Question

Edward (Ted) Williams is an 82year old male who is day 4 post-operative following a bowel resection and formation of a temporary colostomy. Ted had previously had a coloscopy and biopsy that confirmed a malignant mass. He has a past medical history of; heart failure, type II diabetes melilites, obesity and gout. (BMI 37.6m2; Height 175cm; weight 115kgs)

Ted is a widower and lives alone. His wife died 3 years ago following a bout of pneumonia. One year ago, Ted moved into a retirement village located in a regional area two and a half hours from the city. The retirement village is near where he lived with his wife and children until they left home. Ted has 2 grown up children, a son Christopher who lives overseas with his wife and son, and a daughter Janice who lives with her husband and 3 children in the city. While Ted lives alone, he has a partner Gwen 78, who also lives in the same retirement village as Ted.

Current medication:

• Metformin 500mg Mane
• Captopril 12.5mg mane
• Frusemide 40mg mane
  • Allopurinol 100mg Daily
  • Paracetamol 1g QID

Ted is now day 4 post op. He was Nil By Mouth (NBM) for the first 48 hours after surgery. Yesterday he commenced on a full fluid diet and has upgraded to a light diet yesterday evening. Today, Ted was given his regular metformin and ate breakfast. Since then Ted has vomited twice and feels nauseous. He has been given ondansetron 4mg for nausea.

Teds vital signs at 10am are as follows: T 38.1; HR 98 reg; BP 135/85; RR 26; SpO2 94% on 3L NP. He has right sided inspiratory coarse crackles and he has a moist productive cough. He has PCA morphine in situ for effective pain regulation.  Ted has some abdominal pain that he says is at a scale of 4-5/10, he says the pain worsens on palpation to 7/10 and you note that his abdomen is distended. The colostomy bag is intact, and the stoma can be sighted through the bag. The stoma is warm, pink, moist and slightly raised above the skin. There has been no output since his surgery. He has sluggish bowel sounds and has not passed flatus. The abdominal laparotomy has a clear occlusive dressing (opsite) and there is minimal ooze present. He has a redivac drain with 30mls of haemoserous fluid, and a urinary catheter in situ and is passing approx. 60-70mls of urine/hr.

Q1: Use stage one of the clinical reasoning cycle (CRC) ‘Consider the patient situation’ to identify the biopsychosocial, spiritual and cultural impacts of Ted’s surgery for him and his family (250words)

Q2: The information for stage two of the CRC collect cues and information has been provided for you in the case study. Use this information to provide responses to CRC stages three ‘Process the information’ and stage four ‘Identify Problems.’ Please link to pathophysiology and provide evidence from the literature to support your thinking. (600words)

Answer 1

Q1: Use stage one of the clinical reasoning cycle (CRC) ‘Consider the patient situation’ to identify the biopsychosocial, spiritual and cultural impacts of Ted’s surgery for him and his family.

Ans:-

Mr. Edward Williams is an 82 yr. old male who is admitted in hospital for bowel resection and formation of a temporary colostomy.

Previous examinations: - colostomy, biopsy which confirmed a malignant mass.

Considering the situation of the patient:

Patient's details:

▪ Patient name- Mr. Edward Williams

▪ Age-82 yr

▪ Gender- male

▪ Diagnosis- malignant mass

▪ Surgery- bowel resection and colostomy

▪ Hospitalization period -4 days

▪ Investigation - biopsy and colonoscopy

▪ Chief complain- distended abdomen

Worsen pain on palpation to 7/10

Vomited twice, nausea

Bio-Psycho social - Spiritual Mondel- family history:-

Mr. Edward is a widow and lives alona.

His wife died 3 yrs ago following about of pneumonia. Mr. Edward hse 2 child one girl and one boy. One year ago Ted moved into a retirement village located in regional area two and half hours from the city and this village is near where he lived with his wife and children until thy left home. His son Christopher had a son and daughter. His daughter janice had 3 children.

Mr. Edward lives alone, he has a partner Gweb 78, who also lives in the same retirement village as Ted.

Clinical Reasoning Cycle

Clinical Reasoning Cycle is the process in which nurses and other medical practitioners collect indications, process the data and comprehend the problem which the patient is facing. Based on the results, they plan and instrument interventions, gauge outcomes and reflect upon the whole process. Also, this process depends upon ‘disposition’ and is influenced by various factors such as the attitude of a person, several philosophical perspectives as well as the biases.

