture notes, students are expected to apply the clinical reasoning cycle to address the case scenario:

  • Consider 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 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


clinical reasoning cycle


clinical reasoning cycle

Adapted from Tracy Levett-Jones, et al. (2010)


Application of the Clinical Reasoning Cycle 

Based on the stages of the clinical reasoning cycle, the outline of the essay should have:

Title Page: (not included in the essay)

  • Unit Title: NRSG370 – Clinical Integration - Speciality Practice 
  • Student Name:
  • Student ID Number: 
  • Speciality Area:
  • Scenario:
  • Total number of words: 
  • Essay should be formatted 
    1. Introduction 
  • introduces/outlines/situates the topic of the essay
  • clearly describes the way in which the essay will proceed
  • the essay is structured in a logical sequence so that the content flows (headings may be used to develop the structure of the paper)

2. Content

A. Consideration of facts from the patient or situation

Consider the case scenario of your choosing based on your clinical elective as per assessment “Choose the one that best reflects your specialty placement” this is where you determine what information should be collected and how information is going to be collected.

B. Collection of information

You need to discuss the type of information collected and why this information was collected based on the scenario for the clinical elective. For instance, the type of information collected should consider and include the history, current presenting issues and treatment plan, observations, results of investigations done medical records etc.

  1. Processing gathered information (analysing and interpreting)
  2. The most important thing is to analyse the information that you have collected and identify areas of nursing care needs and problems. In this section, your discussion should reflect analysis and interpretation of the patient’s current health status using your established knowledge of physiology, pharmacology, pathology, culture, and ethics to establish needs and issues drawn from the information. This stage allows you to demonstrate synthesis of theory and experience acquired in previous and concurrent nursing units.
  3. Identify the problem
  4. Identify and state the problems/needs or issues you have identified. It is important to identify the problems/needs/issues and the potential cause to determine the reason behind the patient’s current issue. Examples:
  5. Dehydration as a result of loose bowel motion x 4 and vomiting x 2 during am shift
  6. Falls risk as a result of confusion and unsteady gait 
  7. Loss of weight as a result of poor oral intake for one week 
  8. Pain due to post -operative procedure – laparotomy
  9. Hyperglycaemia due to poor diet and lack of knowledge on diabetes

Please note these are examples only, the nature of the problems you identify will depend on the nature of the case study and your analysis and interpretation of the situation.

  • Establish goals

Here, you determine the nursing goals for the patient’s situation. Identify and prioritise at least three (3) nursing problems/issues based on your assessment and collected data.

  • Take action

Here you discuss the nursing interventions or measures you will undertake in order to address the three nursing issues or problems. These measures should take in consideration the ethical, legal, evidence based, holistic -person-centred approach.

  • Evaluation and Reflection 

Evaluate the effectiveness of the nursing interventions you have discussed (presumably which could have been carried out or actually carried out) and reflect on how the interventions could have been improved or done better- State the potential measures that could have been considered or could have been carried out to address the problem. This phase allows you to critically analyse what has been done and how best the care was carried out or could have been improved. 

  • Conclusion

the essays ends with a cogent, defendable conclusion that summarises the discussion 

  • References 

Provide a list of references used in your discussion

Answer

Clinical Reasoning Cycle for Melody

In this paper, we would discuss the pathophysiological condition of Melody King who is suffering from peritonitis due to rupture of the appendix and apply the clinical reasoning framework to evaluate the exact situations.  Therefore, the considerations for these aspects are:

Consider the patient situation

Melody is 36 years old female suffering from severe Right Lower Quadrant abdominal pain. She is admitted to the emergency department with the complication of severe abdominal pain. Her past medical history stated that she had asthma and depression. The personal case history of Melody is unavailable; however, loneliness or unhealthy family and personal circumstances could be a prime cause of her illness. Peritonitis is considered as an inflammation and infection of peritoneum which is a thin tissue covering the whole abdomen and vital organs. In her case, ruptured of appendicitis is responsible for the development of peritonitis. She has developed the pain 2-3 days before, however, ignorance from her end make the condition critical for her. Thus, the medical professionals present in the emergency department suggested the early removal of the ruptured appendix by laparoscopic surgery. A study conducted in the USA suggested that the patients are suffering from asthma are prone to develop depression progressively (Ahmedani, Peterson, Wells & Williams, 2013). Therefore, depression can worsen the condition of peritonitis. In the case of Melody, loneliness along with asthma can increase her depression and ignorance towards her pain. 

