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1. Establish goals for priority of nursing care as related to the nursing problem/issues identified;

2. Discuss the nursing care of the person, link it to assessment data and history;

3. Evaluate your nursing care strategies to justify the nursing care provided;

Prioritization of Three Nursing Problems/Issues Based on the Health Assessment Data

The presented clinical scenario describes the health status of a 36-years old patient (i.e. Ms. Melody King) affected with peritonitis after experiencing a ruptured appendix. The patient exhibited a clinical history of depression and asthma and her therapeutic history included the utilization of drugs including Sertraline (for depression), Seretide (for asthma), and Ventolin (for asthma). Patient’s blood pressure reading of 95/45mmHg affirmed hypotension (Sharma & Bhattacharya, 2018). Patient’s heart rate of 120 beats per minutes affirmed tachycardia; however, the presently recorded heart rate also indicated high-risk of SVT (supraventricular tachycardia) (Patti & Gossman, 2018). Patient’s temperature of 100.94 indicated fever (i.e. an indication of infection or sepsis) (Walter, Hanna-Jumma, Carraretto, & Forni, 2016). Patient’s respiratory rate of 22/minute along with shallow breathing pattern indicated respiratory abnormality (Badawy, Nguyen, Clark, Halm, & Makam, 2017) that correlated with her clinical history of asthma (Thomas & Bruton, 2014). Similarly, patient’s 95% oxygen saturation level (i.e. SpO2) indicated a substantial reduction in pulmonary function that correlated with the clinical history of asthma (Dalbak, Straand, & Melbyea, 2015). Patient’s symptoms of centralized/severe abdominal pain and nausea correlated with the occurrence of severe peritonitis that warranted immediate clinical intervention (Samuel, Ludzu, Cairns, Varela, & Charles, 2013). Patient’s generalized abdominal guarding and distension in the presented scenario indicates the risk of acute or necrotizing pancreatitis requiring therapeutic management (Samuel et al., 2013). Patient’s WBC elevation indicated the occurrence of a suspected bacterial infection/sepsis (Marik, 2014). Similarly, C-reactive protein’s elevation affirmed the presence of severe inflammation (Nehring & Patel, 2018).          

Prioritization of Three Nursing Problems/Issues Based on the Health Assessment Data

The following nursing problems based on Melody’s health status require immediate clinical intervention and management. 

Patient’s clinical history of appendicitis/ruptured appendix, peritonitis, fever, and elevated WBC indicate high-risk of inflammation, obstruction, and infection. Peritoneal inflammation was affirmed by the clinical symptom of nausea and fever. Furthermore, the nurse in the presented scenario needs to evaluate Dunphy's sign and Rovsing's sign to identify the progression and intensity of peritoneal inflammation/infection (Jones & Deppen, 2018). The infection in the presented scenario will substantially elevate the intensity of inflammation and impact the patient’s recovery rate. Patient’s removal of the ruptured appendix in the presented scenario also increases the risk of an intra-abdominal abscess, infection or sepsis.   

Patient’s peritoneal irritation in the presented scenario could have caused centralized abdominal pain and guarding in the existing scenario (Macaluso & McNamara, 2012). The occurrence of infection/ inflammation across the abdominal organs and the parietal peritoneum could have induced the spinal nerves across the mesodermal structures under the impact of sustained noxious stimuli. The acute onset of severe abdominal pain could potentially induce a vascular emergency attributing to aortic dissection or abdominal aortic aneurysm. Patient’s acute pain in the presented scenario also substantiates the requirement of ruling out other potential complications including torsion, mesenteric ischemia, volvulus, and perforated ulcer.  These outcomes indicate the need for immediate nursing intervention for the patient’s acute pain management.   

Immediate Nursing Intervention for Melody’s Acute Pain Management

Patient’s RSBI correlates with her asthma pattern that might require mechanical ventilation to reduce the risk of respiratory failure (Verceles, Diaz-Abad, Geiger-Brown, & Scharf, 546-552). The nurse, therefore, needs to access and monitor Melody’s respiratory pattern to reduce the risk of acute asthma exacerbation or respiratory failure.   

