The profession of nursing comprises of several elements of practice, experience, and technical and professional expertise (Levett-Jones, 2013). The practice of clinical reasoning is one of the most crucial elements in nursing clinical practice. The primary reason for this is that the duties of the nurse are greatly dependent on the logical reasoning cycle that is adapted by nurses in order to prioritise the critical nursing goals, establish appropriate nursing goals, design a plan of action, and evaluate the patient outcomes and the results achieved out of the action plan (Nackaerts, Heremans, & Vervoort, 2016). Nurses are essentially required to apply reasoning and logical prioritization to establish the needs of the patient and plan nursing interventions to address the specific concerns of the patient.
The current project involves the application of the clinical reasoning model for the assessment of clinical nursing needs and priorities for Ms. Melody King, for whom post-operative laparoscopic surgery nursing intervention was undertaken. The current essay contemplates the collection of data, considerations for the patient, and the evaluation of the information collected (Levett-Jones, 2013). Further, the essay sets down the priorities in the nursing plan along with interpreting the outcomes of the action plan for execution of the nursing priorities.
The patient, Melody King, is a 36-year-old female patient admitted for peritonitis following appendix rupture. She presented with severe pain in the lower left quadrant of the abdomen to the emergency department, as she had been experiencing the pain for about 3 days’ time. She underwent emergency laparoscopic surgery for the removal of the appendix which was ruptured.
Melody is currently in the post-operative unit and her medical observations, physical examination, and medical history have to be considered. Patient information has to be retrieved from the concerned physician and surgeon.
Collection of information and cues from patient history and presentations:
The patient information indicates that Melody presents with a history of depression and chronic asthma and respiratory disorders. She is currently taking compliant medications including Ventolin and Seretide for asthma and sertraline for the treatment of depression.
The physical examination details for Melody indicate a low blood pressure value of 95/45 mmHg; increased heart rate of 120 beats per minute; elevated body temperature of 38.3 degree Celsius; slightly elevated or borderline respiratory rate of 22 breaths per minute; near-normal SpO2rate of 95%, since Melody has asthma, the value can be considered normal.
Melody additionally complains of nausea and a pain in the central abdominal region of an approximate rating of 7 or 8 on a scale of 10. Records of physical examination indicate distension in abdominal region. The lab reports of histology and pathology of the patient indicate elevated levels of white blood cells (WBC) and c-reactive protein (CRP).
Analysis and processing of the obtained information:
Melody presented with lower left abdominal pain of a severe range to the emergency department. She has undergone laparoscopic removal of ruptured appendix. Additionally, she has a considerably strong history of depression and asthma and is undergoing treatment for them. Post-laparoscopic surgical nursing involves the monitoring and treatment of subsequent pain, monitoring adverse effects due to the chronic medications and the current post-surgical situation of the patient, keeping a check on the physical examination and pathological reports, and monitoring and treatment for elevated CRP and WBC levels. The patient complains of centralised pain in the abdomen. Additionally, the distension in the abdomen presents higher complication.
In the current scenario, it is important to monitor the effects of Ventolin, Seretide, and sertraline on the current abdominal pain, WBC, and CRP levels (Monticone et al., 2015). The patient has undergone laparoscopic surgery and may have sepsis or septic shock. The primary intervention that is required includes fluid resuscitation (Kojovic et al., 2012). The levels of CRP act as a biomarker, useful for the indication of the patient condition and health status in terms of inflammation present in the body. Elevated levels of CRP indicate the possible conditions such as trauma, infections, inflammation, cardiovascular risk etc. (Cross, Warner, Young, & Weiand, 2012). In the case of Melody, there may be the presence of inflammation at the site of surgery or a septic shock due to which, there is an increase in the levels of CRP produced in the liver. There is a likelihood of trauma in the surgical site and the elevated levels of WBCs in the blood also indicate an immune reaction to trauma or injury at the site of surgery (Ridker, Kastelein, Genest, & Koenig, 2013). The increase in the levels of WBC is known as the condition of leucocytosis and is a result of trauma or the presence margination of neutrophils or the condition of neutrophilia. The amount of increase in the WBC count indicates the severity of injury to the organ (Bonacina, Baragetti, Catapano, & Norata, 2013). The condition of leucocytosis is short in duration and typically lasts somewhere between a few minutes to hours.