                             Peritonitis due to rupture of the appendix                   


Fig1: Peritonitis due to rupture of the appendix (The Allergy & Asthma Clinic and Research Center, 2018)

Collect information

Melody had a previous medical history of asthma and depression. At present, she has a ruptured appendix which is a prime cause of peritonitis. Her clinical observation represented that her BP is 95/45 mmHg, HR is 120 beats per minutes, RR is 22 per minutes, SpO2 is 95% and body temperature is 38.3 °C. Her clinical observation implies that she is suffering from low blood pressure with palpitation and shallow respiration. Therefore, she has advised taking a few medicines to control her body status. The names of the medicines are Ventolin, Seretide and Sertraline. Thus, Ventolin is used to control shortness of breath along with wheezing (WebMD, 2018). In her case, shallow breathing can be improved by this medicine. However, it has few side effects like irritation, nausea, irregular heartbeat, and allergic reactions. Additionally, Seretide is used to avoid asthma attacks and help in respiration. It will also help in preventing inflammation and airways constriction (Seretide, 2018).The medicine can also increase heart rate, headache, and muscle cramp.  Therefore, the medicine Sertraline can prevent anxiety and depression along with the panic attack. Thus, it can cause weakness, insomnia, nausea, and agitation (eMedicine Health, 2018). She has a problem of nausea and centralized abdominal pain. This can be caused by the ruptured of the appendix and the prescribed drugs. The ruptured of the appendix could increase the pain and the medicine of asthma and depression control can create nausea and palpitation. However, the swollen abdomen is a common phenomenon in peritonitis as rupture can cause fluid deposition in the abdominal cavity which can precipitate a distended abdomen.     

Process information

Melody has developed peritonitis due to rupture of the appendix which can often consider as sources of bacterial infection of the peritoneum. The observation of Melody suggested that she is suffering from shallow breathing and low BP. Her progressive asthma is responsible for narrowing her respiration which is also increasing her heart rate and lowering the BP. Therefore, her secondary peritonitis can also enhance the tendency of nausea, shortness of breath and abdominal pain (Chen et al., 2016). As she has already a patient of asthma the present condition of peritonitis also elevated the scenario. Therefore, she is suffering from severe respiratory distress along with pain. In addition, asthma is also increasing the tendency of depression and anxiety. Thus, the medical team is willing to control her breathing problem along with depression.  In her case, the rupture of appendix causes the release of fluids in the abdominal cavity which can cause dehydration in the body. Therefore, dehydration can reduce the BP and create respiratory discomfort. In her case, increasing White Blood Cell (WBC) count is indicating that infections and inflammation is present in the peritoneum. Additionally, her increasing CPR or C-reactive protein is the result of inflammation. 

In this condition, prime importance should be given on rectification of her peritonitis by surgical removal of the appendix and therefore improve, her respiratory status by controlling asthma and depression.   

Identify problem / issue

In this condition, Melody can develop bacteraemia which is known as bloodstream infection due to peritonitis. It can cause fever, abdominal pain, rapid heart rate, low blood pressure, and nausea. In many cases, peritonitis can cause sepsis (Healthline, 2018). It is a condition when the infection spread throughout the body. Sepsis is considered a life-threatening condition which progresses rapidly and causes multi-organ failure due to shock. In many cases it has been isolated that peritonitis can cause hepatic encephalopathy; in which brain discontinue his normal functioning as the liver is unable to remove the toxic substances from the blood (Healthline, 2018) . In a few cases, peritonitis can precipitate progressive kidney failure which is known as a hepatorenal syndrome (Gupta, Mishra, Tiwary & Mishra, 2014). In general, peritonitis can cause a distended abdomen along with bloating, dehydration, rapid pulse rate, and shortness of breath. In case of Melody, ruptured of the appendix is caused peritonitis which increasing symptoms of asthma attack. Therefore, she can experience rapid breathing, chest pain, lack of oxygen in blood and anxiety. Thus, her asthma attack can increase her depression and anxiety level which can adversely affect the whole situation. Therefore, it is essential to take prompt action to reduce the symptoms of peritonitis as it can easily minimize the other physical disturbance of Melody and improve her condition.   

