Clinical Reasoning Cycle Paper | Assignment Help

PATIENT

Haley is an 11 year old girl Aboriginal girl with a weight of 53kg. She was admitted due to abdomen pain and vomiting. She underwent laparoscopy for inflamed appendix. After following surgery she was transferred to ward from recovery. She is attentive and conscious. She is admitted with her mother as the caregiver present.

CUES AND SIGNS

Review:

Haley is a patient of Type 1 diabetes and been under self management at home through insulin pump. she is transferred to the ward room from recovery, 3 hours after undergoing appendectomy.  Her recovery room report states that she is alert and has a capillary refill of 2 seconds. She remains tachycardic and has moderate pain level. She has a low grade fever and her BGL level is elevated. Her incision site and IV site are clean with minimum ooze.

Her ABG detects a change in pH towards acidic.

Gather:

Latest assessment shows RR 30min, BP 90/58mmHg, HR 135 bpm, central capillary refill of 3 seconds, axillary body temperature is 38.7 degrees. Haley’s pain level is 5/10 i.e. moderate and is in sleeping state. She rouses on sound. Her skin is warm and red and her peripheries are cool. She has Actrapid infusion of 1mg/ml and is getting it at 0.03 units/kg/hr. Her body fluids are imbalanced due to surgery and transfer. Patient is answering questions and caregiver is not inquiring or looks worried

Recall:

• Temperature is common after surgery in patients due to weakness or infection (Vijarnsorn et al., 2012)
• High BGL is also caused due to anesthesia and surgery as a result of stress
• High BGL is also a sign of infection or illness (Ata et al., 2010)
• High heart rate is usually caused due to pain (Shao et al., 2011)
• Fluid imbalance also causes various changes in the body such as change in pH level
• Pain medication sometimes also causes drowsiness.

PROCESS INFORMATION

Interpret:

Haley just had surgery and sudden disturbance in her vitals Is expected. However, her signs previously stable in recovery have started to get imbalanced.

• Her systolic BP is on decreasing trend, according to her charts
• Her BGL level is higher than 5 to 10mmol/l
• Her capillary refill is greater than 2 seconds
• Her respiratory rate Is on increasing trend
• Her heart rate is on increasing trend towards 135bmp
• Her body is warm centrally and cold peripherally
• Her pain scale shows 5/10
• Her level of consciousness is now responsive to sounds

 

 

Discriminate:

• Although Haley has a fever greater than 38 which is also a sign of infection, but nil observation of any inflammation at any site in Haley’s body. The more concerning factor is the changes in her vitals i.e. blood pressure, heart rate and capillary refill. These sudden and slow changes are the beginning signs of deterioration. With handling these parameters through underlying problem, the fever will be controlled as well
• Although Haley is woken up by sounds, she is still conscious and answering questions. Her declining consciousness would be handled later on. Initially the cause and management should be done
• Her BGL is very important. High glucose causes critical problems after surgery such as slowed down healing process.

Relate & Infer:

• Fluid imbalance due to surgery and transfer might be the reason for tachycardia and low BP (Balcı et al., 2013). Fluid imbalance causes electrolyte imbalance. This triggers the entire organ system.
• Tachycardia and low blood pressure means the blood is not being circulated properly which might be the reason for Haley to be cold peripherally.
• Prolonged capillary refill time also indicates low peripheral perfusion which causes cold peripherals (Hariri et al., 2019)
• Fluid imbalance also causes changes in pH of the body making it acidic that often disturbs the insulin function causing hyperglycemia.
• Her sleepiness state maybe due to changes in her pH towards acidic as proved by her ABG chart. This acidemia further causes loss of oxygen in the skeletal muscles leading to muscle fatigue (Wan et al., 2017). Haley was alert in her ISBAR report but her recent assessment tells that she is feeling sleepy and is only woken up on sound
• Her pain scale shows moderate pain which might be the reason behind change in physiological parameters as pain triggers sympathetic system to become active. This increases heart rate

Predict:

Based on the assessment, slow changes are being observed in Haley’s clinical presentation. These changes are most often seen in patients after surgery that promises mortality.

