Clinical Integration Specialty Practice †Free Samples to Students

Question: Discuss about the Clinical Integration Specialty Practice. Answer: Introduction The paper deals with case study of the Ms Melody King suffering from peritonitis following the ruptured appendix. As a nurse, I have been assigned to Ms Melody for postoperative care. The nursing goal is to utilise Levett-Jones Clinical Reasoning Cycle, to examine, establish relevant nursing goals for the case study, plan and evaluate patient centred care. The Clinical Reasoning Cycle developed by Levett Jone is the cycle of linked and ongoing clinical situations. This cycle acts as a decision-making framework to consider the patients condition, prioritise the key nursing issues and establish goals. It is difficult to improve the patients health condition without effective clinical reasoning skills (Dalton, Gee Levett-Jones, 2015). The case history of Ms Melody informs that she is 36 year old and was presented to the emergency department for Left Lower Quadrant abdominal pain. The pain was severe and was persistent for 2-3 days. The case reports of immediate laparoscopic surgery requirement for removing the ruptured appendix. As per the admission history, the patient has history of asthma and depression. Her current prescribed and complaint medications include seretide, ventolin, and sertraline. Her clinical handover shows presents blood pressure to be 95/45mmHg, HR 120, Temperature 38.3Celcius, respiratory rate 22/minute and shallow and SpO2 95% on room air. The case reports informs that currently the patient is facing increased nausea. Her centralised abdominal pain assessment score showed 8 on 10. Physical assessment data showed a distended abdomen and generalised abdominal guarding. Further pathology tests were conducted to investigate her condition and a raised white blood cell count and CRP was observed. The patient is diagnosed with peritonitis following ruptured appendix Ms. Melody has been shifted to surgical ward post operation. According to Brambillasca et al. (2017) peritonitis is the inflammation of the peritoneum surrounding abdominal organs. It is known as grave complication of the surgical intervention, appendectomy (surgical removal of ruptured appendix). It is due to the tactical or technical errors rarely made during the operation. In majority of the cases, the condition occurs due to perforation of the appendix. Spread of infection from the digestive organs is the principle condition causing Peritinotis. When the bacterial invasion from the appendicitis into peritoneum occurs, it results in inflammation. White blood cells and CRPs are blood inflammatory makers and when applied to lower quadrant abdominal pain is indicative of infections or inflammatory disease process. CRP is the C-reactive protein secreted by liver when the bacterial infections occur. This is the underlying reason for increased White blood cells and CRP level in the patient (Preto-Zamperlini et al., 2014). Fever, nausea, abdominal distension, tenderness and continued abdominal pain are the common signs and symptoms of this condition, also observed in the patient (fever- 38.3Celcius and pain score of 8 on 10). Further patients infective breathing pattern is evident from her low blood pressure, rapid heart beating and shallow breathing (Chaudhary et al., 2015). Ms Melody has increased risk of depression due to history of asthma and present exacerbation of abdominal pain. If the pain is not treated she might have poor physical and mental health. Depression and anxiety due to pain is common during peritonitis and situational crisis. It may decrease the functional and emotional status of the patient. Depression may also be added by the financial constraints and the expensive treatment (Lutz et al., 2015). Nursing problems/issues based on the health assessment data Increase in pain level Anxiety and depression due to untreated pain Exacerbation of peritonitis and complications due to reduced GI functions Risk of infection and risk of shock due to septicaemia or hypovolemia Elevated pain levels are the prime concern in this case. This first priority area needs to be addressed immediately. Patients with peritonitis have reduced GI functions and hence it must be restored. Hence GI function restoration is the second priority area. If the infection is untreated, it may further exacerbate the complications. Additional complications may include rebound tenderness with guarding in abdomen, bowel sounds may decrease, rigid and distended abdomen. In addition, next to shallow breathing, the breath sounds may decrease and diminished secondary to shallow breathing. If the fever persist the pulse may be bounding. The patient also has the risk of deficient fluid volume that may be caused due to shifting of fluids to intestinal lumen. It may lead to fluid depletion in the vascular space. Thus, it is the third priority area that needs intervention. The patient may also be at the risk for shock related to septicaemia or hypovolemia (Sachs et