Using Levett Jones Clinical Reasoning Cycle For The Provision Of Care For Ms Melody King With Peritonitis, Essay.

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:

1.Consider the person’s situation

2.Collect, process and present related health information

3.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.

4.Establish goals for priority of nursing care related to the nursing problem/issues identified

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

6.your nursing care strategies to justify the nursing care provided

7.Reflect on the person’s outcomes

According to the Nursing and Midwifery Board of Australia (2018), it is the duty of the nursing professional to practice via reflectivity and ethically. One of important nursing reflection frame-work is Levette Jones Clinical Reasoning Cycle (Levett-Jones, 2018). This essay will follow Levett Jones clinical reasoning cycle in order to discuss the provision of care for Ms Melody King, a 36 year old woman with peritonitis following ruptured appendix. The care plan for the patient will be based on her present post surgical condition. The care plan will mainly highlight three main nursing goals through collection of clues and identification of the problems.

Ms Melody King is a 36-year old woman with peritonitis following ruptured appendix. At present she is the post surgical unit following laparoscopic excision of the ruptured appendix. Her present vital statistics include low blood pressure (BP: 95/45 mm Hg), fast heart beat (HR: 120 beats per minute), elevated body temperature (38.3 degree Celsius) and normal level of oxygen saturation at room temperature (95%). Melody is also complaining about nausea along with pain in abdomen (7 to 8 on pain scale). The present observation highlights distended abdomen and the results of blood test showed high level of white blood cells (WBC) and C-reactive protein count (CRP). 

The vital signs accumulated during the post surgical condition highlighted that Ms Melody King has low blood pressure, high body temperature and high heart rate. Her pain stimulus at the central part of abdomen is high along with distended abdomen. Her blood infection rate is also high as indicated by her high WBC count and high serum concentration of CRP. According to McCane and Huether (2018), the main indicators of septicemia are high WBC count and high level of CRP in blood. Her fast heart rate might be due to her past clinical condition of bronchospasm as highlighted through list of medication, Ventolin. Past history also indicates that Ms Melody King has asthma, which might be another reason behind her fast heart rate (McKenna & Lim, 2012).

One of the significant clinical histories for Ms Melody King is her asthmatic tendency. Asthma, a debilitating respiratory illness, hampers the health and well-being of a person via causing breathing problem. Asthma mainly causes inflammation in the airways and thus creating blockage in the pulmonary gas exchange. This blockage in gas exchange increases the heart rate and respiratory rate (Forbes & Watt, 2015). Thus post surgical condition of Ms Melody might report breathing problems. However, the level of oxygen saturation is within the normal range (95 mm Hg) and this may overall further shortness breath arising out of asthma (Forbes & Watt, 2015). Her blood report indicated the presence of septicaemia post surgery. Hence blood infection level needs to be controlled. Another important consideration is depression. According to Lee et al. (2016), post laparoscopic operation following peritonitis, level of depression among the patient increases as the patient is required to take bed-rest for long span of time. Since, Ms Melody King is already a victim of depression, her chances of getting affected with severe depression will be high. 

Identified problems

The first identified problem is low blood pressure. The blood pressure parameter shows that Ms Melody has low blood pressure. This is not normal taking her age into consideration (36 years). On the other hand, clinical history of asthma increases the chance of developing high blood pressure (Chung et al., 2013). Nevertheless, irrespective of her past reported history, her blood pressure was found below the optimum range and this can delay her recovery in the post operative condition. The low pressure accompanied with high heart rate can cause further complications and thus must be taken into consideration (McCance & Huether, 2018).

The second identified problem is high level of blood septicaemia. According to McCance and Huether (2018), post surgical recovery after appendectomy following peritonitis is long as there are chances of internal infection. Ms Melody King’s blood infection rate is high as indicated by the high level of WBC and CRP. This can be a problem under post-operative condition as it may result in sceptic shock of massive outbreak of the type 1 hypersensitivity reaction. Moreover, post-surgical weakness will make Melody more vulnerable to hypersensitivity shock. Her body temperature was high than the normal range (Normal range: 37 degree C). This is however not significantly alarming in comparison to the low blood pressure. But, high body temperature is indicated as first sign of infection or inflammation and case report also reveals that Melody has high level of blood infection. Thus, proper regulation of body temperature is important (Meire & Lee, 2017).

The third identified problem is her shallow respiratory rate. According to Forbes and Watt (2015) shallow respiratory rate is the first indicator of hypoxia. Hypoxia is a pathological condition of the body which is characterised via lack of adequate oxygen supply in the different organs (Trayhurn 2013). The chance that Melody is getting affected with hypoxia is high because she has previous reported cases of bronchospasm as indicated by her list of medication (ventolin) and asthma (seretide).

Another identified problem is her distended abdomen. According to McCance and Huether (2018), distended abdomen or swelling of abdomen mainly results from the accumulation of water or gas inside the abdomen. In case of Melody, accumulations of gas inside the stomach due to indigestion will he high in post surgical condition. Kothadia, Katz and Ginzburg (2015) excision of appendix increases the probability of indigestion leading to increase in the acidic and gastric problems.

Nursing goals and actions

High pain score in the abdomen can hamper health and well-being of Melody (McCance & Huether, 2018). This pain may increase their level of depression in Melody and thus making her post-surgical stay miserable.

Goal 1: To check the condition for hypoxia. Since, Melody is an asthmatic patient and at present suffering from because checking her oxygen saturation is important. McKenna and Lim (2012) highlighted that decrease in oxygen saturation within the body increase the threat of developing nausea. Hypoxic condition if not treated early may result in breathlessness and the conditions are more severe if the patient has asthma (Reddel et al., 2015). Maintenance of adequate level of oxygen within the body with normal bread thing cycle also helps to reduce the pain sensation and threat of developing anxiety (O’reilly, 2014). 