The professional registered nurse will need to prioritize the following care goals for Melody to reduce her risk of sepsis or infection, abdominal distension/pain/guarding, and respiratory complications.

  1. High-risk of Infection or Sepsis
  2. Normalization of patient’s fever to acquire the afebrile status.
  3. Facilitation of patient’s healing and recovery
  4. Reducing the risk of erythema or purulent drainage
  5. Increasing patient’s compliance with the recommended therapy
  6. The configuration of the septic/sterile technique to reduce the risk of abscess drainage  
  7. Acute Abdominal pain, Distension, and Guarding
  8. Reducing the intensity of centralized acute abdominal pain
  9. Administration of relaxation techniques to effectively improve the patient’s comfort and satisfaction
  10. Administration of analgesics in accordance with the physician’s prescription
  11. Administration of antiemetics to minimize the frequency and intensity of patient’s nausea and resultant pain pattern  
  12. Reducing patient’s intestinal irritation and metabolic rate to improve the healing pattern and minimize the intensity of abdominal pain
  13. Promotion of deep breathing exercises and relaxation techniques while improving patient’s coping capacity against the peritonitis manifestations.
  14. RSBI (Rapid Shallow Breathing Index)
  15. Regular evaluation of patient’s oxygen saturation level and deployment of the nasal cannula during the respiratory crisis.
  16. Periodic auscultation of patient’s lung sounds and utilization of suctioning intervention for infiltrate-elimination.
  17. Utilization of peak flow meter to monitor and record the patient’s exhalation pattern.
  18. Adjustment of patient position in a manner to dilate the airway passages and pulmonary bases.  

Melody’s hypotension warrants the regular monitoring of her systolic and diastolic blood pressures while attempting to reduce her overall stress experienced under the impact of clinical manifestations. Furthermore, assessment of patient’s orthostatic hypotension is also needed to evaluate the risk of falls and syncope (Shibao, Lipsitz, & Biaggioni, 2013).  

The registered nurse needs to optimize the fluid administration to facilitate the appropriate maintenance of Melody’s blood pressure and overall circulatory system. The registered nurse also needs to minimize patient’s overexertion while assisting her activities of daily living (ADL) and personal care. This will not only minimize energy expenditure but also equilibrate the patient’s oxygen demand and supply (i.e. oxygen saturation level) to a considerable extent. The ADL support needs to be provided in a manner to improve the overall ventilatory and metabolic output of the treated patient (Castro et al., 2013).   

The registered nurse needs to monitor the patient’s heartbeat to evaluate the risk of cardiomyopathy, peripheral hypoperfusion, low cardiac output, and myocardial ischemia (Gopinathannair & Olshansky, 2015). Accordingly, the nurse will require administering calcium channel antagonists or beta-blockers in accordance with the physician prescription to prophylactically/preventively treat the occurrence of tachycardia-mediated cardiomyopathy. The registered nurse needs to monitor the skin temperature, color, and moisture along with the urine output to evaluate patient’s toxicity level and risk for septicemia and cyanosis (Adeyinka & Kondamudi, 2018). The nurse also needs to evaluate the patient’s state of consciousness and mental status changes based on the recorded hypotension and shallow breathing pattern.

The nurse requires undertaking peritoneal aspiration/lavage to facilitate the assessment of infecting microbe/intraperitoneal hemorrhage in the context of administering appropriate antibiotic regimen (in coordination with the treating physician) (Whitehouse & Weigelt, 2009). The registered nurse needs to facilitate the patient’s semi-fowler position in the context of minimizing the peritoneal irritation and minimizing the intensity of the reported pain. The systematic splinting of the pain region will assist in the reduction of abdominal guarding, pain, and muscle tension. The registered nurse needs to undertake appropriate oral care of the patient in the context of minimizing the intensity of nausea and resultant intraabdominal pressure. Appropriate intraabdominal pressure management is also needed to minimize the intensity of the patient’s acute abdominal pain (Milanesi & Caregnato, 2016). The nurse also requires raising the head of the patient’s bed and access arterial blood gases (ABG) while undertaking a complete respiratory exam based on the recorded respiratory rate and oxygen saturation level. ABG assessment is needed to monitor the patient’s acid-base balance and overall respiratory functionality (Sood, Paul, & Puri, 2010).       

