Levett Jones Clinical Reasoning Cycle

According to the code of professional conduct of the nurse in Australia, it is the duty of the nurse to practise via reflectivity and ethically (Nursing and Midwifery Board of Australia, 2018). In the domain of explaining the nursing reflection, one of the important frameworks is the Levett Jones clinical reasoning cycle (Levett-Jones, 2018). Via following the Levett Jones clinical reasoning framework, this essay will discuss provision of care for the patient, Ms Melody King. The care for the patient will be based on her current medical situation that is post surgical condition after peritonitis from ruptured appendix. This reflection framework will help to devise care plan for Ms Melody Kind based on the current situation and via collection and identification of the problem. The essay will highlight three care requirements for Melody and will devise the action and evaluation plan accordingly.

Patient Situation

Ms Melody King is a patient of peritonitis following ruptured appendix. Currently she is in the post-surgical unit after laparoscopic removal of ruptured appendix. Her current condition include low blood pressure (BP 95/45mmHg), high heart rate (HR: 120), high body temperature (38.3 degree Celsius) normal oxygen saturation at room temperature (95%). Melody has also complained of increased nausea along with high abdomen pain (7-8 on pain scale). Current observation highlights distended abdomen and blood test examination showed high white blood cell (WBC) and C-reactive protein count (CRP)

Collection of cues

Collected vital signs at the time of post surgical condition indicated that Ms Melody has low blood pressure, high heart rate and high body temperature. She also has high pain scale in the central part of the abdomen and distended abdomen. Her high infection rate within the blood is indicated via the high white blood cell count and high count of C-reactive protein (CRP) (McCance & Huether, 2018). Her high heart rate may be due her previous reported case of bronchospasm as indicated by her prescribed drug list which includes Ventolin. High rate might also due to asthma however; she still takes anti-asthmatic medication: Seretide (McKenna & Lim, 2012).

Processing of information

One of the main information that must be taken into consideration while designing care plan for Ms Melody King is her asthmatic tendency. According to Forbes and Watt (2015), asthma is the major respiratory illness that impacts on the overall health and well-being of an individual. Asthma may cause inflammation in the airways and thereby creating blockage in the pulmonary airways and hence increasing the heart rate and respiratory rate of Ms Melody. Thus post surgical complications in case of Melody might include breathing problems. Moreover, her blood reports revealed that she has high white blood cell concentration along with high CRP. Thus indicates high rate of inflammation. This high inflammation is still persists after the surgery then the condition might indicate pulmonary infection. Another, vital information that must be taken into consideration in post-surgical unit is depression of Ms Melody King. However, her oxygen saturation seems to be normal at the time of emergency admission this might overrule the chances of asthmatic condition or bronchospasm going severe (Reddel et al., 2015). According to Forbes and Watt (2015) depression is the most common disorder for the patients with peritonitis and this might further increase in case of Ms Melody King as she is already a patient of depression.

Patient Situation

Identification of problems

The blood pressure of Ms Melody kind is low. This is something unusual taking into consideration of her age (36 years). Moreover, Melody has asthma and this increases the tendency of high blood pressure (Chung et al., 2013). However, her blood pressure is low and this may cast threat to in her post operative condition. Her body temperature is high (38.3 degree; normal body temperature: 37 degree C). This is how ever not that alarming in comparison to that of low blood pressure because increase in the body temperature is regarded as the preliminary symptom of inflammation (as indicated by white blood cells) and might decrease during the post-operative condition. Furthermore, use of antibiotics will further help to decrease the body temperature (Meier & Lee 2017). But low blood pressure along with high heart rate (normal range: 100 beats per minute) are alarming and might pose threat to Melody after laparoscopic removal of the fractured appendix (McCance & Huether, 2018).

Recovery from surgery for a perforated appendix is longer and this is because, the spread of infection resulting out the ruptured appendix must be treated affectively (McCance & Huether, 2018). The test result indicates high WBC count and high concentration of CRP. According to McCance & Huether (2018), increase in the WBC or CRP count can be regarded as the direct indicator for blood infection or sepsis. This can be a problem during the post-operative condition results in the development of hypersensitivity shock. Melody is more vulnerable in encountering hypersensitivity shock because she is physically weak after surgery as indicated by nausea.