The cycle plays a crucial role in patients. This is because a nurse who possesses effective clinical reasoning flairs to impact the patients positively and vice versa. Realising this, our Clinical Reasoning Cycle Nursing experts at Sample Assignment are here to guide you on various aspects which govern these connected and enduring clinical encounters.

Steps in Clinical Reasoning Cycle

Basically, a clinical reasoning cycle consists of 9 steps that are co-related to each other.

Considering the situation of the patient

In the first step, nurses are required to describe the details of the patient, which would include facts and various situations or context of the patient.

Collecting Cues

Here, nurses have to review information like the reports, history of the patients, any previously undertaken nursing assessments and many more such data about the patient. Then, new information has to gathered and finally nursing terminologies and knowledge have to recalled such as therapeutics, epidemiology etc.

Processing information

While processing the information, the nurse has to interpret, discriminate, relate, infer, match situations and predict an outcome.

Identifying the problem

Synthesizing facts and then in referencing in order to make a definitive diagnosis of the problem of the patient is what a nurse has to do here. When the problem would be appropriately identified, only then it would be diagnosed properly.

Establishing Goals

Nurses have to describe what goals they want to achieve, within a particular time frame. When the goal is clear, they can work towards it and make it possible. Thus, we guide students on establishing achievable goals.

Taking appropriate actions

As an efficient nurse, it is also their duty to take desirable actions that are available as these actions would help in bringing desirable outcomes.

Evaluating

The role of a nurse is not just confined to provide effective nursing care to patients. It also concerns itself with evaluating how effective the outcomes and actions are.

Reflecting upon the process

The last and the final step involved in this process is to reflect upon what you have gained from this. It also involves talking about the things that you could have learnt if you would do things differently.

Bio-Psycho Social-Spiritual Model

This model generally includes the following:

Biological

Past

Genetics:

• Consider whether any blood relatives that have had psychiatric problems, substance use problems or suicide attempts/suicides. Is there a history of close relatives who have been hospitalized for psychiatric reasons? What kind of treatments did they get, how did they respond?

History of Pregnancy and Birth:

• Consider pregnancy variables: Was there in-utero exposure to nicotine, alcohol, medications or substances? Anything unusual about pregnancy?
• Note birth complications, such as prematurity, birth trauma or extended periods of hospitalization.

Relevant Previous Illnesses

• Consider any history of head injury, endocrine disorders (e.g. thyroid, adrenal), seizures, malignancies, or neurological illnesses.
• Consider potential lasting effects of past substance use on brain functions such as cognition, affective regulation, etc.

Present

Current Illnesses:

• Identify current illnesses and any direct impact they may have on psychiatric presentation.

Medications:

• Assess current medication regimen. Consider whether these medications have psychoactive effects (e.g. steroids, beta blockers, pain medications, benzodiazepines, SSRI's, antipsychotics). Consider possible side effects of current medications.

Substances:

• Consider the influence of nicotine, alcohol and street drugs on current psychiatric symptoms.
• Consider the possible effects of substance withdrawal.

Psychological

Past

• Comment on any past history of trauma (child abuse, combat, rape, serious illness), as well as resiliency (how the patient coped with trauma, e.g. friends, family, religion).
• Consider the sources of positive self image and positive role models.
• Comment on the patient's experience with loss.
• Comment on the patient's quality of relationships with important figures, such as grand parents, friends, significant teachers, or significant employers.
• Comment on how past medical problems, substance use or psychiatric problems impacted the patient's development and their relevance to patient today.

Present

• Describe the recent events and experiences that precipitated the admission or appointment.
• What are the current stressors? Do they have any symbolic meaning?
• Assess and comment on coping skills, defense mechanisms, presence or absence of cognitive distortions.
• Consider current developmental demands on the person, such as marriage, divorce, birth, children leaving home, loss, aging, etc. What stage of development is the patient at now? Is it appropriate?
• What is the developmental impact of the patient's illness?

Social

• How adequate is the patient's current support system?
• What is the current status of relationships with important figures?
• What are the possible peer influences?
• Consider the patient's current housing arrangement.
• Comment on vocational/financial status.
• Comment on any relevant legal problems.
• Consider the role of agencies (e.g. Veteran's Administration, Child Protective Services, Criminal Justice System) on the patient.
• Comment on cultural influences that may impact the current situation and that might impact treatment.

Spiritual

• Comment on the role of spirituality in the patient's life. Is the patient affiliated with a spiritual community of some sort?
• How does spirituality contribute to the patient's ability to hope, their position on suicide if relevant, or their contact with a supportive community?

