Data Collection for Person-Centred Care
This essay is going to discuss about the various medical problems faced by the patient Bianca Lane who is 20 years old and is suffering from peritonitis after a ruptured appendix. She was admitted to the hospital in the Emergency Department after having pain in the right lower quadrant pain in the abdomen. She was experiencing lack of appetite, fever and nausea. She also had a medical history of asthma and depression and her medication list includes salbutamol, seretide, and sertraline. Post-operation she was experiencing increased nausea, abdominal pain that increases with increase in movement and even breathing. In order to further investigate her condition she was subjected to abdominal x-ray by her doctors that showed that there is increase in the count of WBC and CRP. Thus, this essay will focus on the nursing issues and the associated care that is needed for the fast recovery of the patient.
As per the case study, the information that will be collected by the registered nurse (RN) in order to make sure that the patient gets the required amount of care and the correct treatment process for the faster and speedy recovery involves the observations after operation. This includes the body temperature of the patient, heart rate as well as the blood pressure of the patients. The nurse also needs to measure the respiration or breathing rate of the patient as well. After this the nurse needs to collect the peripheral capillary oxygen saturation or the SpO2.
As after the laparoscopic operations the patient was experiencing nausea, extreme abdominal pain at the time of movement and respiration thus, it is important that the nurse collects all these information as well. All these information will be helpful for the analysis and the diagnosis of the patient (Drake et al., 2014).
In order to collect the information, the RN should be attentive and should make efforts to collect the cues from the patient. This will require the nurse to be experienced and also need that the nurse continuously monitors the patient. The type of the information that was collected by the nurse will depend on the past medical history, and the current issues that was faced by the patients. This will also be dependent on the treatment and the diagnosis plan that will be provide to the patient.
All the information that is mentioned above is collected because it is significant to the patient and the further treatment that will be provided to the patient. The past medical history of Bianca shows that she was depressed and also needed certain treatment for asthma and thus she was on medications that can hamper her future treatment process or can even cause drug reaction.
Processing of Gathered Information
As per the clinical reasoning cycle by Levitt Jones (2010), the processing of the gathered information is a very critical stage. In this phase the nurse will process the data on the health status of the patient. This is relation to the pharmacological and pathophysiology of the disease. This helps the nurses to know the details of the condition of the patient and also to discuss the possible treatment of the patient that will be helpful for the prediction of the outcomes of the patients (Alfa, Toomey & Gupta, 2015).
The gathered information can be processed by the nurse as it is the most important thing to be analysed. As it was noted by the nurse that the patient was suffering from the right lower abdominal pain that reflects the fact that the patient might be suffering from appendicitis. This situation can arise when the appendix becomes inflamed (Bhangu et al., 2015). The pain starts from the middle of the abdomen and then it spreads to lower right abdomen where the pain spreads. The other less common causes are diarrhoea, constipation, nausea, bloating and vomiting. Thus, it is important to conduct laparoscopic operations for the removal of the appendix. All this analysis can only be done if the information that is being collected by the nurse is processed well and interpreted by the doctors and clinicians (Kostic, Xavier & Gevers, 2014; Zhang & Li, 2014).
As per the cycle after the processing of the gathered information the nurse will be able to identify and determiner the various nursing issues that are being faced by the patient. The issues that are identified by the nurse involve the feeling of nausea and bloating (Baadh, Singh & Graham, 2013). This can be due to the extreme pain after the surgery. As appendicitis is often related to the blockage of the opening of the appendix as well as the increase in the inflammatory bowel disease this can result in the increased pain and distended and rigid abdomen (Joshi et al., 2013).
In this essay as per the case study, the nurse identifies the three nursing interventions that includes pain, infection after operation and extended abdomen. After operation the patient was suffering from pain and after measuring the intensity of pain the nurse noticed that the pain scale showed a measurement of 7/10 (Goh, & Corke, 2014). This indicated the fact that the patient is suffering from severe pain that limits the ability of the patient perform the daily activities. This also interferes with the sleep of the patient that further increases the discomfort of the patient. Thus, the nurse should consider this fact and should ensure that the patient receives the correct medicines for the reduction in the amount of pain (Rawal, 2016).
Identification of Nursing Issues
The next issue faced by the patient was post-operative infection. This caused the patient to face severe pain as after the laparoscopic surgery. The reason for such an infection can be the attack of a number of pathogens at the location of the surgical incision. As the patient was having severe pain and complications it can be concluded that the patient was suffering from sepsis that leads to organ failure due to the infection that occurs in the blood of the patient (Argoff, 2014).
The last issue that was faced by the patient was that of extended abdomen. This can be related to the bowel problems and guarding of the abdomen. The distended abdomen can be due to the irritable bowel syndrome that can lead to the bloating and gas that can create cramping of the abdomen and pain in the stomach. This can be due to the appendicitis problem that was earlier faced by the patient before the surgery (Gatchel et al., 2014).
Now it is the duty of the nurse to mitigate the issues that are being identified after the surgery of the patient. These should include the interventions that will result in the improvement of the quality of life and will also help the patient to recover early.