Respiratory Management to Reduce the Risk of Asthma Exacerbation or Respiratory Failure

A reduction in systolic blood pressure directly impacts the mental health and wellness of individuals. Hypotension induces the depression pattern that resultantly elevates the risk of suicidal ideation (Joung & Cho, 2018). That’s why stress management with blood pressure stabilization is highly necessary to facilitate the neurocirculatory improvement in the concerned patient. Hypovolemia with hypertension substantially increases the risk of renal complications (Hur et al., 2014). That’s why appropriate fluid management is highly necessary to effectively control the extracellular volume indices for stabilizing the renal circulation of the treated patient. The extended assistance in patient’s activities of daily living is highly needed to reduce the risk of worsening prognosis (Edemekong & Levy, 2018). Patient’s pain management and abdominal infection prophylaxis are highly needed to reduce the risk of secondary peritonitis and associated complications (Doklesti? et al., 2014). Peritonitis substantially increases the risk of respiratory infection. Therefore, respiratory management and establishment of respiratory control are highly needed to reduce Melody’s risk of respiratory infection and associated complications (Chichom-Mefire, Fon, & Ngowe-Ngowe, 2016).     

The presented clinical scenario provides the best example of the comprehensive nursing management of a patient affected with ruptured appendix and peritonitis. I understand the requirement of maintaining the patient’s vital signs while concomitantly reporting the respiratory system and infectious manifestations to reduce the risk of significant comorbidities (including respiratory arrest or cardiac complications) and morbidity. I could have administered oxygen therapy in a similar scenario to reduce the risk of hypoxia since the vital signs indicated a substantial reduction in the patient’s oxygen saturation level. I could also have administered antibiotic therapy in coordination with the concerned physician (due to reported fever) to minimize the risk of infection progression. I understand that postoperative peritonitis is a serious, debilitating, and life-threatening medical condition that increases the risk of mortality under the impact of severe intra-abdominal infection. Prophylactic management of postoperative peritonitis requires skillful intervention by a registered nurse with the core objective of reducing the inflammation/infection progression and normalization of patient’s respiratory and circulatory systems .

References

Adeyinka, A., & Kondamudi, N. P. (2018). Cyanosis. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482247/

Badawy, J., Nguyen , O. K., Clark, C., Halm , E. A., & Makam , A. N. (2017). Is everyone really breathing 20 times a minute? Assessing epidemiology and variation in recorded respiratory rate in hospitalised adults. BMJ Qual Saf, 26(10), 832-836. doi:10.1136/bmjqs-2017-006671

Care Goals: Stabilizing Blood Pressure and Circulatory System, Abdominal Infection Prophylaxis, and Respiratory Control

Castro, A. A., Porto, E. F., Iamonti, V. C., de-Souza,, G. F., Nascimento, O. A., & Jardim , J. R. (2013). Oxygen and Ventilatory Output during Several Activities of Daily Living Performed by COPD Patients Stratified According to Disease Severity. PLoS One, 8(11), 1-9. doi:10.1371/journal.pone.0079727

Chichom-Mefire, A., Fon, T. A., & Ngowe-Ngowe, M. (2016). Which cause of diffuse peritonitis is the deadliest in the tropics? A retrospective analysis of 305 cases from the South-West Region of Cameroon. World J Emerg Surg, 1-11. doi:10.1186/s13017-016-0070-9