Haley being a type 1 diabetic patient requires immediate address to her findings before it accelerates. With the increase in her physiological parameters and BGL, her body will go in shock that ultimately might lead to multi-system organ failure and death.

Match:

• There have been increased events of such condition as Haleys where diabetic patients are seen to show deteriorating conditions post surgery (Wang et al., 2019). It is mostly due to the incidence of infection contracted during the surgery. This causes postoperative fever, high BGL and slow changes in vitals.
• Due to surgery it is observed that majority of patients that have an imbalance of fluid for a long period of time has a direct effect on cardiac properties (Mitchell et al., 2015). These affect the kidney function and overall homeostasis.

IDENTIFY PROBLEMS

Synthesize:

“Risk of shocks related to fluid imbalance and hyperglycemia”

This nursing diagnosis is based on different links and relationship between the changes in Haley’s condition. Her ABCDEG assessment shows changes in her circulation readings that had an increasing trend. This differed from her readings from recovery room one hour back. This increasing trend in her heart rate, capillary refill and respiratory rate and decreasing trend in her systolic blood pressure are initial warning signs of deterioration.

There are a number of reasons for this change, it may be due to fluid imbalance, hyperglycemia or moderate pain occurrence.  Haley is at a risk of shock that might occur if the underlying condition is not treated. With the loss of proper blood circulation, the heart will pump faster to negate this situation; blood capillaries will constrict causes a decrease in blood pressure. Respiratory rate will increase to meet the requirement of oxygen by various organs causing increase in breathing effort and decrease in SpO2. This compensatory effort of the body will ultimately lead to cardiogenic shock or septic shock depending upon the underlying condition.

These changes in the patient physiological parameters are also due to Pain. Pain activates the body’s sympathetic system. According to assessment reports, Haley is feeling pain at a moderate level which requires clinical review.

Hyperglycemia is a condition where there is abnormally large amount of glucose in blood. Due to stress on the body after surgery, there has been incidence where a sudden increase in BGL level is seen. Such glucose is quite dangerous as it slows down the healing process and further cause chance of infection (Verhoeven et al., 2011). Haley has been observed to have a high BGL level even though insulin is being infused. 

Fluid imbalance:  According to her ISBAR reports, Haley passed urine prior to surgery and her fluid infusion has been clamped for transfer. She has also been given Hartmann solution that has been clamped for transfer. As mentioned in her assessment report, fluid imbalance is present. This imbalance in the body leads to accumulation of lactic acid and decrease in sodium bicarbonate.  It causes an acidic pH and leads to metabolic acidosis. Metabolic acidosis shows changes in physiological parameter that ultimately leads to shocks (Kimmoun et al., 2016). Acidosis also causes low blood pressure and increased heart rate and rapid breathing. This leads to the conclusion that an imbalance in the fluid status causing acidic pH is present that requires immediate attention.

ESTABLISH GOALS

The main role of the nurse after diagnosis is to note a list of goals that are holistic and can be easily applied to that specific patient. Through applying SMART criteria, nurses can produce an effective action plan that will try to achieve the target. After thorough analysis of Haley’s assessment report and comparison with the previous and standard observation, 3 most important goals that need to be addressed are:

• A balanced fluid status of 65 ml/kg:

Electrolytes are within their normal range and homeostasis is maintained. Body pH is neutral and within 7.35- 7.45. This fluid balance is the average fluid status required in children Haley’s age. Her weight is normal and proper circulation is promoted (Alobaidi et al.,2018).

• BGL level between 5 to 10mmol/l:

Normal BGL level is less than 5mmol/l but since Haley is diabetic and went through surgery, it is directed to try to achieve 5-10mmol/l. Keeping the glucose in check will prevent risks of infection in patients and further decrease the occurrence of shocks (Ambiru et al., 2008).

• Pain level is absent or 1-3 on pain scale:

Pain is managed and absent according to pain scale (Tsze et al., 2018).  Patient’s vitals are within reference range: i.e. heart rate is within 80-120 bpm, respiratory rate is between 20 to 30, systolic blood pressure is with 90-110mmHg, capillary refill time is less than 2 seconds (Fleming et al., 2011) . Patient is alert and her fever is below 38.