Mrs. Deborah Scott Nursing Case Study Sample

Clinical Reasoning Cycle

This essay discusses the case study for the care of Mrs. Deborah Scott by the nursing staff using the Levett-Jones clinical reasoning cycle. This cycle of reasoning helps to respond to her unstable clinical manifestation during her hospitalization in the medical ward and to ensure that there is a best possible positive outcome for her as a patient in less amount of time.

Considering the Situation of The Patient

Mrs. Deborah Scott is a woman of 65 years who is admitted to the Public Hospital. She was taken to the Emergency Department (ED) after being found lying in her bedroom by her husband. This is Deborah 's third hospital admission, with a downturn in the last six months. The x-ray in the chest is suggestive of broken ribs and chest wall injuries.

Collect Cues and Information.

She has a record of medical problems like diabetes which is type II insulin-dependent, and osteoarthritis. She also has medical conditions like chronic obstructive pulmonary disease (COPD), and hypertension. She is taking prescribed medications for all the above-mentioned conditions which include vitamin D, panadol Osteo, ventolin, atenolol, spironolactone, telmisartan, metformin, novolin 70/30, and symbicort drugs. The medications reveal that she has high blood pressure issues on the risk of heart failure and strokes. She suffers from Osteoarthritis and taking Panadol Osteo for fast and effective pain relief and discomfort associated with aches. Because of her age, she is on vitamin D supplements as well so that she does not get deficient in Vit D as the deficiency causes thin and brittle bones (Christodoulou et al., 2013). This is her third fall in the last six months so she is in medications. the medications Ventolin and symbicort prescribed also treats her COPD condition as it relaxes muscles in the airways and increases airflow to the lungs (Lin et al., 2018).

Process Information

A most frightening problem of fractured ribs is the flail chest in which three or even more rib fractures on the involved ribs at two points, generating a floating rib part and causing this part to paradoxically move along with the rest of the chest. Flail chest mortality ranges from 10 percent to 15 percent (Perera & King, 2018). In all patients with potential thoracic trauma, the physical examination should be done. It is important to record the full collection of vital elements including correct measurement of respiratory rate and oxygen saturation, and from time to time. For bilateral breath sounds, the patient must also be monitored and then palpated for pain, deformity, or crepitus. A close examination of the chest must be done for bruise or bleeding. The patient mostly have complained about severe pain in the chest wall, and may have tachypnea and splinting or respiratory insufficiency.

The chest movement has to be observed for flial chest. Inspired by the flail section, the remainder of the chest extends and the flail section expires when the majority of the chest contracts are taken out. When ribs are fractured there is potential for injury to the lungs or any other organ near to the ribs (Kuo & Kim, 2019). The fracture location inside the thorax could be used to recognize areas of potential injury. The first or second rib fracture can lead to lung injury, injury to the aorta, subclavian artery, and brachial plexus. Usually, the first and second ribs are not fractured because these are well guarded, making them harder to break. Lower rib rupture on the left can cause spleen serious injuries, and on the right side, the liver can get injured. Renal injuries may occur if the fractures happen in the eleventh and twelfth ribs. Assessment of respiratory specifications in patients with significant trauma to the chest can be a strong indicator of the severity of the injury and possible prognosis (Akgul Ozmen, Onat, & Aycicek, 2017).

Identify Problems

Pain- Effective management of intense pain is based on a precise and effective evaluation of pain in the patient. The evaluation should use a recognized tool that requires patient involvement to systematically record pain intensity on move. It has also been demonstrated that pulmonary function and morbidity associated with multiple rib fractures are improved. Mrs. Deborah Scott can be provided the combination of a local anaesthetic such as bupivacaine, and an opioid such as fentanyl through an epidural catheter. These two are synergistic in effect, and the desired analgesic effect in the patient can be achieved fast while reducing the potential for unintended side-effects (Parate et al., 2015). Epidural analgesia is given to only patients who are nursed in high-dependency facilities in hospital settings.

The drug Paracetamol possesses desirable analgesic effects, especially when it is used in combination with other medicines. It reduces the pain as it has a morphine-sparing effect. NSAIDs such as diclofenac or ibuprofen are also given to patients for pain relief. It inhibits enzyme cyclo-oxygenase (COX) activity and thus it prevents the release of inflammatory mediators or prostaglandins. It also helps in reducing the inflammation related to bone injury and tissue damage to the surrounding area (Crofford, 2015). However, caution must be used because NSAIDs are known to reduce activity in osteoblast (bone-forming cell), as the patient, Mrs. Deborah Scott is having osteoporosis (De Luna-Bertos et al., 2013). Therefore, the discontinuation of the medication should be considered if any symptoms of delayed bone union are reported during the time of recovery.

Pneumothorax- It is a condition that occurs in the collapsed lung, pressure changes occur inside the chest. This may be caused by a fractured rib splitting the lung in the chest wall, or a puncture. Symptoms may include difficulty in breathing, trouble in swallowing, chest pain, and blood coughing in some cases (Swierzy et al, 2014). A pneumothorax usually requires a procedure using a chest tube to drain the air out from the chest. The pneumothorax treatment principles include five principles: eliminating air, decreasing air leakage, curing pleural fistula, supporting re-expansion, and prevent potential recurrences, and it is important to treat medical conditions, preventing other complications (Huang et al., 2014).