Establish goals

In the case of Melody, the prime concentration should be given on the elimination of peritonitis. Therefore, surgical elimination of ruptured appendix is an important fact of improvement. It will definitely diminish her abdominal discomfort, pain, and WBC count. The inflammation and infection can be reduced by this surgical attempt. Therefore, it will also reduce the chances of renal failure and sepsis (Gupta, Mishra, Tiwary & Mishra, 2014). In addition, she should advise to take intravenous antibiotics or antifungal medications to improve her conditions. In the same time medicines are essential to rectify her respiratory status and dehydration. Thus, rectification of asthma can stable her condition. Thus, use of medicine to prevent the asthma attack can recover her respiratory disturbance and respiratory rate. Additionally, it will also reduce her depression and anxiety (Ahmedani, Peterson, Wells & Williams, 2013). Therefore, improvement of dehydration by the intracellular fluid can elevate her blood pressure; as a result, she can feel better and progress rapidly. Consequently, a close monitoring is essential to identify any further complications. In case of an emergency, the patient should transfer to an intensive care unit.      

Take action

The necessary action should be taken by considering the following aspects:

  • Elimination of ruptured appendix.
  • Reduction of the bacterial inoculum.
  • Prevention of persistent and recurrent peritonitis.  

Laparoscopic approach

It is a surgical attempt commonly used for treating peritonitis due to complicated appendix. It is an effective approach as it is related to short time of hospitalization and minimum chances of infections. In case of Melody laparoscopic approach would be beneficial (Healthline, 2018).   

Post- operative care 

In the post-operative condition, the patient should be monitored closely. Therefore, the incident of sepsis, organ activity, and adequacy of volume resuscitation can be monitored properly. In addition, the systematic antibiotic administration should be maintained without any interruption.It can be assumed that the patient condition can be improved within 24-72 hours after the surgical attempt (Medscape, 2018). However, the time of recovery can vary according to the condition of the patients. Lack of improvement can indicate further infections or recurrent intraperitoneal infections. In the case of Melody, the serious condition due to a rupture of the appendix required to prolong antibiotic therapy, which can also increase the chances of secondary infections (Mayoclinic, 2018). Therefore, a close monitoring system will able to identify any sign and symptoms of further infection.     

Prevention of surgical site infection 

Melody requires a surgical intervention which significantly increases the risk for surgical site infection (SSI) and delays the healing process (Healthline, 2018). Therefore, the nurses should provide enough attention to such complications. Thus, safe handling of the patient and maintenance of personal hygiene is essential to prevent the SSI. Therefore, the administration of antibiotics, dry dressing, and wound protector device can help in prevention.

Other treatment

Depending on the situation and complication pain medication, intravenous fluid administration, oxygen supplementation, and blood transfusion can be practiced (Mayoclinic, 2018)

Evaluate outcomes

The ruptured of the appendix is responsible for her peritonitis and safe removal of the contamination sources can able to recover her pain and progress her recovery. However, she can develop further infections which need proper monitoring process and evaluation. Thus, it can be assumed that the peritonitis is responsible for her asthma attack and increasing depression level (Mayoclinic, 2018). The medical intervention along with surgical attempt would definitely improve her condition. Therefore, it would also diminish her pain, dehydration, and abdominal distress. The nurses should ensure the patient safety by maintaining personal hygiene and cleanliness. This would avoid further contamination of the surgical site. The whole process of treatment would assist the recovery process of Melody.     

Reflect on the process and new learning

In this case, it has been noticed that ignorance toward the abdominal pain is responsible for the rupture of the appendix and expanded peritonitis.  As she has already a past history of asthma, the condition is aggravated by the emergency. Thus, the medical professionals are trying to controlling the asthma attack by medicines and inhalers and removal of the appendix by surgical means. It can be stated that a restricted life would beneficial and avoid further chances of inflammation.      

From the above case study, I realize the fact that rapid treatment is essential to avoid the complication of peritonitis and enhance the life expectancy rate. Therefore, personal hygiene and care are important to identify the complications of peritonitis for captivating quick action.  

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