Clinical case study


Clinical Reasoning Cycle represents the cyclical and ongoing nature of clinical interventions in clinical practice and the importance of reflection and evaluation. It consists of eight main steps; consider the patient situation, collect information/cues, process information, identify issues/problems, establish goals, take action, evaluate outcomes, and reflect on new learning and processes. In reality, though the cycle presents the phases as distinct and separate element, they merge and boundaries existing between them tend to be blurred. Aiken et al. (2003) suggests that having effective clinical reasoning skills can positive impact on patient outcome and having poor clinical reasoning skills can lead to make a nurse to fail to detect patient deterioration leading to a “failure-to-rescue” (NSW Health, 2006). This is important especially when considering the increasing number of escalating healthcare complaints and adverse patient outcomes (NSW Health, 2006). NSW indicates that the key reasons for increasing adverse patient outcome are: inappropriate management of complications, failure to institute correct treatment, and failure to properly diagnose. All these are pegged on poor clinical reasoning skills. The focus of this paper is to utilize the Clinical reasoning Cycle to plan and evaluate person-centered care.

Patient Situation

She is thirty five years old and she presented to the emergency department with left lower quadruple abdominal pain from home. Her husband is staying with her. She has two children and her mother in law is looking after them.

 

 

Patient Cues/Information

Her pain has been radiating to right lower quadruple abdominal pain. Her pain started last night at about 0300 and her partner called an ambulance. She described her pain as sharp pain in her word. She is complaining of nausea and vomiting and she had one episode of vomiting after she was admitted into the emergency department. She does not have any medical or surgical history. She does not take any medication and she does not have any allergy as far as she knows. She does not remember her last normal menstrual period was and the last time she eats and drinks was at about 1900 yesterday when they had dinner. She does not have a problem to go to toilet. It is important to note that the patient physical and history can be used as the basis for choosing the relevant diagnostic testing that ultimately leads to an accurate and timely diagnosis. Previous studies have demonstrated that medical students as well as physicians make diagnosis based in the patient’s history or chief complaints in 70-90% of the cases. This suggests that for both medical students and physicians, history taking plays an important part in the diagnosis process.

Process Information

Her heart rate and blood pressure are elevated due to pain and she is febrile. She is complaining of generalized abdominal pain 10 out of 10. Her blood glucose level is within therapeutic range.

Her heart rate, blood pressure and temperature are higher than normal range as she was screaming and crying due to pain. However, not only because of pain, infection can lead to hyperthermia and hypertension (Shin, 2011). Infections elevate C – reactive protein (CRP) levels, an antibody like protein and increased CRP levels promote atherosclerosis so it can lead to high blood pressure (Shin, 2011). She said she does not have any medical or surgical history at first but after her pain has settled by administering Morphine and Endone and my buddy nurse and I established therapeutic relationship with her, she told me that she has termination of pregnancy done one week ago.

Identifying Problems/Issues

She was complaining of generalized lower abdominal pain and she has a fever. Lower abdominal pain can be signs of appendicitis, constipation, pelvic and she has a fever. Lower abdominal pain can be sings of appendicitis, constipation, pelvic pain, groin pain, urinary tract infection and diverticular disease. She presented to ED with left lower quadruple abdominal pain so it cannot be appendicitis. She said she does not have problems to go to toilet and I have checked her full ward test which showed NAD (No Abnormality Detected). She does not have a disturbance of bowel function so diverticular disease can be ruled out. I have talked to my buddy nurse and an emergency department medical officer that it could be her pelvic or groin pain. She has been diagnosed with pelvic Inflammatory disease (PID). PID is a complication of sexually transmitted disease (STD) in women. It infects female reproductive organs. It can cause irreversible damages to the fallopian tubes, ovaries, uterus, and other sections of the female reproductive system. It is the primary cause of infertility among women. There are various causes of PID including untreated Chlamydia, gonorrhea, childbirth, pelvic procedures, and abortion. Normally, the work of the cervix is to prevent bacteria that enter the vagina from entering and spreading to female internal reproductive organs. As such, in the event the cervix becomes infected and it loses its ability to prevent organisms from travelling to the upper genital tract via the cervix leading to PID. The results of the ultrasound and what was revealed from the patient’s medical history suggests abortion as the likely cause of her PID. The symptoms of PID may vary and may include vomiting and nausea, and pain in the lower abdominal area or right upper abdomen, and abdominal menstrual periods as evidenced in this case study. Others may include painful urination, pain during sex, high fever or chills, increased period pain, and abnormal vaginal discharge which may be green or yellow in color. PID is common condition among sexually active women. It is estimated that each year about 10,000 women in Australia are hospitalized for PID. Like it happened to my patient, many patients with PID no not know that they are infected since they experience no symptoms and signs.