al., 2017). Thus, intensive care is to be delivered to the patient to reduce infection. It is the fourth priority area. Nursing goals The main nursing goal in this case is to deliver postoperative therapy to prevent the exacerbation of Peritonitis. The nursing goals appropriate for Ms Melody with peritonitis include the following- Decrease the level of pain Reduce the risk of infection at the site of operation Reduce the risk of fluid volume deficit Prevent complications Restore the normal GI functions Reduce the level of anxiety and depression These goals are developed as per the priority nursing area. Nursing intervention The first nursing interventions is to monitor the consciousness, intake and output, and vital signs. Ms Melody will be frequently noted for decreased pulse pressure, increase in fever, tachycardia and tachypnea. Patients blood pressure would be monitored by artereial line to eliminate the risk of shock (Williams Hopper, 2015). The second intervention is to provide sterile surgical wound care to prevent infection and related complications. With the increase in pain, the infection is indicated to be accelerated. Perineal Cleansing with appropriate solution is necessary to prevent cross contamination and limit bacterial growth (Han et al., 2015). The third intervention is to administer the medication that is analgesic and anti-emnetics as prescribed. Anti-emetics are effective in reducing nausea and vomiting that exacerbates abdominal pain. Analgesics reduce the intestinal irritation from circulating. It promotes pain relief (Litz et al., 2017). The fourth intervention is to set and move the patients position to prevent drain uprooted. According to Doenges et al. (2014) analgesics together with proper body positioning can help relieve pain. Ms Melodys body position will be changed frequently, and maintain wrinkle free bedding as edematous tissue with poor circulation is to prone breakdown. Ms Melody can be maintained in semi-Fowlers position as it will allow wound drainage by gravity. It will reduce abdominal tension and also reduce pain. Other comfort measures such as breathing, massage or diversional activities will be provided to promote relaxation and enhance coping abilities. The fifth intervention is to take the recording of all intake and output to ensure fluid replacement. It will be followed by administering and close monitoring of the IV fluids. It reflects the overall hydration status. Observation of the drain properties is essential and the color number will be recorded. Drainage monitoring is the vital element of the postoperative care (Kubota et al., 2015). The sixth intervention is to schedule adequate rest and uninterrupted periods of sleep to conserve energy and limit fatigue. In addition, the patient was provided oxygen via nasal prongs to maintain normal oxygen saturation. It was required as the patient also has history of asthma (Ignatavicius Workman, 2015). Evaluating nursing care strategies The following outcomes can be observed that indicates response to nursing intervention and care plan- The signs of peritonitis disappeared is the normal body temperature, pulse rate, and breathing The patient reports relive in pain and demonstrates relaxation skills The patient demonstrates improvement in the fluid balance indicated by stable vital signs, adequate urinary output weight within acceptable reason. Normal drinking and eating is restored The patient is free of drainage of erythema, wound site is clean without infection Reduction in anxiety and depression to manageable level. The patient demonstrates the awareness of feelings Prevention of complications (postoperations) Reflection on the persons outcomes While I was on my clinical placement on surgical ward of ___hospital , I was caring for Ms Melody admitted for appendicitis and Peritonitis. I was assigned for postoperative care and the case history showed for exacerbation of pain and vital signs indicated infective pattern. Psychiatric anxiety and depression was prominent due to illness and situational crisis and history of asthma. I was working under the supervision of RN and strictly followed the guidelines of Nursing and Midwifery board standard 6.2 (Nursing and Midwifery Board of Australia - Registered nurse standards for practice, 2017). Firstly, I have administered the medication as prescribed by the physician an adjusting the patient to semi-Fowlers position. It will help her regain her comfort, reduce pain and level of oxygen. Senior nurse leader appreciated me for my nursing decision and care plan. I have applied the nursing critical thinking and reasoning skills. I have regularly observed the vital signs and educated the patient about the pros and cons of not adhering to medication and instructions. Secondly, I have adhered to patient centered care. I have used active listening skills and was sympathetic, when the patient described her pain and symptoms. I asked the patient to rate her pain and used PQRST method of assessing pain (Wells, Pasero McCaffery, 2017). To