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Question:
Discuss about the Clinical Reasoning Cycle For Emergency Department.
Answer:
Introduction

Femoral neck fracture in the elderly people after a fall is common and may lead to several complications apart from the physical burden of pain and mobility restriction (Hu et al., 2012). Such clinical condition can also increase the economic burden of the patients considerably. This essay would discuss the ethical, legal, evidence based and holistic patient centered care by establishing realistic goals by using the clinical reasoning cycle.

Content
Consideration of facts from the patient or situation

The case study of choice for this paper is about Jack Bunn, age 69, who had been presented in the emergency department after he had suffered from a fall directly on the lateral aspect of the tight hip. Physical examination has revealed that the right leg has been shorted and rotated externally and therefore Jack is not able to get up and is experiencing intense pain. 

His current vital signs are- • Vital Signs: BP 145/80, HR 120, SpO2 96% on 2L via nasal prongs, Temp 37.1° Celsius, RR 10;

  • Drowsy but responds to voices
  • Pinpoint pupils;
  • Neurovascular observations (Right Lower Limb): Cool, pale, touch present, movement present, capillary refill sluggish, dorsalis pedis present but thready;
  • Pain 3/10.

The respiratory rate of the patient is a bit lower than the normal value. Patient who have underwent arthroplasty have greater risk of having coronary heart diseases. A low, weak and a thready pulse can occur due to the decreased amount of blood circulation. Decreased blood circulation can be related to the occurrence of cardiogenic shock in people (Carpintero et al., 2013). Furthermore the patients after the surgery are more prone to hypervolemic shock because of the loss of blood and the fluids. Cool and pale skin can be due to the vasoconstriction and the hypo perfusion of the skin.

Processing gathered information (analyzing and interpreting)

The patient is hypertensive but the blood pressure us seen to be well controlled after the surgery. The normal heart rate of ranges between 70- 100 bpm, but the heart rate in this patient has found to be having the heart rate a bit higher than the normal value. However after surgery patients can have an elevated heart rate and high blood pressure (Carpintero et al., 2013). Being in pain can increase the blood pressure. The undergoing anesthesia also can have impact on the blood pressure. Researches have proven that the airways of certain patients are sensitive to the placement of the breathing tube that affects the heart rate and increases the blood pressure (Khan et al., 2013). One of the possible side effect of the surgery is that when a body is under anesthesia, the part of the body might not receive enough oxygen which may give rise to mild hypoxemia in the blood due to which the blood pressure can increase (Carpintero et al., 2013).

Another abnormality that can be seen are the pin point pupils. According to Pathan and Williams (2012), there are certain drugs like the prescription opoids and narcotics that can cause the pupil to shrink to the pinpoint size. The case study reveals that the patient has received 20 mg of intravenous morphine for pain, which can be related to the pin point size of pupil.

Identification of the problem/ issue

On the basis of the information collected and the interpretation of the findings it was identified that the patient was having an increased heart rate, which is probably due to the anesthesia, pain or the other medications (Carpintero et al., 2013). Another clinical priority identified is the pinpoint pupil which is again due to pain killers such as the opiates such as Morphine (Pathan & Williams, 2012) . And the final clinical priority is to manage the pain in the patient. It is evident from the case study that the pain scale of the patient is 3 out of ten, which signifies moderate pain. Hence the goal is to manage that the pain does not increase on being discharged or moved.

Establish goals

Short term goals

  • To restore the normal heart rate.

It should be mentioned that tachycardia in patients can be detrimental especially for the one who have a history of hypertension. Hence the goal is to restore the heart rate to normal level within a day.

  • To control the blood pressure.

 It has to be remembered that high blood pressure can cause serious complications such as stroke and hence should be controlled. Blood pressure should be controlled by adhering to the medications.

To manage the pain.

Any pain that is poorly relieved can be distressing for all groups of people. It reduces the mobility, socialization, delays the rehabilitation, causes sleeping disorder and cause subsequent utilization of the health resources increasing the burden of the health care cost (Barrington et al., 2013). Hence it is necessary to manage the pain.

  • To manage the side effects of the pain killers.

It is evident from the case study that the patient had a pinpoint pupil, which can be due to the use of the opiates (Pathan & Williams, 2012). Furthermore, it is also evident from the case study that the patient was having nausea. It has to be remembered that the use of certain medications like Tramadol can cause nausea. Furthermore, excessive intake of the painkillers can cause constipation or diarrhea (Pathan & Williams, 2012). 

Long term goals
  • To restore mobility in the patient

Hip arthroplasty restricts the mobility of the patient up to a great extent especially if the patient is elderly. In most of the cases the patient should be able to resume their normal activities after 5-6 weeks after the surgery (Hung et al., 2016). But speedy recovery is accomplished by exercises. 

  • Proper two weeks follow up after the discharge.

Discharge and a probable transfer to a follow up treatment is planned right from the beginning of the treatment period. Follow up care after the process of discharge is an important part in the improvement of the patient. There are several complications that can occur after a hip arthroplasty in this patient such as deep vein thrombosis, gait restrictions, respiratory problems, and medication allergy (Berstock et al., 2014). Hence a regular follow up after the discharge reduces hospital readmissions and helps to catch the complications early and to mitigate any growing issue.

Take action/Interventions

The case study reveals the fact that the patient Jack is a 69 years old patient and had underwent a hip arthroplasty, hence a holistic care approach should be taken up by the nurses which included both the physical health and the spiritual health of the patient.

Short term interventions

It is necessary to control the blood pressure of the patient. Hypertension can be a frequent problem after the surgery. One of the preventive approach for managing the hypertension is to replace the long acting hypertensive medicines of the patient several days before the surgery. In order to reduce the hypertension caused due to surgical incision, anesthesia, and tracheal intubation can be treated by short-acting β-blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors or the vasodilators (Varon & Marik, 2008).

