NRSG378: Principles of Nursing Extended Clinical Reasoning Assessment Answer

1-The case report describes the patient who is a woman and is 22 years old with abdominal pain, nausea, and vomiting. The right bottom quadrant pain started three days ago and has grown sharper and more extensive. Her stomach is guarded. Her abdomen is painful and swollen, with few auscultation noises (Baird et al., 2017). Pale, chilly, and clammy, her lips are dry. She has tachycardia, hypotension, fever, and minor respiratory distress. Her labs suggest systemic inflammation and infection with increased WBC, CRP, and lactate. Her biography shows that she lives in a shared house, works part-time in a bookshop, and studies veterinary nursing full-time. She doesn't smoke, eats well, and exercises. She occasionally drinks and smokes pot when anxious. Sertraline and Salbutamol treat her asthma and depression (Singh & Saadabadi, 2019). The severity and duration of stomach pain, nausea, and vomiting, abdominal guarding and tenderness, and systemic inflammatory indicators and symptoms of infection are important patient presentation aspects. These findings suggest acute appendicitis with perforation and peritonitis (Baird et al., 2017). Sepsis is a life-threatening condition that demands immediate medical intervention (Prescott & Angus, 2018).

Kate has acute appendicitis symptoms. Untreated appendicitis can cause perforation, peritonitis, and sepsis (NHS, 2022). The function of the tiny, finger-like appendix at the beginning of the big intestine is unknown. It may aid digestion and the immune system, but a lumen blockage can cause appendicitis (Jones et al., 2021). Kate's dull, right lower quadrant ache was likely appendicitis. Heat packs and paracetamol relieved sporadic pain. As inflammation developed, the discomfort became acute and continuous, causing abdominal guarding and reluctance to move. Peritoneal inflammation can irritate nerves and produce pain. Appendicitis' enlarged and sore abdomen matches Kate's. As appendix infection increases, it can expand and fill with pus, causing palpable distension and soreness. Auscultation shows little abdominal sounds, which is typical with appendicitis (Patel & Thavamani, 2022). Inflammation decreases peristalsis. Inflammation and infection may cause Kate's high heart rate, low blood pressure, and high temperature. Cytokines and other inflammatory mediators release vasodilation, lowering blood pressure. Constipation and dark urine indicate dehydration, a common appendicitis consequence (Sellars & Boorman, 2017). Kate's high white blood cell count and C-reactive protein indicate inflammation (Sellars & Boorman, 2017). Perforation and subsequent peritonitis increase white blood cell count and C-reactive protein levels (Sellars & Boorman, 2017).

Kate's full nursing assessment includes the following:

1. Review of medical history and drugs: This will provide further information on her health and medications that may affect her present state or treatment.
2. Assessing pain severity, location, onset, duration, and character helps select pain management strategies (Howell, 2018).
3. Bowel and bladder assessment: Her condition or therapy may influence her bowel and bladder function.
4. Nutritional assessment: Her present and prior nutrition, appetite, and consumption may be impacted by her disease or therapy (Jones et al., 2021).
5. Psychological assessment: Her mental state, coping skills, and support system may be influenced by her condition or therapy.
6. Vital signs and oxygen saturation monitoring will check the patient's cardiovascular and respiratory health and identify potential issues.
7. Skin assessment: This will detect pressure injuries or skin breakdown caused by extended immobility during therapy.
8. Family and social history: This will reveal her support system, family dynamics, and environmental elements that may affect her disease or therapy (Jones et al., 2021).

Problem 1:Acute Pain

Kate's acute discomfort is the nursing priority since it can reduce her quality of life, mobility, and risk of DVT and inadequate lung expansion. The case study indicates that Kate's pain is worsening and requires PRN morphine (Waddimba et al.,2022). Kate's discomfort should be assessed and managed individually based on her age, weight, and medical history. Analgesia can follow the WHO pain ladder. Relaxation, heat, and diversion can also help control pain.