Action: The gaol will be accomplished via monitoring of the oxygen saturation within the body. This can be done via the use of pulse oximetry (O’reilly, 2014). Pulse oximetry is a non-invasive method of oxygen monitoring and it helps to denote peripheral oxygen saturation within the blood (SpO2). At any point of time, if the oxygen saturation is found below 90, external supply of oxygen will be provided to Melody. Proper supply of oxygen within the body will promote active breathing and will help to reduce the consequences of hypoxia.

Goal 2: Relief from pain. The reason behind this is, comfort is the important for fast recovery in post-operative unit. The pain stimulus is high in Melody due to distended abdomen. Proper reduction of pain stimuli will help Melody to relax and this will promote fast recovery.

Action: The main actions which will be taken in order to nullify the high pain score is proper patient monitoring (Barr et al., 2013). Since, pain score of Melody is high an early intervention of doctor is must in order to manage the pain. My duty will be to provide the patient proper pain relieving medication as prescribed by the doctor. Patient position is also vital towards proper management of pain and as a registered nurse I will modify the lying position of Melody in order to provide her utmost comfort. If Melody was in naso-gastric tube (NG tube) in order to reduce her gastric distension, then as a post-operative nurse, I will also check the placement of the NG tube and will cross-verify whether the pain is resulting from miss-placement of the NG tube and then will take necessary actions for pain reduction.

Evaluation of outcomes

Goal 3: The third goal will be to control of the high rate of infection. The goal is vital because, Melody’s blood report highlight that her WBC count and CRP count is extremely high. Reduction of the blood infection will promote fast recovery in the post-operative condition. If blood infection is not controlled then it might give rise of spesecemia (McCance & Huether, 2018).

Action: The main action which I will take to reduce the internal infection is to notify the doctor and showing him the blood report. If the doctor prescribes antibiotic then I will follow the doctor’s guidelines to proper administration of antibiotic and checking the blood infection level periodically.

The main actions which I will take into consideration while giving care to Melody is proper monitoring of her blood infection level, oxygen saturation level and proper tabulation of vital parameters. If at any point of time, I find her vital parameters deviating fro normal, I will can in doctor. I will also involve in active conversation and therapeutic relation with Melody in order to reducing the chance of Melody passing into depression. Lee et al. (2016) highlighted active communication with patient helps to reduce the probability of developing depression in post-operative ward. 

Evaluation of the outcomes will be done via periodic monitoring and comparing past and present patient’s health record data. The main parameters which will be monitored include WBC count, CRP count, blood pressure, oxygen saturation, respiratory rate and heart rate.

One of my new learning is, I will indulge in active communication with the patient. This will not help to side-pass the chance of depression but will also increase his or her participation in care plan. This belongs under standard 9 of NMBA code of conduct. I will also consult with other healthcare professionals while drafting care plan for patient.

Conclusion

Thus from the above discussion, I can be concluded that there main goals for Melody’s care plan are control of internal infection, pain management and monitoring of the oxygen saturation. Another additional factor which must be taken into consideration is patient’s depression in post-operative ward. Active communication and interaction will help to overcome the chances of patient’s depression and will increase patient participation in care plan. 

References

Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., ... & Coursin, D. B. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical care medicine, 41(1), 263-306.

New learnings

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Chung, K. F., Wenzel, S. E., Brozek, J. L., Bush, A., Castro, M., Sterk, P. J., ... & Boulet, L. P. (2013). International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. European Respiratory Journal, erj02020-2013.

Forbes, H., & Watt, E. (2015). Jarvis's Physical Examination and Health Assessment. Elsevier Health Sciences.

Kothadia, J. P., Katz, S., & Ginzburg, L. (2015). Chronic appendicitis: uncommon cause of chronic abdominal pain. Therapeutic advances in gastroenterology, 8(3), 160-162.

Lee, D. S., Marsh, L., Garcia-Altieri, M. A., Chiu, L. W., & Awad, S. S. (2016). Active mental illnesses adversely affect surgical outcomes. The American Surgeon, 82(12), 1238-1243.

Levett-Jones, T. (2018). Clinical Reasoning: Learning to think like a nurse (2nd Ed). Frenchs Forest, N.S.W: Pearson. Access date: 15^th August 2018. Retrieved from: https://www.utas.edu.au/__data/assets/pdf_file/0003/263487/Clinical-Reasoning-Instructor-Resources.pdf

McCance, K. L., & Huether, S. E. (2018). Pathophysiology-E-Book: The Biologic Basis for Disease in Adults and Children. Elsevier Health Sciences.

McKenna, L. & Lim, A.G. (2012). Pharmacology for nursing and midwifery. (1st Australian and New Zealand Edition). Broadway: Lippincott Williams & Wilkins

Meier, K., & Lee, K. (2017). Neurogenic fever: review of pathophysiology, evaluation, and management. Journal of intensive care medicine, 32(2), 124-129.

Nursing and Midwifery Board of Australia. (2013). National competency standards for the registered nurse. Access date: 15^th August 2018. Retrieved from: https://www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx

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

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Trayhurn, P. (2013). Hypoxia and adipose tissue function and dysfunction in obesity. Physiological reviews, 93(1), 1-21.

Yu, C. W., Juan, L. I., Wu, M. H., Shen, C. J., Wu, J. Y., & Lee, C. C. (2013). Systematic review and meta?analysis of the diagnostic accuracy of procalcitonin, C?reactive protein and white blood cell count for suspected acute appendicitis. British Journal of Surgery, 100(3), 322-329.