The non -invasive pharmacological interventions included the administration of the NSAIDs and the opoid analgesics (McKenna & Lim, 2012, Kaye et al., 2013). A less localized method of multimodal anesthesia involves the placement of a peripheral nerve block (Reid, Eccleston & Pillemer, 2015).

If the drugs are having delirious effect on the patient then the dosages should be modified as per the patient's requirement. Other non-pharmacological therapies such as touch therapies, physiotherapy can be done to reduce the intake of painkillers (Reid, Eccleston & Pillemer, 2015)..

Long term interventions

A physiotherapist can be consulted with to decide a proper exercise regimen for Jack. Exercises like Bending and flexing of the ankle, contraction and the relaxation of the quadriceps muscles, contraction and the relaxation of the gluteal muscles (Bandholm & Kehlet, 2012).

A community nurse can be referred to Jack in order to take a two weeks follow up, where all the vital signs should be checked. The surgical part should be checked for the circulation, feeling and movement. The incision point should be checked for any infection or discharge .The patient might be instructed to do thigh squeezes, ankle pumps and buttock squeezes to improve the circulation. The diet of the patient should be re assessed in the follow up (Di Monaco & Castiglioni, 2013).

Evaluation

After the appropriate nursing interventions the patient outcome can be evaluated by monitoring the vital signs and get an overview of Jack’s current health condition (Rathert et al., 2014). The pain assessment can be done by using a numeric rating scale. Lower the value, better is the outcome. Finally a verbal feedback can be obtained from the patient to assess the general wellbeing of the patient, regarding his gait disturbances or nausea or vomiting or any sort of discharge from the wound.

Reflection

Case study analysis enhances the skill of clinical reasoning and critical thinking among the nurses.  This has helped me to develop my judgment, evaluation and the problem solving skills. Clinical reasoning helps has helped me to link the symptoms of the patient with the underlying pathophysiology that has further helped me to plan the goals for this concerned patient. Clinical reasoning and critical thinking forms the base of the evidence based practice. The establishment of the long and the short term goals has helped be to consider the interventions required for this specific patient. This has also helped in my understanding the importance of the multidisciplinary teams in enhancing care for the patients. As per the NMBA standard 1, it is necessary to assess, analyses, and use the best possible evidence in making decisions and provide a safe quality of care to the patient (Nursing and Midwifery Board of Australia., 2018). A thorough analysis of this case study has helped me to comply with this standard and overall enhanced my professional standard.

Conclusions

In conclusion it can be said that the post-operative period after a femoral neck fracture can be eventful and lead to hospital readmissions. However a proper assessment of the clinical manifestation before the discharge and a proper discharge planning can improve the quality of life posy discharge. The clinical reasoning cycle has proved as an active tool for the nurses for deciding a patient specific interventions.   

References

Bandholm, T., & Kehlet, H. (2012). Physiotherapy exercise after fast-track total hip and knee arthroplasty: time for reconsideration?. Archives of physical medicine and rehabilitation, 93(7), 1292-1294.

Barrington, J. W., Halaszynski, T. M., & Sinatra, R. S. (2014). Perioperative pain management in hip and knee replacement surgery. American journal of orthopedics (Belle Mead, NJ), 43(4 Suppl), S1-S16.

Berstock, J. R., Beswick, A. D., Lenguerrand, E., Whitehouse, M. R., & Blom, A. W. (2014). Mortality after total hip replacement surgery: A systematic review. Bone & Joint Research, 3(6), 175–182. https://doi.org/10.1302/2046-3758.36.2000239

Carpintero, P., Caeiro, J. R., Carpintero, R., Morales, A., Silva, S., & Mesa, M. (2014). Complications of hip fractures: A review. World Journal of Orthopedics, 5(4), 402–411.

Di Monaco, M., & Castiglioni, C. (2013). Which type of exercise therapy is effective after hip arthroplasty? A systematic review of randomized controlled trials. Eur J Phys Rehabil Med, 49(6), 893-907.

Hu, F., Jiang, C., Shen, J., Tang, P., & Wang, Y. (2012). Preoperative predictors for mortality following hip fracture surgery: a systematic review and meta-analysis. Injury, 43(6), 676-685.

Hung, W. W., Egol, K. A., Zuckerman, J. D., & Siu, A. L. (2012). Hip fracture management: tailoring care for the older patient. JAMA, 307(20), 2185-2194.

Kaye, A. D., Baluch, A., & Scott, J. T. (2010). Pain Management in the Elderly Population: A Review. The Ochsner Journal, 10(3), 179–187.

Khan, M. A., Hossain, F. S., Ahmed, I., Muthukumar, N., & Mohsen, A. (2013). Predictors of early mortality after hip fracture surgery. International orthopaedics, 37(11), 2119-2124.

McKenna, L. & Lim, A.G. (2012). Pharmacology for nursing and midwifery. (!st Australian and New Zealand Edition). Broadway: Lippincott Williams & Wilkins

Nursing and Midwifery Board of Australia. (2018). Code of Professional Conduct for Nurses in Australia. Access date: 15th August 2018. Retrieved from: https://www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx

Pathan, H., & Williams, J. (2012). Basic opioid pharmacology: an update. British journal of pain, 6(1), 11-16.

Rathert, C., Wyrwich, M. D., & Boren, S. A. (2013). Patient-centered care and outcomes: a systematic review of the literature. Medical Care Research and Review, 70(4), 351-379.

Reid, M. C., Eccleston, C., & Pillemer, K. (2015). Management of chronic pain in older adults. The BMJ, 350, h532.

Varon, J., & Marik, P. E. (2008). Perioperative hypertension management. Vascular Health and Risk Management, 4(3), 615–627.

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