Clinical Reasoning Assessment - Essay Example

?Clinical Reasoning Assessment for Post-Operative Cholecystitis and Cholylithiasis Patient Introduction Data about patient are always collected to provide basis for decision-making among nurses. Nursing diagnosis have taken relevant developments the past decades as the legal ban on diagnosis was altered making nurses accountable for decisions in diagnosis of health problems (Malen, 1986). It had been noted that data collected were important in providing an understanding to health problems previously problematic in medical language but differences of non-standard terms used by different nurses led to another barrier. The North American Nursing Diagnosis Association or NANDA standardized, identified and classified health problems dealt by nurses. Diagnosis is an abstraction of signs, symptoms, and inferences based on the patient assessment and scientific knowledge of the attending nurse (Malen, 1986). This paper will provide the nursing diagnosis and the supporting evidence for postoperative cholecystitis and cholylithiasis patient. The patient is Cicek Olcay, 53 years old, Turkish, and admitted at Day Procedure Unit or DPU (Bullock and Henze, 1999). All admission requirements had been collected and indicated, the checklist completed. Her gall bladder has been removed and pain was only experienced during a transition or transfer to the ward from the post anaesthetic recovery room or P.A.R.U. Pathophysiology of cholecystitis and cholelithiasis – it is an acute inflammation of the gall bladder associated with obstruction of by the gall stones. The causes can be that common bile duct stones were formed in the bile duct, or they may be formed in and transported from the gall bladder (Doenges et al, 2010). It was suggested that Cholelithiasis is usually asymptomatic while Cholecystitis can result if stone becomes lodged in one of the ducts (Cuschieri, Dubios, Mouiel, Mouret, Becker, Buess, G, et al, 1991). Etiology The stones usually develop in and obstruct the common bile duct or the cystic duct; it is also found in the hepatic, small bile, and pancreatic ducts. 90% of cases involve stones in the cystic duct or calculous cholecystitis, and the other 10% involve cholecystitis without stones or acalculous cholecystitis according to Gladden & Migala (2007). The stones are made up of cholesterol, calcium bilirubinate, or a mixture caused by changes in the bile composition. Bile cultures are positive for bacteria in 50% to 75% of cases but bacterial proliferation may be a result or consequence of cholecystitis, but never the cause (Gladden & Migala, 2007). Other causes include stasis of bile or bacterial infection or ischemia of the gallbladder. The failure to remove impacted stone can lead to bile stasis or bacteremia and septicemia causing cholangitis which is considered a medical emergency. The statistics for morbidity of gallstones are two to three times more frequent in females than in males. The perforation occurs in 10% to 15% of cases, and 25% to 30% of clients either require surgery or develop complications (Gladden & Migala, 2007). Mortality was indicated that about 10,000 deaths occur annually; about 7,000 deaths result from gallstone complications, such as acute pancreatitis. There is 4% mortality rate for calculous cholecystitis and about 10-50% rate for acalculous cholecystitis. Care Setting Severe acute attacks of cholecystitis and cholelithiasis usually require brief hospitalization. This type of care is applicable for the acutely ill, hospitalized client and surgery is usually performed after symptoms for the illness have subsided (Bisgaard et al, 1999). Nursing Priorities The priority for the nurse during the care for patient with cholecystitis and cholelithiasis is to relieve pain and promote rest. In addition, the patient should be assisted to maintain fluid and electrolyte balance, prevent complications, and provided with information about disease process, prognosis, and treatment needs (Doenges et al, 2010, 498). The following are subjective data, objective data, vital sign, nursing diagnosis, rationale, goals and objectives as well as nursing interventions based on evidence: Subjective data: Pain in incision site as verbalized by the patient Objective data: Pain scale: 8/10 (with 10 as the highest), facial grimace, guarding behavior over the abdomen, restlessness, pupillary dilation. Vital Sign (V/S) BP: 130/90 mmHg, PR: 87, RR: 25, T: 37 Nursing Diagnosis: Acute pain related to post-operative incision secondary to laparoscopic cholecystectomy. Rationale: Unpleasant sensory and emotional experience caused by actual tissue damage through incision or breaking of skin, especially abdominal layers. A-delta myelinated fiber perceive a sharp pain when noxious thermal or mechanical stimulation occurs. When mechanical stimuli activate the unmyelinated C fiber, the cutaneous pain is felt as long lasting, burning pain or sharp pain (Barkun, Barkun, Sampalis, Fried, Taylor, Wexler, et al, 1992). Goals and Objectives: After 30 minutes of nursing interventions, the patient should report pain alleviation from severe pain 8/10, to moderate pain 3- 4/10, or totally relieved from pain. The nurse must be able to identify and use appropriate interventions to manage pain and discomfort. The patient should then appear to be relaxed, able to rest or sleep and participate in activities properly. Nursing Interventions: The attending nurse should be able to assess pain, character, location, severity, precipitating and relieving factors and duration. She should use a pain rating scale. The rationale for the intervention is that pain assessment provides clues about diagnosis. It is used to determine treatment required. The nurse should also encourage relaxation of the patient. The rationale