Problem 2: Gas Exchange

Kate's gas exchange, which can cause hypoxemia and respiratory failure, is the second nursing priority. The case study demonstrates Kate has a 24 bpm respiratory rate and slight work of breathing. Her room-air SpO2 is 97%, indicating mild hypoxemia. Kate's respiratory condition, supplemental oxygen, and deep breathing and coughing exercises are top priorities. Chest physiotherapy can move secretions and promote breathing (Ologun et al., 2017)

Problem 3: Anxiety

Kate's anxiety, which increases pain perception, impairs decision-making, and slows healing, is the third nursing priority. The case study reveals that Kate is nervous and upset about her studies. Assess Kate's anxiety, provide emotional support and education, and adopt anxiety-reducing practises like therapeutic conversation, music therapy, and relaxation (Umbrello et al., 2019). If needed, mental health professionals can be referred (Butterfield et al., 2017).

The three most important aspects of nursing care that need to be addressed for Kate are her acute pain, her poor gas exchange, and her worry. The nurse will be able to improve Kate's physical and psychological well-being, as well as boost her recovery and minimise potential consequences if she addresses these issues as soon as possible and in an efficient manner

The two most crucial aspects of Kate's life are probably her ability to take care of herself and her social connections. First is, Kate's capacity to complete self-care tasks including washing, clothing, and grooming may be impacted by her admittance. She has mentioned feeling weak and exhausted, which may make it challenging for her to complete these duties on her own. Her difficulty breathing and chest pain can also make it difficult for her to carry out strenuous activities like cooking or climbing stairs. As a result, Kate might need help with self-care tasks while she's in the hospital and might need to be referred for rehab or home care services once she leaves (Gilissen et al., 2017). Second, Kate's admission can also have an effect on her social connections, which are essential to her general wellbeing. Her hospitalisation might make it more difficult for her to socialise and engage with her loved ones, which could make her feel lonely and anxious. By offering emotional support, encouraging communication with her family and friends, and providing opportunities for socialisation during her hospital stay, it is critical for nurses to fulfil these psychosocial requirements (Cates et al., 2018) Kate's hospitalisation may have an effect on her capacity to engage in self-care activities and maintain social connections. To improve her general well-being and assist in a smooth transition back to her home following discharge, it is crucial for nurses to identify and address these problems.

3- A patient like Kate, who has been diagnosed with perforated appendix leading to secondary peritonitis can be given following classes of drugs.

Antibiotics: Antibiotics, such as ceftriaxone, are typically prescribed to patients in order to treat illnesses that are brought on by bacteria. Ceftriaxone is a cephalosporin that is of the third generation and acts by inhibiting the process by which bacteria produce their cell walls (Bui & Preuss, 2022). This, in turn, stops the growth and replication of germs. It is given for the treatment of dangerous infections such as sepsis and peritonitis, both of which can arise as a consequence of an appendix that has been perforated. Specifically, it is used to treat perforated appendix infections. When it comes to the administration of antibiotics, nursing considerations include monitoring for adverse effects like allergic responses, evaluating for therapeutic response, and making sure the appropriate dosage is given (Bui & Preuss, 2022).

Analgesics are typically taken to alleviate pain, and one example of this type of medication is morphine (Dhaliwal & Gupta, 2019). Morphine is a form of opioid analgesic that works by decreasing the experience of pain by binding to specific opioid receptors in the brain and spinal cord (Dhaliwal & Gupta, 2019). This reduces the amount of energy that the brain and spinal cord devote to processing painful sensations. Morphine is prescribed to patients who are experiencing moderate to severe pain.It is prescribed for the management of moderate to severe pain, which is likely what Kate is going through as a result of her perforated appendix. When it comes to the administration of analgesics, nursing considerations include monitoring for adverse effects like respiratory depression, evaluating for therapeutic response, and making sure the appropriate dosage is given. In addition, because morphine has the potential to cause constipation, it is essential for the nurse to monitor and manage Kate's bowel movements in order to reduce the risk of constipation and increase the likelihood of regular bowel movements (Dhaliwal & Gupta, 2019).