Dalbak, L. G., Straand, J., & Melbyea, H. (2015). Should pulse oximetry be included in GPs’ assessment of patients with obstructive lung disease? Scand J Prim Health Care, 33(4), 305-310. doi:10.3109/02813432.2015.1117283

Doklesti?, S. K., Bajec, D. D., Djuki?, R. V., Bumbaširevi?, V., Detanac, A. D., Detanac, S. D., . . . Karamarkovi?, R. A. (2014). Secondary peritonitis -evaluation of 204 cases and literature review. J Med Life, 7(2), 132-138. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197493/

Edemekong, P. F., & Levy, S. B. (2018). Activities of Daily Living (ADLs). In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470404/

Gopinathannair, R., & Olshansky, B. (2015). Management of tachycardia. F1000Prime Rep, 1-5. doi:10.12703/P7-60

Hur, E., Özi?ik, M., Ural, C., Yildiz, G., Ma?den, K., Köse, S. B., . . . Duman, S. (2014). Hypervolemia for Hypertension Pathophysiology: A Population-Based Study. Biomed Res Int, 1-9. doi:10.1155/2014/895401

Jones, M. W., & Deppen, J. G. (2018). Appendicitis. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK493193/

Joung, K. I., & Cho, S. I. (2018). Association of low blood pressure with suicidal ideation: a cross-sectional study of 10,708 adults with normal or low blood pressure in Korea. BMC Public Health., 1-10. doi:10.1186/s12889-018-5106-5

Macaluso , C. R., & McNamara, R. M. (2012). Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med, 789-797. doi:10.2147/IJGM.S25936

Marik, P. E. (2014). Don’t miss the diagnosis of sepsis! Crit Care, 18(5), 1-3. doi:10.1186/s13054-014-0529-6

Milanesi , R., & Caregnato , R. C. (2016). Intra-abdominal pressure: an integrative review. Einstein (Sao Paulo), 14(3), 423-430. doi:10.1590/S1679-45082016RW3088

Nehring, S. M., & Patel, B. C. (2018). StatPearls [Internet]. In C Reactive Protein (CRP). Treasure Island (FL): StatPearls Publishing;. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK441843/

Patti, L., & Gossman, W. G. (2018). Rhythm, Tachycardia, Supraventricular (SVT). In StatPearls [Internet]. USA: StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK441972/

Samuel, J. C., Ludzu, E. K., Cairns, B. A., Varela, C., & Charles, A. G. (2013). A patient with severe peritonitis. Malawi Med J, 25(3), 86-87. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859995/

Sharma, S., & Bhattacharya, P. T. (2018). Hypotension. In StatPearls [Internet]. Pennsylvania, USA : StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499961/

Shibao, C., Lipsitz, L. A., & Biaggioni, I. (2013). Evaluation and treatment of orthostatic hypotension. J Am Soc Hypertens, 7(4), 317-324. doi:10.1016/j.jash.2013.04.006

Sood, P., Paul, G., & Puri, S. (2010). Interpretation of arterial blood gas. Indian J Crit Care Med, 14(2), 57-64. doi:10.4103/0972-5229.68215

Thomas, M., & Bruton, A. (2014). Breathing exercises for asthma. Breathe, 312-322. doi:10.1183/20734735.008414

Verceles, A. C., Diaz-Abad, M., Geiger-Brown, J., & Scharf, S. M. (546-552). Testing the prognostic value of the rapid shallow breathing index in predicting successful weaning in patients requiring prolonged mechanical ventilation. Heart Lung, 41(6), 1-13. doi:10.1016/j.hrtlng.2012.06.003

Walter, E. J., Hanna-Jumma, S., Carraretto, M., & Forni, L. (2016). The pathophysiological basis and consequences of fever. Crit Care. doi:10.1186/s13054-016-1375-5

Whitehouse, J. S., & Weigelt, J. A. (2009). Diagnostic peritoneal lavage: a review of indications, technique, and interpretation. Scand J Trauma Resusc Emerg Med, 1-5. doi:10.1186/1757-7241-17-13

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