is to promote rest, redirect attention and enhance coping (McGinn, Miles, Uglow, Ozmen, Terzi, Numby, 1995). The nurse should also allow the patient splint incision when moving to provide support to the incision and decrease pain. Splinting provides incision support as well as decreases muscle tension. This helps promote cooperation with therapeutic regimen. The nurse should also help the patient seek alternative methods of pain relief such as relaxation exercises like deep-breathing exercise, massage and distraction. The rationale is that relaxation exercise is a system used to bring about a state of physical and mental awareness as well as tranquillity (Bardsley et al, 1992). The nurse may also apply massage to reduce muscle tension and promote comfort; distraction is to focus on other non-painful stimuli, and promote bed rest and in low fowler’s position in order to help reduce intra-abdominal pressure (Doenges et al, 2010). Subjective data: Patient has difficulty of breathing especially when there is pain in the abdomen which the patient experiences. Objective data: Unable to breathe normally, patient feels cold on both upper and lower extremities, RR:24 cpm, O2 saturation- 88%. Nursing Diagnosis: Ineffective breathing pattern related to pain on post-operative site. Rationale: Due to the pain felt after the laparoscopic cholecystectomy operation, there is a decreased lung expansion and decreased respiratory depth or vital capacity leading to inadequate ventilation for the client. Goals and Objectives: After 3 minutes of nursing intervention, the client will be able to establish a normal effective respiratory pattern. Nursing Interventions: The attending nurse should administer oxygen at the lowest concentration to manage underlying pulmonary condition, respiratory distress or cyanosis. It also helps to elevate head of bed and place client in semi-fowlers position to promote physiological and psychological ease. The patient should be encouraged to slower deeper respiration using pursed lip technique and deep breathing exercise. This will aid client in being in control of her situation (Majeed et al, 1996). The nurse should monitor the pulse oximeter to verify the improvement and maintenance of oxygen saturation. The patient should be encouraged to have adequate rest period between activities to decrease fatigue. The administration of medication prescribed by the physician such as analgesics will promote deeper respiration (Gupta et al, 2002). Evaluation: after 30 minutes of nursing intervention, the goals are met as evidenced by established normal or effective respiratory pattern with respiratory rate of 20cpm and oxygen saturation of 100 % (Belda et al, 2005). Subjective data: Patient may complain that suture in abdomen is itchy. Objective data: Ruptured skin, facial grimace, incision, disruption of skin surface, presence of sutures (Pasquina, 2006). Nursing diagnosis: The presence of impaired skin integrity related to surgical incision on abdomen secondary to laparoscopic cholecystectomy. Rationale: The invasive procedure opens an area of the body and allows a clear view of the underlying or the organs underneath the skin. This may be a therapeutic approach to drain discharges on the operative site. Goals and Objective: after 4 hours of nursing intervention, the patient will remain free from infection and bleeding. Nursing Intervention: The nurse should monitor surgical site for any sign and symptoms of infection in order to identify poor wound healing or infection. This will aid to expedite treatment. Nurse should apply pressure to the incision site to find out hemostasis, and to prevent bleeding. The nurse should also guide patient to have good skin hygiene by washing thoroughly and pat dry the skin surrounding the wound carefully. The skin provides a barrier to infection and patting skin to dry instead of rubbing decreases risk of dermal trauma to fragile skin. The nurse should change dressings on incision and over drainage tube insertions sites and puncture sites. Clean the area using sterile technique to decrease number of organisms and reduces chance of infection. The nurse should encourage patient to have adequate fluid intake and provide support information that improved nutrition and hydration will improve skin condition (Doenges, Moorhouse, and Murr, 2010). Subjective Data: The patient complains difficulty in moving due to pain and suture in my abdomen Objective data: Limited range of motion, not able to move freely, slowed movement, pain scale of 8/10. Nursing Diagnosis: Impaired physical mobility related to pain at incision site. Rationale: pain impairs mobility and activity; full function may be affected and be delayed. Nursing Intervention: The patient should be guided to change position frequently when on bed rest and support affected parts or joints with pillows because mobility aids can increase level of movement. Nurse should encourage proper use of assistive devices in the home setting for maximal patient effort or involvement in activity, The nurse should massage skin, keep skin clean and dry, keep linens dry and wrinkle free to lessen discomfort, maintain muscle strength or joint mobility, enhances circulation and prevent skin breakdown. Deep breathing should also be encouraged with coughing exercise. Head of bed should be elevated and the client turned side to side. These will help stimulate circulation and prevent skin irritation. The exercise would also mobilize secretions, improve lung expansion and reduce risk of respiratory complications. Early ambulation with abdomen support will prevent postop complications. Splinting provides incisional support and decreases muscle tension to promote cooperation with therapeutic regimen. Adequate rest periods in between activities should also be