The case of Melody is complicated due to the various associated problems in the patient. The nursing intervention must address the important concerns adequately. The primary problems or concerns in the patient include:
- Centralised abdominal pain and elevated levels of CRP and WBCs, indicating trauma, injury, or sepsis in the surgical site
- Nausea, low BP, and elevated respiratory rate, pulse, and temperature
- Side effects of Ventolin, Seretide, and Sertraline in the increase of the symptoms of abdominal pain and dysfunction
The patient has several complications due to the presence of ongoing compliant medication and likelihood of trauma or injury at the site of surgery (Brenner, & Kautz, 2015). The nursing concerns include the elimination and treatment of the injury and monitoring regular medication and associated adverse events.
The increased level of WBC and CRP increase the suspicion of blunt trauma or an occult injury at the site of operation (Tabatabaie, Maleki, & Talebpour, 2017). The priorities of nursing care for Melody therefore constitute the main goals of:
- Assessment of injury or trauma and execute the treatment plan for the trauma and leukocytosis
- Provide adequate care for abdominal pain, nausea, BP, raised temperature and pulse
- Monitor the side effects of Ventolin, Seretide, and Sertraline.
The three primary nursing goals have almost the same degree of importance. All the three priorities are equally crucial. However, the highest priority is given to the determination of trauma as indicated by the CRP and WBC biomarkers.
Action and execution:
The nursing intervention needs to focus on the post-operative care for the patient. These interventions include resuscitation and disinfection to microbial infections.
- Directing the patient to the concerned physician for the examination or radiology to determine the presence of trauma or injury and subsequently follow the treatment prescribed by the physician for the treatment of the trauma
- Providing continuous fluid resuscitation to the patient and maintaining sterility and provision of prophylactic interventions to the patient experiencing complications related to the surgery and related trauma or injuries.
- Monitoring abnormalities in the physical examination observations including heart rate, pulse, blood pressure, and body temperatures (Philips et al., 2013).
- Monitoring the effects of Ventolin, Seretide, and Sertraline.
The intervention primarily focuses on the post-operative care for the patient along with providing ample support and resuscitation. The elimination of trauma and related pain along with immune reactions such as increased pulse, body temperature, and reduced blood pressure are of critical importance (Sista et al., 2013).
Ventolin and Seretide can cause nausea and increase in body temperature. Sertraline can lead to pain sensation in most situations. Therefore, the doses and the particular reactions to these drugs have to be constantly monitored.
Outcomes of the action and evaluation:
The observations in the patient records indicate the following outcomes of the intervention:
- Leukocytosis has reduced and the WBC count is within the normal range. The trauma was detected and treated according to the instructions of the concerned physician
- The physical examination values of blood pressure, BP, pulse, and respiratory rate are borderline-normal. The complaints of nausea and pain are mostly in control upon continuous monitoring with the intake of compliant medications such as Ventolin, Seretide, and Sertraline.
- Reflections of the nursing experience:
The current experience in the case of Melody was particularly challenging due to the number of complications and associated medical concerns. This case has served as the perfect example for the importance of the clinical reasoning model. The case seemed exasperating at first due to the high number of complications and the presence of leukocytosis and increased CRP. However, the clinical reasoning model made it possible to enumerate the specific patient concerns and allot the priorities according to the urgent concerns. The clinical reasoning model and logical analysis of the concerns of the patient, the trauma or the injury, and the related concerns enabled timely treatment for the patient. Nursing care includes sound technical knowledge and reasoning for the appropriate identification of nursing priorities.
The concept of clinical reasoning is one of the crucial elements of nursing care. Interventions for the care of post-operative laparoscopic patients require technical knowledge and abilities to assess the physical examination and surgical reports of the patient. In cases of continual chronic medications for a particular patient, the drug interactions and adverse effects have to be monitored and prevented. The concept of clinical reasoning provides a holistic ground for the analysis and identification of patient concerns along with enabling the appropriate course of action for the nurse.
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