Clinical Reasoning Cycle and patient scenario – objective structured clinical assessment

Written Assessment – 500 Word Academic writing that is supported using contemporary evidence

Guided by the Clinical Reasoning Cycle and patient scenario, students are required to utilise clinical reasoning and demonstrate knowledge regarding the care of Lisa. In this written assessment students will need to clearly identify one problem, presenting sound rationales that support their decision. Students are encouraged to draw on the patient’s story, cues and related information as they do this. Students are required to outline one goal, nursing care/action and how evaluation will take place; providing rationales supported by literature. Students must focus their nursing care to address the identified problem

 SCENARIO:

You a third-year nursing student working on a surgical ward allocated to the high dependency area. It is 7:30am and you have just received the following handover from night staff. Your buddy nurse asks you to care for Lisa today.

Lisa a 38-year-old mother of two who competes in triathlons. Lisa presented to the emergency department 48 hours ago with an acute abdomen and was diagnosed with perforated bowel secondary to suspected diverticulitis. Lisa underwent emergency midline laparotomy with division of adhesions and resection of 10 centimetres of bowel. Since returning to the ward she has suffered intractable pain that is not well controlled with a PCA and intrawound catheters. Her pain is reduced to a 2/10 for about 2 hours after the local anaesthetic via the intra-wound catheters and then increases to 7-8/10. Lisa attempted to sit out of bed yesterday but was unable to sit due to the pain and discomfort while sitting. She had a CT scan which was NAD.  Overnight Lisa had a 10-minute period of AF which altered blood pressure. She was given IV potassium and magnesium by MET Call Team.

On Assessment the following is identified:

CNS: Alert and Orientated rating her pain at a 6/10 and increasing. Lisa has a Fentanyl PCA with 20 mcg background, and 20mcg boluses with a 5 minute lock out which was increased after review by the pain team yesterday. In the last hour she has had 12 demands and 8 deliveries. Lisa has equal limb strength and is able to move herself in bed with assistance. Her GCS is 15 and PEARL.  Lisa prefers to lay flat in left lateral position curled up, asking that you do not sit her up as it hurts too much.

CVS: IVC X 2 insitu, one in right forearm, the other in left forearm, both VIP score 0. IV therapy is running at a 6 hourly rate.  She has warm peripheries and is slightly diaphoretic. Her vital signs are stable with a heart rate of 80-90 beats per minute in sinus rhythm, blood pressure ranges from 100-106/ 56-60, Temperature is 37.2 celcius.  Overnight she has had short runs of AF, self-reverting on the monitor, lasting about 10 minutes. During the most recent episode of AF at 0500hrs today she felt short of breath and her Blood Pressure fell to 85/50. Currently she is in sinus rhythm.

RESP: Respiratory rate of 16-20 shallow breathing, oxygen saturation of 95% on using the AIRVO2 at 50% Flow 40L/min nasal prongs insitu.  She has a very weak cough non-productive. On auscultation air entry to bases is quiet but heard in the midzones.

GIT: Abdomen is tender to touch, but soft. Bowel sounds are present throughout all quadrants. Bowels have not been open but she is passing flatus. She remains nil oral at this stage only having ice for comfort, awaiting surgical review.  Currently no nausea and has not vomited overnight.

Renal: IDC remains insitu due to immobility. Over the past 4 hours the urine output has been 110ml.  Urine test was NAD.

Metabolic: BSL range between 6.0 and 8.0mmol/L, electrolytes have been stable and morning blood tests of U&E, Mg, K, PO4, LFT, FBE and Coags have been taken at time of MET Call. For repeat at 1000hrs.

Wound: Midline dressing intact, minimal ooze on dressing. No heat or redness noted. Intrawound catheters insitu. No pressure areas but marking from sheets noted on back.

Social: family aware and husband and children will be visiting in the afternoon.

Regular Medications:

PRN Medications:

Intrawound Block orders:

Drug: Ropivacaine 0.2%

• Dose: 20ml per catheter
• Frequency: 4/24
• Times given since midnight: 0100, 0500

PCA Orders:

Drug: Fentanyl

• Dose 500mcg in 50ml N/Saline
• Concentration: 10mcg/ml
• Route: IV
• Bolus dose: 20mcg
• Lock out: 5 minutes
• Background infusion rate: 2ml/hr

  Academic standards require:

• the use of third person, unless specifically indicated otherwise;
• APA 6th edition for in-text citations and reference list;
• Regarding the number of references, there is no exact number. You will need at least 4 or 5 high quality references through. By high quality it means nursing journals, not text books and absolutely no websites.
• adherence to word count;
• a 12-size font in either Arial, Times New Roman or Calibri;
• 1.5 spacing; and
• submitted using a MS word document only

Note this assessment does not require an introduction or conclusion. 

Answer/ notes:

I am thinking of Sepsis / septic shock or pain as the problem. Have attached few articles supporting it. We need to unfold the cues and then come up with the reason for the problem. Teacher said that we need to look at the patient history and medication. Since she had 2 episodes of AF I feel it might be related to progressive septic shock. Or is it due to underlying cardio vascular problem due to her being a Triathlon? Very low BP – septic shock?

She had an emergency midline laparotomy – a major surgery –

She has a pain that we are unable to control using PCA. Is the Pain due to – surgery? Peritonitis due to perforated bowel – secondary to diverticulitis?

Triathlon – is her BP and heart rate normal for her? – her current BP is very low – what can that mean to her? – AF?  (Article attached)