encouraged (Monks, 2002). Subjective Data: The question on what to do after the operation may be posted by the patient Objective Data: presence of incision on the abdomen due to post-operative (Ferreyra, 2008). Nursing Diagnosis: Deficient knowledge about self-care activities related to incision care, dietary modifications, medications, reportable signs and symptoms (Dreyfuss et al, 1998). Rationale: laparoscopic cholecystectomy is the surgical removal of the infected gall bladder. The client has a deficiency of cognitive information related to specific topic such as self-care activities about incision care, dietary modification, and prognosis and discharge plan (Ballantyne, 1998). Goals and Objectives: after 1-2 hours of interventions, the client will be able to verbalize an understanding of the operative procedure and prescribed post-operative regimens (Arozullah 2000). Nursing Interventions: The nurse should assess readiness of client to learn through motivation, cognitive level and physiological status in order to motivate patient to learn content and be free of distractions from learning, such as pain and emotional distress. The nurse should emphasize a quiet environment conducive to learning because environmental noise can prevent the learner from focusing on what is being taught. Nurse should teach the patient wound care and infection control measures such as keeping incision clean and dry; if dressing is applied, change using aseptic technique, monitor for signs of infection at incision site and drain insertion site (Hunt, 1985). The short hospital stay following cholecystectomy should allow the patient to feel at home. When postoperative infections occur, the client should know signs and symptoms of infection; understanding the rationale for these interventions will increase the client’s willingness to comply with instructions. Evaluation: after 1-2 hours of interventions, the goal was fully met, patient was able to verbalize an understanding of the operative procedure and prescribed postoperative regimens (Doenges et al, 2010). Nursing Diagnosis: acute pain related to biological injuring agents: obstruction or ductal spasm, inflammatory process, tissue ischemia and necrosis possibly evidenced by reports of pain, biliary colic, facial pain; guarded behaviour, autonomic responses including changes in blood pressure (BP), pulse or self-focusing; narrowed focus Desired Outcomes/Evaluation Criteria: The client will expect pain control or report pain is relieved or controlled. Patient will also demonstrate use of relaxation skills and diversional activities depending on individual preference. Nursing Interventions: In pain management, nurse should observe and document location, severity, and character of pain, such as steady, intermittent, or colicky. This will guide in differentiating cause of pain and provide information about disease progression or resolution, development of complications, and effectiveness of interventions. Nurse should also note the response to medication then report to physician if pain is not being relieved. Severe pain not relieved by routine measures may indicate complications development and the need for further intervention. Nurse should promote bed rest, allowing client to assume position of comfort (Rothen, 1999). Bed rest in low-Fowler’s position decreases intra-abdominal pressure; although patient will naturally assume least painful position. In using soft cotton linens, calamine lotion, oil bath, and cool, moist compresses as indicated, it is expected that irritation and dryness of the skin and itching sensation are reduced. The nurse should control environmental temperature because cool surroundings help reduce dermal discomfort. The nurse should encourage use of relaxation techniques such as guided imagery, visualization, and deep-breathing exercises. The nurse should provide diversion activities to redirect attention help improve coping. Nurse should provide time to listen to and maintain frequent contact with client to help alleviate anxiety and refocus attention to relieve pain (Lawrence et al, 1996). Collaborative approach should be used to maintain nothing by mouth (NPO) status. Nurse should insert and maintain nasogastric (NG) suction as indicated to remove gastric secretions that stimulate release of cholecystokinin and gallbladder contractions. Nurse should administer medications as indicated such as Anticholinergics, dicyclomine (Bentyl), clyco-pyrrolate (Robinul), and propantheline (Pro-Banthine). The medications antispasmodics and anticholinergics decrease gallbladder and biliary tree tone, which decreases pain. Administration of sedatives such as phenobarbital will promote rest, relax smooth muscle, and relieve pain. Opioids such as meperidine (Demerol) and hydrocodone with acetaminphen (Vicodin, Lortab) may be given to reduce severe pain. Antiemetics such as ondansetron (Zofran), prochlorperazine (Compazine), and promethazine (Phenergan) can relieve nausea and vomiting. Antibiotics either single agent or anti-infective combinations will treat infectious process, reduce inflammation and potential for systemic complications. Treatment for acute cholecystitis usually requires single-agent therapy, but a more serious infection requires combination drug treatment and has broad-spectrum coverage. Conclusion: In evidence-based nursing, it is important to undertake a thorough diagnosis of patient in order to assess her condition. For a post-operative cholecystitis and cholylithiasis patient, pain prevention and promotion of independence is important for a patient and proper nursing interventions should be conducted in a way that will achieve these goals. It is also important that infection be avoided for the patient’s well-being. 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