Clinical Reasoning Cycle Case Study Answer

Introduction

The case study is about a patient named Sarah Smith, aged 36 years old, who is admitted to the respiratory ward. The patient was admitted to the ED as she has been experiencing shortness of breath, fever, and a productive cough. COVID-19 test is negative and Influenza PCR is pending. The medical history of the patient suggests that she experienced mild asthma in childhood, she was a non-smoker and is vaccinated for COVID-19. The social history of the patient suggests that the patient lives with partner Michael along with two children who are aged 6 and 8. The patient also works as a teacher part-time in a primary school. Objective data of the patient is recorded, the temperature is 39.2, pulse rate is 100 breaths/minute, BP is 110/60 mm Hg, respiratory rate is 28 breaths/ min, SpO2 was 92% and GCS score is 14. The subjective data suggest that the patient is breathless to eat, hence consuming small sips of fluid. The patient needs two pillows and the patient reported 2/10 pleuritic thoracic pain, along with its analgesics should be reduced. The patient has experienced dry mucous membranes and sunken eyes.

Collect cues

The current status of the patient suggests that she has been experiencing shortness of breath, fever, and a productive cough. Upon studying the objective and subjective data, it has been concluded that the patient is diagnosed with community-acquired pneumonia (CAP). CAP is the major and leading cause of mortality or morbidity around the world. The clinical presentation of CAP varies widely and it ranges from mild pneumonia which is also characterized by some respiratory distress and sepsis. There are several causes of CAP and these are described below. Some of the causative agents are influenza A, Streptococcus pneumonia, chlamydophila pneumonia, and Mycoplasma pneumonia. In the case study, the patient has experienced some symptoms of these conditions and these are shortness of breath, fever, and a productive cough. Several risk factors affect CAP and are cigarette smoking, and chronic lung diseases such as cystic fibrosis, COPD, and bronchiectasis. Stroke, dementia, brain injury, cerebral palsy, and other brain disorders. Other than this there are several illnesses and if people are diagnosed with such illnesses they are at high risk, these conditions are diabetes, heart disease, and liver cirrhosis. Many patients with immune system problems such as due to cancer treatment, organ transplants, HIV or AIDS, and other diseases.

Process

While collecting objective data it has been observed that there are several abnormal data of the patient present, these are mentioned below. The pulse rate measured is 100 beats/per minute, however, the normal pulse rate is between 60-100 beats per minute. The RR of the patient is noted to be 28 breaths/min, while the normal range is 12-14 breaths/min, BP recorded of the patient is 110/60 mm Hg, while normal BP is 120/80 mm Hg, this also does not lie in the normal range (Sapra et al., 2021). When the Sp02 level is measured then it is also lower than expected, it should be 92%, while it should be 95%. The urine output of the patient is 350 ml in 12 hours, and orange in color, however, the normal range is 800-2,000 milliliter/ day, hence the value is not maintained (Brekke et al., 2019). In CAP the patient faces problems in the breathing process and the same has been observed in the case study. Dry mucus is observed and breathing problems are also affected. All these cues which are collected need to be taken care of. There are several causes of CAP and these are, and the person with a high risk of diabetes, heart disease, and liver cirrhosis is more prone to getting affected by CAP. If the immune system of the person is weak, the chances of getting affected by CAP increase (Shneyderman et al., 2022).

Two problems/ issues

The first problem is that the patient is facing breathing issues, in this the patient is unable to breathe and hence, it affects the functioning of other organs. It can cause panic attacks, and in some cases, it might lead to fatigue and dry mouth. In other cases, it can cause respiratory problems and it is also a precursor of cardiovascular issues. The irregular breathing pattern also creates tension in other parts of the body. If the breathing rate is not maintained, then the body is unable to absorb the oxygen, and the concentration of carbon dioxide is increased. The muscles which control the movement of the lungs should function effectively (Hashmi et al., 2023).

Pyrexia is another complication that is observed, in this the body temperature is raised and fever is observed. In this condition elevation of the core temperature is observed and it is set above a certain point. The set point which is present should be regulated in the hypothalamus. The patient with pyrexia is often presented with fever, along with cough and purulent sputum. In addition to it, pleuritic chest pain and dyspnea. To control this it is necessary that this condition needs to be understood and taken care of (Sharma et al., 2023).

Establish goal

The first problem which is mentioned here is a breathing problem hence, the goal which is defined here is to maintain the breathing pattern. The breathing pattern which is maintained will help to maintain the other body function. Restoration of breathing patterns ensures that oxygen is restored so that every part of the body receives an adequate amount of oxygen.

The next goal is to control the temperature of the body because, in pyrexia, there is an increase in the body temperature. There might be several factors that lead to an increase in body temperature. All these factors need to be understood and then steps should be taken towards it (Bolzani et al., 2017).