Establishing Goals

I want to improve her hemodynamic status by lowering her blood pressure, heart rate and temperature so that her hemodynamic status can be stabilized. I want to manage her pain by giving her analgesia. I want her to go back to normal status over the next hour. Bossuyt, Reitsma, and Bruns (2003) suggest that it healthcare professional should clinically examine hemodynamically unstable patient because the exercise provides a low risk, potentially useful diagnostic and timely prognostic information.

Taking Action

As soon as she came to a cubicle, I have checked her temperature, blood pressure, heart rate, respiratory rate and oxygen saturation. I asked her pain and let her describe her pain in her own word. I have assessed her airway, breathing, circulation, disability and exposure. My buddy nurse inserted peripheral intravenous device and took her blood and send them to the pathology. This physical examination was important because the findings from this process were used to treat and risk-stratify the patient. According to Sonke, Verbeek, & Kiemeney (2009) the use of selected findings from the physical examination has been validated to serve as the surrogate marker of a short-term treatment efficacy. It has also been validated to justify and replicate findings obtained through more invasive methodologies.  As evidenced in this case study, physical examination findings guided the diagnostic and treatment decision.  I have done her full ward test. I have discussed with a medical officer about her pain so she has given analgesia. She went to ultrasound to check her reproductive system.  She was diagnosed with Pelvic Inflammatory disease (PID).

Her hemodynamic status will be my nursing priority as the patient was febrile, hypertensive and with a faster than normal range of heart rate. Sevransky, Nour, & Susla (2007) indicates that in a patient, hemodynamic forces demonstrates as blood flow and blood pressure paired values at various nodes in the cardiovascular system. As such, by monitoring the hemodynamic status it is possible to make an early detection of possible inadequacy of perfusion which is critical to making a decision as to whether the patient needs active intervention.

Evaluate Outcomes

I gave Morphine and Endone under supervision as my patient was in severe pain. Morphine and Endone are both narcotic analgesics. Meier (2003) suggests that Morphine and Endone should be used to treat severe to moderate pain. I also found it appropriate to use these drugs because my patient did not have severe breathing problems or asthma, a paralytic ileus, a blockage in the stomach or intestines. She was crying and screaming and her hemodynamic status was not stabilized. As her pain started from left lower quadruple abdominal region, I ruled out appendicitis since she had not had any trouble visiting the toilet. Patients with appendicitis present with similar symptoms to those with PID. However, unlike PID patients, Appendicitis patients tent to experience the inability to pass gas, have diarrhea or constipation with gas, and abdominal swelling. After her full ward test, I ruled out urinary tract infection, diverticulitis and constipation. Urinary tract infection, constipation and diverticulitis present with almost similar symptoms.  However, clinical assessment and diagnostic can isolate them. I did the clinical examination taking into consideration Sevransky, Nour, & Susla (2007) view that clinicians can use clinical examination to classify a patient with a disease, follow the response of the patient to therapy, identify asymptomatic patients with syndrome (or disease), rule out disease, examine whether a specific syndrome or disease is present, and risk stratify a patient. After her pain has settled, her blood pressure and heart rate came back to normal.

Reflecting on the Process and New Learning

I realized the important of monitoring patients’ vital signs frequently and establish therapeutic relationship with patients. It is very important to know anatomy and physiology as her signs and symptoms can lead to certain disease.

 

 

 

 

 

 

 

 

References

Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M. and Silber, J.H. (2003) Educational levels of hospital nurses and surgical patient mortality. JAMA.290 (12), 1617–1620.

NSW Health (2006). Patient Safety and Clinical Quality Program: Third report on incident management in the NSW Public Health System 2005-2006, NSW Department of Health. Sydney.

Bossuyt, P.M., Reitsma, J.B., & Bruns, D.E. (2003). Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD initiative. Ann Intern Med; 138: 40–44

Meier, B. (2003). Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death. Melbourne: Rodale.

Sonke, G.S., Verbeek, A.L.M., & Kiemeney ,L.L. (2009). A philosophical perspective supports the need for patient-outcome studies in diagnostic test evaluation. Journal of Clinical Epidemiology; 62:58–61

Sevransky, J.E., Nour, S., & Susla, G.M. (2007). Hemodynamic goals in randomized clinical trials in patients with sepsis: A systematic review of the literature. Crit Care;11:R67

Shin, J. H. (2011). Management of chronic pelvic pain. Current Pain and Headache Reports, 15(5), 377-385.

 

Leave a comment

Your email address will not be published. Required fields are marked *