Establish Goals

Resolve the chest pain that Mrs. Deborah Scott is experiencing or at least make sure that pain levels are reduced to a satisfactory level so that she can continue and carry out daily life activities without much distress in the best possible way. Mrs. Deborah Scott should be called upon to self-report on the pain levels, as it remains the good and best option to determine whether the pain has dropped down. Healthcare professionals also need to use a behavioural rating scale and pain monitoring tool for acute care to evaluate the effects of medications, other medicinal options used to establish efficacy (Gélinas, 2016). A person suffering from pneumothorax faces serious impact the respiratory mechanics, so the nursing care should necessitate ventilation assistance to promote the level of blood oxygen and potentially fix the fractures with plates of metal.

Evaluate Outcomes

Mrs. Deborah Scott should be evaluated and re-evaluated in terms of pain levels and until she does not report comfortable levels of pain. She should be made enable to undertake her daily activity of life. Her breathing problems have to be resolved. She can be educated and made aware of her conditions so that she can avoid breathing difficulties by avoiding the triggers. She is also made to understand the importance of living a good and healthy lifestyle which includes dietary habits and regular physical exercises.

Reflection on Clinical Reasoning Cycle

Every time I have to make sure that the patient is properly handed over using tools like ISOBAR, because in this case, Mrs. Deborah Scott medical details were missing which is critical in delivering clinical treatment. There were no details provided such as the collection of vital signs after her hospital admission. Being the person in charge of the team I should have asked the multidisciplinary health team members for all the required documents related to Mrs. Deborah Scott nursing care (NMBA, 2020). In conclusion, I also understand how critical is management skills and timely interventions for me being a nurse in the acute hospital settings. Comprehensive and complete documentation, teamwork skills, and effective communication would make the distinction between the life and death of a patient. The development of clinical reasoning and critical thinking in nurses helps to ensure patients safety and holistic care by open-minded which is the positive aspect of this practice.

References for Clinical Reasoning Cycle

Akgul Ozmen, C., Onat, S., & Aycicek, D. (2017). Radiologic findings of thoracic trauma. Therapeutics and Clinical Risk Management, 13, 1085–1089. https://doi.org/10.2147/TCRM.S143845

Christodoulou, S., Goula, T., Ververidis, A., & Drosos, G. (2013). Vitamin D and bone disease. BioMedical Research International, 396541. https://doi.org/10.1155/2013/396541

Crofford, L. J. (2013). Use of NSAIDs in treating patients with arthritis. Arthritis Research Therapeutics. 15, S2. https://doi.org/10.1186/ar4174

De Luna-Bertos, E., Ramos-Torrecillas, J., García-Martínez, O., Guildford, A., Santin, M., & Ruiz, C. (2013). Therapeutic doses of nonsteroidal anti-inflammatory drugs inhibit osteosarcoma MG-63 osteoblast-like cells maturation, viability, and biomineralization potential. The Scientific World Journal, 809891. https://doi.org/10.1155/2013/809891

Gélinas C. (2016). Pain assessment in the critically ill adult: Recent evidence and new trends. Intensive Critical Care Nursing. 34, 1‐11. doi:10.1016/j.iccn.2016.03.001

Huang, Y., Huang, H., Li, Q., Browning, R. F., Parrish, S., Turner, J. F., Jr, Zarogoulidis, K., Kougioumtzi, I., Dryllis, G., Kioumis, I., Pitsiou, G., Machairiotis, N., Katsikogiannis, N., Courcoutsakis, N., Madesis, A., Diplaris, K., Karaiskos, T., & Zarogoulidis, P. (2014). Approach of the treatment for pneumothorax. Journal of Thoracic Disease, 6(4), S416–S420. https://doi.org/10.3978/j.issn.2072-1439.2014.08.24

Kuo, K., & Kim, A. M. (2019). Rib Fracture. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541020/

Lin J, Zhou X, Wang C, Liu C, Cai S, Huang M. (2018) Symbicort® Maintenance and Reliever Therapy (SMART) and the evolution of asthma management within the GINA guidelines. Expert Review Respiratory Medicine. 12(3), 191‐202. doi:10.1080/17476348.2018.1429921

Nursing and Midwifery Board of Australia. (2020). Registered nurse standards for practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

Parate, L. H., Manjrekar, S. P., Anandaswamy, T. C., & Manjunath, B. (2015). The effect of addition of low dose fentanyl to epidural bupivacaine (0.5%) in patients undergoing elective caesarean section: A randomized, parallel group, double blind, placebo controlled study. Journal of Postgraduate Medicine, 61(1), 27–31. https://doi.org/10.4103/0022-3859.147032

Perera TB, King KC. (2019). Flail Chest. [Updated 2019 Nov 29]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534090/

Swierzy, M., Helmig, M., Ismail, M., Rückert, J., Walles, T., & Neudecker, J. (2014). Pneumothorax [Pneumothorax]. Zentralbl Chir. 139(1), S69‐S87. doi:10.1055/s-0034-1383029

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