make her feel comfortable, I have explained the cause of her infection and complications. The more awareness she will have the better she can cope with the intervention. After interventions, nursing assessment was ongoing and precise. Ms Melody was continuously assessed for pain, fluid and electrolyte balance and monitoring of the GI functions to assess response to the intervention. I was mindful of using safety strategies and holistic approach to improve mental and physical wellbeing of Ms Melody. I have consulted physician for analgesics and oxygen therapy to be provided (Tang et al., 2015). Thus, I can conclude that the patient centred care and on time medication improved the health outcomes of patients. I was successful in addressing the individual needs and goals of patient. The patients right of autonomy, respect and dignity were maintained by involving her in health related decisions. Her values, needs and preferences were respected (Krger et al., 2016). She hadaccess to health information, treatment options and have a freedom of choice regarding physical and emotional comfort. During care, the patients privacy and confidentiality of information were maintained. The standards and code of ethics of Nursing and Midwifery Board of Australia were strictly followed (Gray Rowe Barnes, 2016). Further, I think there should be Education and training for using different pain assessment tools. References Brambillasca, P., Benigni, A., Maffioletti, M., Sonzogni, V., Lorini, L. F., Corbella, D. (2017). Anesthetics considerations in peritonitis.Journal of Peritoneum (and other serosal surfaces),2(1). Chaudhary, P., Ishaq Nabi, G. R., Tiwari, A. K., Kumar, S., Kapur, A., Arora, M. P. (2015). Prospective analysis of indications and early complications of emergency temporary loop ileostomies for perforation peritonitis.Annals of gastroenterology: quarterly publication of the Hellenic Society of Gastroenterology,28(1), 135. Dalton, L., Gee, T., Levett-Jones, T. (2015). Using clinical reasoning and simulation-based education to'flip'the Enrolled Nurse curriculum.Australian Journal of Advanced Nursing, The,33(2), 29. Doenges, M. E., Moorhouse, M. F., Murr, A. C. (2014).Nursing care plans: Guidelines for individualizing client care across the life span. FA Davis. Gray, M., Rowe, J., Barnes, M. (2016). Midwifery professionalisation and practice: Influences of the changed registration standards in Australia.Women and Birth,29(1), 54-61. Han, L., Shen, C., Tian, Y. (2015). Clinical Treatment and Nursing Care of Gastrointestinal Stromal Tumor Acute Abdomen.Journal of Gastroenterology and Hepatology Research,4(11), 1821-1825. Ignatavicius, D. D., Workman, M. L. (2015).Medical-Surgical Nursing-E-Book: Patient-Centered Collaborative Care. Elsevier Health Sciences. Krger, R., Hilker, R., Winkler, C., Lorrain, M., Hahne, M., Redecker, C., ... Jost, W. H. (2016). Advanced stages of PD: interventional therapies and related patient-centered care.Journal of Neural Transmission,123(1), 31-43. Kubota, A., Goda, T., Tsuru, T., Yonekura, T., Yagi, M., Kawahara, H., ... Umeda, S. (2015). Efficacy and safety of strong acid electrolyzed water for peritoneal lavage to prevent surgical site infection in patients with perforated appendicitis.Surgery today,45(7), 876-879. Litz, C. N., Stone, L., Alessi, R., Walford, N. E., Danielson, P. D., Chandler, N. M. (2017). Impact of outpatient management following appendectomy for acute appendicitis: An ACS NSQIP-P analysis.Journal of Pediatric Surgery. Lutz, P., Nischalke, H. D., Strassburg, C. P., Spengler, U. (2015). Spontaneous bacterial peritonitis: The clinical challenge of a leaky gut and a cirrhotic liver.World journal of hepatology,7(3), 304. Nursing and Midwifery Board of Australia - Registered nurse standards for practice. (2017).Nursingmidwiferyboard.gov.au. Retrieved 10 August 2017, fromhttps://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered- nurse-standards- for-practice.aspx Preto-Zamperlini, M., Farhat, S. C. L., Perondi, M. B. M., Pestana, A. P., Cunha, P. S., Pugliese, R. P. S., Schvartsman, C. (2014). Elevated C-reactive protein and spontaneous bacterial peritonitis in children with chronic liver disease and ascites.Journal of pediatric gastroenterology and nutrition,58(1), 96-98. Sachs, A., Guglielminotti, J., Miller, R., Landau, R., Smiley, R., Li, G. (2017). Risk Factors and Risk Stratification for Adverse Obstetrical Outcomes After Appendectomy or Cholecystectomy During Pregnancy.JAMA surgery,152(5), 436-441. Tang, R., Tian, X., Xie, X., Yang, Y. (2015). Intestinal Infarction Caused by Thrombophlebitis of the Portomesenteric Veins as a Complication of Acute Gangrenous Appendicitis After Appendectomy: A Case Report.Medicine,94(24). Wells, N., Pasero, C., McCaffery, M. (2017).Improving the Quality of Care Through Pain Assessment and Management.Ncbi.nlm.nih.gov. Retrieved 16 August 2017, from https://www.ncbi.nlm.nih.gov/books/NBK2658/ Williams, L. S., Hopper, P. D. (2015).Understanding medical surgical nursing. FA Davis.