NRSG378: Extended Clinical Reasoning Assessment Answer

Pathophysiology and Patient Assessment

The name of the patient is Kate, a 22-years old, she was admitted to the emergency department. The symptoms with which she was presented in the ED are nausea, abdominal pain, general malaise, and vomiting. The patient stated that the pain started 3 days before. In the initial stage, the pain was localized in the right lower quadrant and dull. However, it started to develop. Last night the pain started to peak and she vomited. The bowel movements were also irregular and dark yellow. The patient has been diagnosed with perforated appendicitis, in this the common symptoms which are observed are the same as mentioned in the case study. The HR of the patient is 118 bpm, the pulse is regular, BP recorded is 90/60 mmHR, RR recorded is 24 bpm, mild WOB, temp is 39.2C and SpO2 97% on RA.Some of these symptoms are sudden pain on the right side of the abdomen, with time the pain becomes worse, vomiting, and nausea (Jones et al., 2022).

The major pathophysiology of acute appendicitis is due to the rupture or perforation of the appendicitis. In this condition, the stool content is leaked into the appendix, and then it is moved into the abdominal cavity. In addition to it, there is also the release of inflammatory mediators, bacteria, and fluids, all of which are released in the abdominal cavity. Due to the release of these substances, the peritoneal surface again becomes inflamed, disrupting normal function. Pain is a very common symptom observed and it is due to peri-umbilical, and the place where it is present. In the initial stage, the pain can be dull, localized, and poor (Krzyzak & Mulrooney, 2022). However, later it migrates to the right iliac fossa, where the pain is sharp and localized. Another symptom is vomiting, and mainly it is after pain. The major reason for it is due to rebound tenderness, some pain, and in severe cases it might be due to appendiceal abscess.

Several nursing assessments need to be performed; these are mentioned here. The patient has experienced some pain, this pain needs to be assessed and the source of this pain needs to be studied (Becker et al., 2018).

Several nursing assessments need to be followed in acute appendicitis, and these are: vital signs need to be assessed and any change in the temperature or heart rate should be noted. In several cases, there are chances of increased heart rate like in the case study it is 118 bpm, and this can be an indication of infection or inflammation. Other than this patient's pain level and location needs to be monitored, as it changes continuously. The BP recorded is 90/60 mmHR, RR recorded is 24 bpm. In addition to it, there is pain in the right lower quadrant, it is necessary to control the pain, as it will provide some effective measures. Nursing management is highly important, as it covers several aspects, in addition to it, it also provides holistic care to the patient (Krzyzak & Mulrooney, 2022). All the needs of the patient are addressed and taken care of. In several cases, it has been observed that there is a volume deficit, and this volume deficit needs to be worked on. Ways should be adopted to overcome volume deficit.

Nursing and Patient Issues

Several nursing issues are present, however, the top 3 priorities will be discussed here. The priority which needs to be addressed is that Kate is in a lot of pain, the pain score is recorded as 8/10, and this pain is becoming worse, hence it requires immediate attention. If the pain is not managed effectively then it will hamper the quality of care. However, if it is managed appropriately then quality of life becomes better. The likelihood of patients sleeping better and leading a better life is increased. If the person feels more energy during the day and they are more active, this prevents certain complications. Controlling pain management will help to ease the suffering of the patient (Snyder et al., 2019).

As the abdominal pain was becoming worse and sharp, it was intolerable. All these conditions have led to vomiting, regular vomiting will lead to dehydration. Hence, nurses should ensure that the hydration level is maintained so the patient can carry out day-to-day activities. Hydration level is important because it will maintain the functioning of the person, hence, it needs to be adapted (Teng et al., 2021).

Due to such a high frequency of vomiting the patient is unable to eat and drink, which will lead to weakness among the patient. Hence, the nurses need to ensure that the patient is regularly provided with IV so nutrition status needs to be maintained. The requirement of IV is high as it will balance the nutritional status of the person. IV fluid will enable the patient to regain strength and along with it the patient's bloodstream should be taken care of.

There are several potential impacts of Kate's admission, the most important thing which needs to be considered is a reduction in pain. Upon admission, the pain will be reduced immediately and it will provide immediate relief (Breeding & Conran, 2020). If the patient is in continuous pain, then they will feel discomfort and hence, they will not be able to carry out daily life activities.

As the patient is vomiting regularly, the hydration level is reduced, hence, upon immediate admission, the hydration level is maintained. Immediately after admission IV fluid will be administered hence, the fluid level will be maintained. Changes in these two sections will help to improve the biological status of the person, hence, the overall functioning will be improved (Moris et al., 2021).

Since the patient presents a history of depression, hence, special care for the patient needs to be taken. In several instances patients might require emotional support, hence, emotional support should be provided. Actual issue is the emotional strength which is lacking is provided it will improve the health status at several levels. In addition to it, functioning should also be improved and work should be done in that direction.