Culture

Culture is the patterns of ideas, customs and behaviours shared by a particular people or society. These patterns identify members as part of a group and distinguish members from other groups. Culture may include all or a subset of the following:

Given the number of possible factors influencing any culture, there is naturally great diversity within any cultural group. Generalizing specific characteristics of one culture can be helpful, but be careful not to over-generalize.

• ethnicity
• language
• religion and spiritual beliefs
• gender
• socio-economic class
• age
• sexual orientation
• geographic origin
• group history
• education
• upbringing
• life experience

Culture is:

• dynamic and evolving,
• learned and passed on through generations,
• shared among those who agree on the way they name and understand reality,
• often identified ‘symbolically’, through language, dress, music and behaviours, and
• Integrated into all aspects of an individual’s life.

Q2: The information for stage two of the CRC collect cues and information has been provided for you in the case study. Use this information to provide responses to CRC stages three ‘Process the information’ and stage four ‘Identify Problems.’ Please link to pathophysiology and provide evidence from the literature to support your thinking.

Ans:-

Processing information:-

Education Today the nurse will talk to you about:

Doing activities

Controlling pain

Taking medications

Drinking fluids You may go home in 24 to 48 hours if you are progressing and meeting your daily goals.

The catheter will be removed if you can walk to the bathroom. If your catheter is removed, use the collection hat in the bathroom so the nurse can measure your fluid output. Tell your nurse if you pass gas or have a bowel movement. A dietitian may visit you today to discuss your diet if requested by you or your physician. If your procedure involved the creation of a colostomy or an ileostomy, a nurse specialist will visit you to discuss the appliance and its care. A social worker is available to help plan for post-hospital care. Diagnostic Tests Your blood pressure and temperature will be checked three times today. The nurse will check your abdomen for sounds, swelling and pain. Your doctor may or may not order blood tests. Medication Tell your nurse if you: Have pain Cannot sleep Are nauseous Feel itchy Feel restless or nervous Nutrition No nausea is a good sign. Your doctor may start you on sips of water and allow you to drink liquids. No straws! The IV will stay in place until you are able to drink fluids easily. Treatments Keep turning every two hours, and ask a staff member if you need assistance. Leg sleeves will be on while in bed. Tri-flow:Use it 10 times every hour. Activities Today you will: Sit in a chair for 45 minutes (or more) at least three times Walk in the hallway with staff assistance, or by yourself, at least 4 timesat least four times Comb your hair, brush your teeth and shave. Ask staff if you need assistance Daily Goals We hope that by the end of the day: Your pain is under control You are able to sit in chair for 45 minutes three times You are able to walk in hallway four times You are able to drink fluids without problems Your catheter is removed and you are able to use bathroom You raise three balls in the tri-flow Your leg sleeves removed You receive a visit from nurse specialist regarding colostomy or ileostomy appliance (if applicable) You are able to open/close colostomy or ileostomy appliance clamp and empty contents (if applicable) You will have a ride to take you home.

Need to Know: Your doctor may let you go home today! Discharge can occur as early as 10 a.m.

The nurse will review instructions about: Diet Medications Activity and Exercise Do you know when to call your doctor? Call immediately if you:

Feel nauseated Feel bloated or have stopped passing gas Have chills or fever There is redness or burning at incision site Medication Your doctor will write a list of medications you are to continue taking at home. Nutrition Your doctor will select your diet.

Your doctor may send you home with either liquid or solid food.

Activities Today, you will: Continue to do as much as you can independently. Ask staff if you need assistance. Daily Goals Today: You are ready to go home! You are able to take pain pills without problems. You are able to walk independently. You are able to drink fluids easily. You are able to comb hair, brush teeth, shave, and get dressed with little or no assistance. You are aware of the danger signals to watch for at home. You know when to call the doctor. You are able to care for your colostomy or ileostomy appliance without guidance.

Traditional surgery results in an average hospital stay of a week or more and usually 6 weeks of recovery. Less invasive options are available to many patients facing colon surgery. The most common of these is laparoscopic surgery, in which smaller incisions are used.

You are likely to have pain that comes and goes for the next few days after bowel surgery. You may have bowel cramps, and your cut (incision) may hurt. You may also feel like you have the flu. You may have a low fever and feel tired and nauseated.

Side effects of a bowel resection include:

Pain.

Fatigue.

Bleeding.

Blood clots.

Diarrhea.

Constipation.

Bowel obstruction.

Infection.