The first issue that has been identified by the nurse includes the increased pain that was being faced by the patient. The interventions that should be taken by the nurse includes the fact that the nurse should know the details of the pain history of the patient. The nurse should also consider the previous methods that are being used for the reduction of the pain and should then assess the actual reason of the pain (Angus & Van der Poll, 2013). The nurse should also consider the fact that the patient was already under medication for asthma and depression and thus should recheck for any kind of drug reaction that can occur between the earlier prescribed medicine and on the recent medicines.
The next issue was the sepsis or infection in the blood that can lead to organ failure of the patient. The nursing intervention should include the reduction for the chances of infection. The other interventions include the fact that there is adequate perfusion of the tissue or proper movement of the blood across the circulatory system. The nurse should take measures like using hygienic tools and equipment at the time of surgery, maintaining hygiene at the time of operation so that there is less transmission of the infection to the patient. This external measures will reduce the rate of sepsis to a great extent (Campaign et al., 2013).
Nursing Interventions
The last issue is the distended abdomen and the intervention of the problem is slightly difficult. The nurse should make sure that the patient receives the right amount of diet at smaller portions and should also make note of the food items that is not easily digested by the patient like lactose or high fibre. This can also be due to the intake of the antidepressant medicines as that has already been mentioned in the medical history of the patient. So the nurse should make sure that the medicines taken by the patient does not cross react with any other prescribed medicine (Foley et al., 2014).
After the prescribed interventions the Clinical Reasoning Cycle by Levitt Jones suggests that the nurse should evaluate the effectiveness of the nursing interventions. The interventions taken by the nurse will help the patient to overcome the adverse health conditions that are being faced by the patient (Campaign et al., 2013). The control of the hygiene conditions at the time of operations or surgery will definitely help reduce the rate of sepsis in the patient. The pain can be reduced by the correct management of pain that includes the use of the visual analogue scale and the numeric rating scale. The regulation of the dietary habits and portions will also help in the reduction of the distended abdomen (Foley et al., 2014).
If I was the RN then I would have used a different approach for the treatment of the patient. I would have thoroughly assessed the patient that will include the physical examination and the assessment of the patient reports. Then I would have asked the patient to share whether the patient suffers from any kind of allergy from any medicines and then would ask the clinician to prescribe the medicine for the recent disorders. Then I would ask the patient about the diagnosis and treatment process so as to give a holistic approach to the treatment process. This way I would emphasize on the patient centered approach that will focus on the patient and not only on the illness.
Conclusion
Thus, the essay will link the clinical reasoning cycle with the case study that will help in the analysis and diagnosis of the patient. It can be concluded that the three nursing issues that are faced by the patient includes pain, extended abdomen and infection. This is important that the nurse identifies all these issues and addresses them so that the interventions can result in better recovery of the patient. This will include the process of providing Bianca with quality of care so that she does not suffer from any further problems and will also help in her recovery.
References
Alfa-Wali, M., Toomey, P., & Gupta, A. (2015). Treatment of uncomplicated acute appendicitis. Jama, 314(13), 1402-1403.]
Angus, D. C., & Van der Poll, T. (2013). Severe sepsis and septic shock. New England Journal of Medicine, 369(9), 840-851.
Argoff, C. E. (2014). Recent management advances in acute postoperative pain. Pain Practice, 14(5), 477-487.
Baadh, A. S., Singh, S., & Graham, R. E. (2013). A mysterious cause of a surgical abdomen. The Journal of emergency medicine, 44(2), 336-339.
Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J. H., & Drake, F. T. (2015). Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. The Lancet, 386(10000), 1278-1287.
Campaign, S. S., Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., … & Jaeschke, R. (2013). International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med, 41(2), 580-637.
Drake, F. T., Mottey, N. E., Farrokhi, E. T., Florence, M. G., Johnson, M. G., Mock, C., … & Flum, D. R. (2014). Time to appendectomy and risk of perforation in acute appendicitis. JAMA surgery, 149(8), 837-844.
Foley, A., Burgell, R., Barrett, J. S., & Gibson, P. R. (2014). Management Strategies for Abdominal Bloating and Distension. Gastroenterology & hepatology, 10(9), 561–571.
Gatchel, R. J., McGeary, D. D., McGeary, C. A., & Lippe, B. (2014). Interdisciplinary chronic pain management: past, present, and future. American Psychologist, 69(2), 119.
Goh, S., & Corke, P. (2014). Postoperative pain management. Australian Prescriber, 37(3), 76-78.
Joshi, G. P., Bonnet, F., Kehlet, H., & PROSPECT collaboration. (2013). Evidence?based postoperative pain management after laparoscopic colorectal surgery. Colorectal Disease, 15(2), 146-155.
Kostic, A. D., Xavier, R. J., & Gevers, D. (2014). The microbiome in inflammatory bowel disease: current status and the future ahead. Gastroenterology, 146(6), 1489-1499.
Rawal, N. (2016). Current issues in postoperative pain management. European Journal of Anaesthesiology (EJA), 33(3), 160-171.
Zhang, Y. Z., & Li, Y. Y. (2014). Inflammatory bowel disease: pathogenesis. World journal of gastroenterology: WJG, 20(1), 91.
Order an Essay Now & Get These Features For Free:
Turnitin Report
Formatting
Title Page
Citation
Outline