4- Kate is in a critical condition for the first twenty-four hours after surgery, and it is imperative that nursing care methods be put into action in order to hasten her recovery and reduce the risk of complications. The different approaches to nursing care should be implemented in the following order of importance. First is that it is important to keep an eye on vital signs such as blood pressure, heart rate, breathing rate, and temperature on a regular basis in order to identify any changes that may be an indication of complications such as bleeding or infection. Postoperative hypertension is rather prevalent and has to be evaluated and managed as soon as possible (Howell, 2018). After the initial period, Kate's vital signs should be checked and monitored often every 15 minutes; afterwards, the frequency of these checks should increase to every hour based on how well Kate is doing (Jones et al., 2021). It is essential to do a thorough assessment of the patient's level of discomfort because pain is a known contributor to elevated levels of both blood pressure and heart rate (Jones et al., 2021). .

Second, managing pain is one of the most important aspects of postoperative recovery. The nurse should use a pain assessment tool on Kate, such as a numerical rating scale, in order to determine how much pain she is in. It is possible to alleviate pain by taking analgesics like opioids or nonsteroidal anti-inflammatory medicines (NSAIDs), which can be given to the patient. It is the responsibility of the nurse to ensure that the drug is administered in accordance with the prescription, to monitor how effectively the medication is working, and to assess the patient for any potential adverse effects, such as drowsiness, constipation, or respiratory depression (Nasir & Ahmed, 2020). Third, patients who have undergone abdominal surgery are more likely to experience postoperative respiratory complications such as atelectasis and pneumonia. To reduce the risk of Kate developing respiratory issues, she should be encouraged to undertake exercises that focus on deep breathing and to use an incentive spirometer (Chughtai et al., 2017). Regular checks of Kate's oxygen saturation levels, breathing rate, and auscultation of lung sounds should be performed by the nurse. Oxygen therapy may be necessary for Kate if she experiences any kind of respiratory distress, such as feeling short of breath or having an elevated respiratory rate

Fourth is, Deep vein thrombosis (DVT) prevention is important for Kate because she will be immobile after surgery and is at risk of getting DVT. It is important for the nurse to urge Kate to do foot and ankle exercises, ambulate as soon as she is able, and wear stockings that prevent blood clots (Waheed et al., 2018). A preventive anticoagulant medication such as low molecular weight heparin (LMWH) could be recommended to Kate if she is at a high risk of developing DVT (Solari & Varacallo, 2018). Because of the anaesthesia and the pain medication, Kate faces the possibility of developing urine retention. Kate's fluid intake and output should both be monitored by the nurse, and Kate should be encouraged to urinate every two to three hours (Solari & Varacallo, 2018). In the event that Kate is unable to void, the nurse should check for bladder distension and evaluate the possibility of catheterization. In the grand scheme of things, these nursing care practices are absolutely necessary for facilitating Kate's recuperation and avoiding complications after her operation (Jones et al., 2019). The nurse may assist Kate in making a healthy and rapid recovery by carefully monitoring her vital signs, maintaining a balance of fluids and electrolytes, caring for her wounds, and assessing her level of pain. Additionally, the nurse will encourage Kate to move around and participate in her own medical treatment (Jones et al., 2019). 