No nausea is a good sign. Your doctor may start you on sips of water and allow you to drink liquids. No straws will be allowed if you have had a laparoscopic bowel procedure done. The IV will stay in place until you are able to drink fluids easily

Bowel Resection Patient Care IV. You will have an IV placed in your hand or arm to give you fluids and medication. It will remain in place until you are able to drink liquids. Catheter. A catheter will be inserted into your bladder during surgery, to drain urine. Leg sleeves. These will be on while you are in bed.

Identifying the problem

Medical History:

Heart failure.

Type II diabetes melilites.

Obesity and gout. (BMI 37.6m2; Height 175cm; weight 115kgs)

Stoma

Mr. Edward (Ted) Ted lived in retirement village. He lives alone. His wife died 3 years ago.

He was on NBM Diet. {48 hours after OT} The abdominal laparotomy, minimal ooze has a clear

Current medication:

· Metformin 500mg Mane

· Captopril 12.5mg mane

· Frusemide 40mg mane

· Allopurinol 100mg Daily

· Paracetamol 1g QID

· ondansetron 4mg [for nausea.]

Bio-Psycho social - Spiritual Mondel- family history:-

Mr. Edward is a widow and lives alona.

His wife died 3 yrs ago following about of pneumonia. Mr. Edward hse 2 child one girl and one boy. One year ago Ted moved into a retirement village located in regional area two and half hours from the city and this village is near where he lived with his wife and children until thy left home. His son Christopher had a son and daughter. His daughter janice had 3 children.

Mr. Edward lives alone, he has a partner Gweb 78, who also lives in the same retirement village as Ted.

Collecting clues:-

History-Past medical History:

Heart failure.

Type II diabetes mellitus.

Obesity and. gout.

Past surgical history: not mentioned present History: - bowel resection and formation of a temporary colostomy. He has right sided inspiratory coarse crackle and he has a moist productive cough. He has PCA morphine in situ for effective pain regulation ted has some abdominal pain that hs says is at a scale of 4-5/10. He says the pain worsens on palpation to 7/10. His abdomen is distended.

Evidence-Based Practice

Evidence-based health care practices are available for several conditions such as asthma, heart failure, and diabetes. However, these practices are not always implemented in care delivery, and variation in practices abound. Traditionally, patient safety research has focused on data analyses to identify patient safety issues and to demonstrate that a new practice will lead to improved quality and patient safety. Much less research attention has been paid to how to implement practices. Yet, only by putting into practice what is learned from research will care be made safer. Implementing evidence-based safety practices are difficult and need strategies that address the complexity of systems of care, individual practitioners, senior leadership, and ultimately changing health care cultures to be evidence-based safety practice environments.

Nursing has a rich history of using research in practice, pioneered by Florence Nightingale. Although during the early and mid-1900s, few nurses contributed to this foundation initiated by Nightingale, the nursing profession has more recently provided major leadership for improving care through application of research findings in practice.

Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. Best evidence includes empirical evidence from randomized controlled trials; evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion. When enough research evidence is available, the practice should be guided by research evidence in conjunction with clinical expertise and patient values. In some cases, however, a sufficient research base may not be available, and health care decision making is derived principally from nonresearch evidence sources such as expert opinion and scientific principles.

Pathophysiology of Heart Failure

In heart failure, the heart may not provide tissues with adequate blood for metabolic needs, and cardiac-related elevation of pulmonary or systemic venous pressures may result in organ congestion. This condition can result from abnormalities of systolic or diastolic function or, commonly, both. Although a primary abnormality can be a change in cardiomyocyte function, there are also changes in collagen turnover of the extracellular matrix. Cardiac structural defects (eg, congenital defects, valvular disorders), rhythm abnormalities (including persistently high heart rate), and high metabolic demands (eg, due to thyrotoxicosis) also can cause HF.

Pathophysiology of type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a heterogeneous disorder with varying prevalence among different ethnic groups. In the United States the populations most affected are native Americans, particularly in the desert Southwest, Hispanic-Americans, and Asian-Americans. The pathophysiology of type 2 diabetes mellitus is characterized by peripheral insulin resistance, impaired regulation of hepatic glucose production, and declining β-cell function, eventually leading toβ -cell failure.

Pathophysiology of Obesity

Obesity is an exaggeration of normal adiposity and is a central player in the pathophysiology of diabetes mellitus, insulin resistance, dyslipidemia, hypertension, and atherosclerosis, largely due to its secretion of excessive adipokines.

Pathophysiology of Gout

Gout can be considered a disorder of metabolism that allows uric acid or urate to accumulate in blood and tissues. When tissues become supersaturated, the urate salts precipitate, forming crystals.