Take action

Several nursing interventions can be adopted to control the breathing rate and some of them are described below. The nurse should help the patient by teaching them the breathing style. In addition to these conditions, breathing patterns can also change due to heart failure, hypoxia, airway obstruction, diaphragmatic paralysis, infection, neuromuscular impairment, trauma or surgery that causes musculoskeletal impairment and pain, cognitive impairment, anxiety, diabetic ketoacidosis, uremia, thyroid dysfunction, peritonitis, drug overdose, AIDS, acute alcohol withdrawal, cardiac surgery, cholecystectomy, liver cirrhosis, craniocere. Increased heart rate, blood pressure, and inefficient breathing patterns can all be brought on by pain. To avoid pain, some people breathe very shallowly. They are unable to receive enough oxygen as a result. The nurse needs to look for both vocal and nonverbal indications of discomfort. There are several breathing control exercises such as respiratory muscle training and this will help in normalizing breathing. The nurses can also assess the medical history of the patient and then steps should be taken accordingly to control the breathing rate. In certain cases, nurses also provide help with mechanical ventilation, which assists the patient in the breathing process. Nurses should also measure the ABG level, this will allow them to get a clear idea of the gas exchange process and how they work effectively. The breathing pattern of the patient should be observed and then underlying disease dysfunction or process should be studied. Some of the rates or the depths of breathing patterns are mentioned below and these are: apnea, in which this temporary cessation of breathing occurs, in some cases ataxic pattern is also observed (Whited & Graham, 2023).

To control pyrexia, certain steps can be adopted. The first important thing is the administration of drugs. Certain essential drugs which are used are: ibuprofen or acetaminophen, these medications should be used according to the instructions present on the label. Several risk factors contribute to it, all these risk factors need to be taken into consideration (Hopkinson et al., 2017).

Evaluate

All the nursing care strategies which are adopted by the nurse help to improve the patient's condition. When the breathing pattern is worked on for the patient, it will improve. Mechanical ventilation is used because it will help restore breathing. To control pyrexia, the temperature should be controlled. In certain cases of pyrexia, the temperature should be controlled, this will help to maintain the well-being of the patient. The temperature of the body is raised in pyrexia and the major reason for it is an increase in inflammation, hence, this needs to be controlled. All the risk factors which are present should be controlled and effective steps need to be taken (Marlow et al., 2019).

Reflect

From this case study, there are several learning things, the first important thing to note down is to work toward the well-being of the patient. Upon administration of drugs, the nurse will develop an idea about the drugs and how they should be administered.

Conclusion

 In the case study, while observing the patient, a large number of the patient's data do not lie in the normal range, hence, this needs to be balanced. There are mainly two problems identified in the patient: the first problem is that the patient is facing breathing issues, and in this, the patient is unable to breathe. Pyrexia is another complication that is observed, in this the body temperature is raised and fever is observed. Both these conditions should be managed for adequate functioning. Several nursing interventions can be adopted to control the breathing rate and body temperature.

References

Bolzani, A., Rolser, S.M., Kalies, H., Maddocks, M., Rehfuess, E., Swan, F., Gysels, M., Higginson, I.J., Booth, S., & Bausewein, C. (2017). Respiratory interventions for breathlessness in adults with advanced diseases. The Cochrane Database of Systematic Reviews, (6), CD012683. https://doi.org/10.1002/14651858.CD012683

Brekke, I.J., Puntervoll, L.H., Pedersen, P.B., Kellett, J., & Brabrand, M. (2019). The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PloS One, 14(1), e0210875. https://doi.org/10.1371/journal.pone.0210875

Hashmi, M.F., Modi, P., & Basit, H, et al. Dyspnea. (2023). StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499965/

Hopkinson, N.S., Baxter, N., & London Respiratory Network (2017). Breathing SPACE-a practical approach to the breathless patient. NPJ Primary Care Respiratory Medicine, 27(1), 5. https://doi.org/10.1038/s41533-016-0006-6

Marlow, L.L., Faull, O.K., Finnegan, S.L., & Pattinson, K. T.S. (2019). Breathlessness and the brain: The role of expectation. Current Opinion in Supportive and Palliative Care, 13(3), 200–210. https://doi.org/10.1097/SPC.0000000000000441

Sapra, A., Malik, A., & Bhandari, P. (2022). Vital sign assessment. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553213/

Sharma, S., Hashmi, M.F., & Badireddy, M. (2023). Dyspnea on exertion. StatPearls, Available from: https://www.ncbi.nlm.nih.gov/books/NBK499847/

Shneyderman, M., Yin, E., Levin, A., Aliu, O., Sun, D., & Cohen, A. J. (2022). Vital sign measurement and response to abnormal measures in surgical specialty clinics. JAMA Network Open, 5(4), e229491. https://doi.org/10.1001/jamanetworkopen.2022.9491

Whited, L., & Graham, D.D. (2023). Abnormal Respirations. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470309/

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