References

Baird, D. L., Simillis, C., Kontovounisios, C., Rasheed, S., & Tekkis, P. P. (2017). Acute appendicitis. Bmj, 357. https://doi.org/10.1136/bmj.j1703

Butterfield, N., Schultz, T., Rasmussen, P., & Proeve, M. (2017). Yoga and mindfulness for anxiety and depression and the role of mental health professionals: a literature review. The Journal of Mental Health Training, Education and Practice, 12(1), 44-54. https://doi.org/10.1108/JMHTEP-01-2016-0002

Bui, T., & Preuss, C. V. (2022). Cephalosporins. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551517/

Cates, D. S., Gomes, P. G., & Krasilovsky, A. M. (2018). Behavioral health support for patients, families, and healthcare workers. Bioemergency Planning: A Guide for Healthcare Facilities, 195-214. https://doi.org/10.1007%2F978-3-319-77032-1_16

Chughtai, M., Gwam, C. U., Mohamed, N., Khlopas, A., Newman, J. M., Khan, R., & Mont, M. A. (2017). The epidemiology and risk factors for postoperative pneumonia. Journal of clinical medicine research, 9(6), 466. https://doi.org/10.14740%2Fjocmr3002w

Dhaliwal, A., & Gupta, M. (2019). Physiology, opioid receptor. https://www.ncbi.nlm.nih.gov/books/NBK546642/

Gilissen, J., Pivodic, L., Smets, T., Gastmans, C., Vander Stichele, R., Deliens, L., & Van den Block, L. (2017). Preconditions for successful advance care planning in nursing homes: a systematic review. International journal of nursing studies, 66, 47-59. https://doi.org/10.1016/j.ijnurstu.2016.12.003

Howell, S. J. (2018). Preoperative hypertension. Current anesthesiology reports, 8, 25-31. https://doi.org/10.1007%2Fs40140-018-0248-7

Jones, M. W., Lopez, R. A., & Deppen, J. G. (2021). Appendicitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493193/

Jones, M. W., Lopez, R. A., Deppen, J. G., & Kendall, B. A. (2021). Appendicitis (Nursing). https://europepmc.org/article/NBK/nbk568712

Nasir, M., & Ahmed, A. (2020). Knowledge about postoperative pain and its management in surgical patients. Cureus, 12(1). https://doi.org/10.7759%2Fcureus.6685

NHS. (2022). Complications-Appendicitis. https://www.nhs.uk/conditions/appendicitis/complications/

Ologun, G. O., Ridley, D., Chea, N. D., Golden, D., Lihau-N'Kanza, A., & McPhail, P. (2017). Severe acute respiratory distress syndrome after laparoscopic appendectomy in a young adult. Cureus, 9(9). 10.7759/cureus.1664

Patel, K. S., & Thavamani, A. (2022). Physiology, peristalsis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556137/

Prescott, H. C., & Angus, D. C. (2018). Enhancing recovery from sepsis: a review. Jama, 319(1), 62-75. 10.1001/jama.2017.17687

Sellars, H., & Boorman, P. (2017). Acute appendicitis. Surgery (Oxford), 35(8), 432-438. https://doi.org/10.1016/j.mpsur.2017.06.002

Singh, H. K., & Saadabadi, A. (2019). Sertraline. https://europepmc.org/article/nbk/nbk547689

Solari, F., & Varacallo, M. (2018). Low molecular weight heparin (LMWH). https://europepmc.org/article/nbk/nbk525957

Umbrello, M., Sorrenti, T., Mistraletti, G., Formenti, P., Chiumello, D., & Terzoni, S. (2019). Music therapy reduces stress and anxiety in critically ill patients: a systematic review of randomized clinical trials. Minerva anestesiologica, 85(8), 886-898.https://dx.doi.org/10.23736/S0375-9393.19.13526-2

Waddimba, A. C., Newman, P., Shelley, J. K., McShan, E. E., Cheung, Z. O., Gibson, J. N., & Petrey, L. B. (2022). Pain management after laparoscopic appendectomy: Comparative effectiveness of innovative pre-emptive analgesia using liposomal bupivacaine. The American Journal of Surgery, 223(5), 832-838. https://doi.org/10.1016/j.amjsurg.2021.09.019

Waheed, S. M., Kudaravalli, P., & Hotwagner, D. T. (2018). Deep vein thrombosis. https://www.ncbi.nlm.nih.gov/books/NBK507708/ 

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