Another problem in case of Melody is her shallow respiratory rate, According to Forbes and Watt (2015) respiratory rate is a preliminary indicator for hypoxia. According to Trayhurn (2013), hypoxia is a pathological condition of the body is characterised as the lack of adequate oxygen supply in the tissue. Hypoxia can be localised or general. In case of Ms Melody King, the chances are high for generalised hypoxia (Semenza, 2014). Since Ms Melody is a patient of asthma and also suffers from bronchiospasm, her tendency of developing hypoxia is further high.

Distended abdomen is another problem that can be highlighted in case of Melody. According to McCance and Huether (2018) distended abdomen is mainly used to refer swelling of the abdomen and not solely of the stomach. The possible cause for distended abdomen may include increase in the accumulation in the abdomen resulting from water retention or may be due to gas accumulation due to indigestion. Kothadia, Katz and Ginzburg (2015) highlighted that one of the most common cause of appendectomy is indigestion, which may give rise to distended abdomen.

Collection of cues

High level of pain is also a problem for Melody as it might hamper her health and well-being. Her pain might be the reason for the distended abdomen or due to high level of blood spcesemia as evident from high WBC count and CRP (McCance & Huether, 2018). Proper assessment of the reason behind the pain and effective intervention is mandated in case Melody.

Goal 1: Relief from pain

Comfort of the Patient is important (Forbes & Watt, 2015). In case of Melody, acute pain might be the reason behind inflammation or abdominal distension. The importance of this goal is, if pain is not managed properly, it can lead to depression and thus should be avoided. The reason behind this, Melody has previous reported case of depression and is on anti-depressive medication.

Action: I will notify doctor about the high pain level of Melody and will ask doctor to chart pain medication in order to help Melody with effective pain management. Proper positioning also important in order to manage pain and I will do it accordingly under the supervision of doctor (Forbes & Watt, 2015). If the patient is on NG (naso-gastric tube) tube in order to decrease gastric distension then I will check the placement of the nasograstic tube. This is because, improper placement of NG tube can lead to pain due to leakage of bowel contents into the peritoneum (Nguyen et al., 2016).

Goal 2: Controlling high infection rate

Infection, raised temperature, distended abdomen and high WBC and CRP count are main indicators of infection and this internal infection should be resolved. According to Kothadia, Katz and Ginzburg (2015), Infection after appendectomy is very common. At least 7 out of 10 cases of appendectomy are associated with high infection rate. If infection is not resolved it can also lead to sepsis as this might be the case of Melody as she has high WBC and CRP (McCance & Huether, 2018).

Action: My action in the domain of nursing intervention will be to notify doctor about the increase in body temperature and other signs of infection and requirement for re- assess patient. If medication (antibiotic therapy) is prescribed and charted, then it will be my duty as a registered nurse to give medication on a timely manner as antibiotics are required to be given at specified dose, time and rate/mode of administration (Yu et al., 2013).

Goal 3: Checking the condition of hypoxia

Processing of information

To ascertain the chances of breathing problem via checking hypoxic condition. The rationale behind this goal is, Melody is patient of asthma and at present suffering from nausea. McKenna and Lim (2012) highlighted that decrease in the oxygen saturation in the body increases the tendency of developing nausea. Moreover, such hypoxic condition leading to breathless is extremely relevant in case as asthmatic patient under post surgical condition (Reddel et al., 2015). O’reilly (2014) reported that maintenance of proper breathing cycle with adequate oxygen saturation helps to reduce pain sensation in the pain scale.

Action: O’reilly (2014) stated that monitoring of the oxygen saturation level is usually done with the help of pulse oximetry. According to Chan, Chan and Chan (2013) pulse oximetry is a non-invasive method that is used for monitoring oxygen saturation of an individual. It mainly provides the reading via denoting the peripheral oxygen saturation (SpO2). Proper supply of the external oxygen in case of drop in SpO2, will help to maintain normal oxygen level in the body and thereby helping to control hypoxia (O’reilly, 2014). I will also call in a professional physiotherapy in order to promote active breathing in addition to external oxygen supply if needed (Reddel et al., 2015).