Pharmacological Management

The major class of drugs which is used are: cefotetan and cefotaxime, these drugs are highly used. It is a single-drug use therapy and this drug provides gram-negative coverage along with anaerobic coverage. This drug is mainly responsible for stopping the growth of bacteria. These antibiotics only help in the treatment of bacterial infections. The major mechanism of action is to inhibit cell wall synthesis as it binds and inhibits the bacterial penicillin-binding protein. The inhibition is important because it affects the cell wall biosynthesis. It is a second-generation antibiotic and it requires single-drug therapy which will provide broad gram-negative coverage (Becker et al., 2019). The half-life of the drug is about 3.5h. The major function which takes place is that it inhibits cell wall synthesis as it binds to one or more penicillin-binding proteins. This step inhibits the final transpeptidation step of peptidoglycan synthesis and it results in the death of the cell wall. There are several side effects of drugs and some of these are: the patient might get affected by diarrhea, and in some cases, hypersensitive reactions might be observed. The hepatic enzyme evaluation might also be present. Other than this some common complications are: there can be prolongation in the bleeding time, other than this neutropenia, thrombocytopenia is also observed. Several nursing considerations might be followed and these are: if the person is getting affected by a lower respiratory tract infection then this medication can be avoided. Skin structure and infection should not be present, other than this urinary tract infection should also be provided, other than this intra-abdominal infection should also be not present (Gebre Selassie et al., 2021).

Another class of drug that is used for treatment is analgesics, this drug is used highly because in this condition patients might be in pain and this drug will help to relieve the pain. Although NSAIDs are used in pain relief, opioids might be used at the time of surgery to relieve any pain ((Longani & Ahmed, 2019). This class of medication is available widely, it is safe and inexpensive. There are several side effects of this medication, however, a common side effect is observed in the gastrointestinal system, and along with it bleeding is also observed. This drug acts directly on the spasmolytic action of the smooth muscle cell, and hence it helps to relieve or in some cases prevent the smooth muscle spasm of several organs. There are several indications of the drug and these are: it should not be administered after surgery, in cases if the patient has undergone surgery like fractured bone then it should be avoided. In addition to it, if the patient has encountered some acute pain, for example, a twisted ankle or headache, then administration of this drug needs to be avoided (Longani & Ahmed, 2019).

Nursing Intervention

There is a set of actions that needs to be taken to take care of the patient post-surgery, these actions and interventions are mentioned below. The most important thing to take care of is to get adequate rest, this will help the person to recover. If the person is leading a fast and inadequate lifestyle, it will slow down the recovery process, hence, complete rest should be taken. Lifting of any heavy objects should be avoided, this will help to avoid any strain on the abdominal muscle. However, the patient might resume their daily activities after some time. Other than this, it is necessary to maintain a clean environment, this is highly important to provide wound care to postoperative patients (Jones et al., 2021). After surgery, it is important to monitor a patient's vital signs such as heart rate and temperature. If hygiene is not maintained then there are several chances of infection, hence, it needs to be worked on. Some antibiotics might need to be administered, and these are essential as it is prescribed by the provider (Becket et al., 2018).

In several cases, it has been observed that the patient is in a lot of pain, and the level of pain needs to be controlled, this will help in adequate functioning of the patient. In some cases, as the intake of food is limited, the bowel movement might be affected. Hence, it is highly essential that bowel movement should be monitored and if there is any irregularity, it should be immediately reported. After surgery due to long resting time, some body parts might ache. Hence, the position must be maintained, it should be right-side lying or should be low to semi-fowler position to promote comfort. In several cases, the client might face some problems in the respiration process. Hence, it is necessary to maintain the respiratory rate of the person. One of the major steps which need to be taken is usually to remove the inflamed appendix. Before surgery, some antibiotics are administered and are administered to treat the infection. (Jones et al., 2022).

By keeping the patient updated on the care plan and making sure they are aware of their diagnosis and treatment options, you can lessen their worry. To maintain circulation, encourage patients to walk as much as is safe or permitted. To prevent DVT/clots, serial compression devices (SCD) and TED hose should be used if the patient is immobilized. Keep an eye out for regular bowel motions. Opioids can be required for pain management, however they frequently cause constipation. Encourage people to drink enough water and to use a stool softener. Appendicitis patients may be evaluated objectively or subjectively. Analyze the degree of the pain (Chaudhari et al., 2021). Analyze pertinent laboratory results. Check the patient's vital signs before operation. Women of childbearing age, individuals whose diagnosis is in doubt, and obese patients may benefit from a laparoscopic appendectomy. If the appendix has ruptured and there are signs of peritonitis or an abscess, conservative treatment is administered 6 to 8 hours before an appendectomy and consists of intravenous (IV) fluids and antibiotics. Within 24 to 48 hours following the onset of symptoms, an appendectomy is often carried out under general or spinal anesthesia. IV hydration, antipyretics, antibiotics, and analgesics are all included in preoperative care after a confirmed diagnosis (Nguyen & Lotfollahzadeh, 2022).

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