Actions

The main actions that I will take while monitoring Ms Melody King under post operative condition include thorough monitoring of her oxygen saturation through pulse oximetry. If I find that her oxygen level below 95 to 90%, I will immediately call in the concerned doctors. The doctor will determine the exact amount of oxygen that will be required by Melody externally. Once the doctor devises the external oxygen supply care plan, I will monitor the supply of oxygen along with the change in her oxygen saturation level. While controlling her infection within the body I will also monitor her white blood cell count and her CRP level in the blood serum. If I find that her inflammation rate is not decreasing even during the post operative condition, I will further inform the doctor so that he can take the necessary action. Lastly I will also make sure that Ms Melody Kind may not pass into depression while her stay in the post-operative unit. This is as per the previous reported case history; Ms Melody suffers from depression and also takes anti-depressive medication. Hence, I will converse and encourage her to fight back with her problem and will give her positive source of hope and inspiration while discussing her care plan and rate of progress. According to Rathert, Wyrwich and Boren (2013) discussing the care plan with the patient, increases patient involvement. This helps to reduce the unwanted apprehension and improvement of the overall health outcome.

Identification of problems

Evaluation of outcomes

In order to evaluate the outcome of her overall rate of recovery in the post surgery unit, I will monitor the blood pressure, heart rate, respiratory rate and oxygen saturation. This monitoring of the vital signs of Ms Melody Kind will help to get an overview of her current health condition. I will also monitor her infection rate in the blood from her white blood cell count and CRP concentration in the blood serum.

Reflection of process and new learning

From the analysis of this case study, I emerged in new learning in the professional role of registered nurse. One of my new learning highlights that it is the duty of the nurse to involve patients in the health care plan via discussing the possible outcome and the importance of the therapy imposes. This goes with the competency standards of the Nursing and Midwifery Board of Australia (2013). According to the standard 9, it is the duty of the registered nurse to help patient to participate in the informed decision making and this in turn helps to improve the overall quality of care. In my new learning, I have also understood the importance of the consultation with the other healthcare professionals in order to improve the patient outcome and the value of the evidence-based practice in nursing care.

Conclusion

Thus from above discussion based on clinical reflection, it can be concluded that controlling and coordinating the internal inflammation is curial for patient who have ruptured appendix, even after undergoing laparoscopic surgery. Apart from proper monitoring of the oxygen saturation is also importance. Since Ms Melody King is a patient of asthma, monitoring her oxygen saturation further holds additional importance. Lastly, it can be said that it is the role of the nurse to involve patient in the care plan and practice via following the evidence based guidelines. This help to improve the overall outcome of the care along with the promotion of patient’s health and well-being.

References

Chan, E. D., Chan, M. M., & Chan, M. M. (2013). Pulse oximetry: understanding its basic principles facilitates appreciation of its limitations. Respiratory medicine, 107(6), 789-799.

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.

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.

Nguyen, D. P., Nickels, L. C., & De Portu, G. (2016). Nasogastric tube placement. In Atlas of Emergency Medicine Procedures (pp. 411-413). Springer, New York, NY.

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

O’reilly, M. (2014). U.S. Patent No. 8,670,811. Washington, DC: U.S. Patent and Trademark Office.

Rathert, C., Wyrwich, M. D., & Boren, S. A. (2013). Patient-centered care and outcomes: a systematic review of the literature. Medical Care Research and Review, 70(4), 351-379.

Reddel, H. K., Bateman, E. D., Becker, A., Boulet, L. P., Cruz, A. A., Drazen, J. M., … & Lemanske, R. F. (2015). A summary of the new GINA strategy: a roadmap to asthma control. European Respiratory Journal, 46(3), 622-639.

Semenza, G. L. (2014). Oxygen sensing, hypoxia-inducible factors, and disease pathophysiology. Annual Review of Pathology: Mechanisms of Disease, 9, 47-71.

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.