Clinical Reasoning Cycle Paper Online Tutoring

PATIENT

Haley is an 11 year old girl Aboriginal girl with a weight of 53kg. She was admitted due to abdomen pain and vomiting. She underwent laparoscopy for inflamed appendix. After following surgery she was transferred to ward from recovery. She is attentive and conscious. She is admitted with her mother as the caregiver present.

CUES AND SIGNS

Review:

Haley is a patient of Type 1 diabetes and been under self management at home through insulin pump. she is transferred to the ward room from recovery, 3 hours after undergoing appendectomy.  Her recovery room report states that she is alert and has a capillary refill of 2 seconds. She remains tachycardic and has moderate pain level. She has a low grade fever and her BGL level is elevated. Her incision site and IV site are clean with minimum ooze.

Her ABG detects a change in pH towards acidic.

Gather:

 

Latest assessment shows RR 30min, BP 90/58mmHg, HR 135 bpm, central capillary refill of 3 seconds, axillary body temperature is 38.7 degrees. Haley’s pain level is 5/10 i.e. moderate and is in sleeping state. She rouses on sound. Her skin is warm and red and her peripheries are cool. She has Actrapid infusion of 1mg/ml and is getting it at 0.03 units/kg/hr. Her body fluids are imbalanced due to surgery and transfer. Patient is answering questions and caregiver is not inquiring or looks worried

Recall:

  • Temperature is common after surgery in patients due to weakness or infection (Vijarnsorn et al., 2012)
  • High BGL is also caused due to anesthesia and surgery as a result of stress
  • High BGL is also a sign of infection or illness (Ata et al., 2010)
  • High heart rate is usually caused due to pain (Shao et al., 2011)
  • Fluid imbalance also causes various changes in the body such as change in pH level
  • Pain medication sometimes also causes drowsiness.

PROCESS INFORMATION

Interpret:

Haley just had surgery and sudden disturbance in her vitals Is expected. However, her signs previously stable in recovery have started to get imbalanced.

  • Her systolic BP is on decreasing trend, according to her charts
  • Her BGL level is higher than 5 to 10mmol/l
  • Her capillary refill is greater than 2 seconds
  • Her respiratory rate Is on increasing trend
  • Her heart rate is on increasing trend towards 135bmp
  • Her body is warm centrally and cold peripherally
  • Her pain scale shows 5/10
  • Her level of consciousness is now responsive to sounds

Discriminate:

  • Although Haley has a fever greater than 38 which is also a sign of infection, but nil observation of any inflammation at any site in Haley’s body. The more concerning factor is the changes in her vitals i.e. blood pressure, heart rate and capillary refill. These sudden and slow changes are the beginning signs of deterioration. With handling these parameters through underlying problem, the fever will be controlled as well
  • Although Haley is woken up by sounds, she is still conscious and answering questions. Her declining consciousness would be handled later on. Initially the cause and management should be done
  • Her BGL is very important. High glucose causes critical problems after surgery such as slowed down healing process.

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Relate & Infer:

  • Fluid imbalance due to surgery and transfer might be the reason for tachycardia and low BP (Balcı et al., 2013). Fluid imbalance causes electrolyte imbalance. This triggers the entire organ system.
  • Tachycardia and low blood pressure means the blood is not being circulated properly which might be the reason for Haley to be cold peripherally.
  • Prolonged capillary refill time also indicates low peripheral perfusion which causes cold peripherals (Hariri et al., 2019)
  • Fluid imbalance also causes changes in pH of the body making it acidic that often disturbs the insulin function causing hyperglycemia.
  • Her sleepiness state maybe due to changes in her pH towards acidic as proved by her ABG chart. This acidemia further causes loss of oxygen in the skeletal muscles leading to muscle fatigue (Wan et al., 2017). Haley was alert in her ISBAR report but her recent assessment tells that she is feeling sleepy and is only woken up on sound
  • Her pain scale shows moderate pain which might be the reason behind change in physiological parameters as pain triggers sympathetic system to become active. This increases heart rate

 

Predict:

Based on the assessment, slow changes are being observed in Haley’s clinical presentation. These changes are most often seen in patients after surgery that promises mortality.

Haley being a type 1 diabetic patient requires immediate address to her findings before it accelerates. With the increase in her physiological parameters and BGL, her body will go in shock that ultimately might lead to multi-system organ failure and death.

Match:

  • There have been increased events of such condition as Haleys where diabetic patients are seen to show deteriorating conditions post surgery (Wang et al., 2019). It is mostly due to the incidence of infection contracted during the surgery. This causes postoperative fever, high BGL and slow changes in vitals.
  • Due to surgery it is observed that majority of patients that have an imbalance of fluid for a long period of time has a direct effect on cardiac properties (Mitchell et al., 2015). These affect the kidney function and overall homeostasis.

IDENTIFY PROBLEMS

Synthesize:

“Risk of shocks related to fluid imbalance and hyperglycemia”

This nursing diagnosis is based on different links and relationship between the changes in Haley’s condition. Her ABCDEG assessment shows changes in her circulation readings that had an increasing trend. This differed from her readings from recovery room one hour back. This increasing trend in her heart rate, capillary refill and respiratory rate and decreasing trend in her systolic blood pressure are initial warning signs of deterioration.

There are a number of reasons for this change, it may be due to fluid imbalance, hyperglycemia or moderate pain occurrence.  Haley is at a risk of shock that might occur if the underlying condition is not treated. With the loss of proper blood circulation, the heart will pump faster to negate this situation; blood capillaries will constrict causes a decrease in blood pressure. Respiratory rate will increase to meet the requirement of oxygen by various organs causing increase in breathing effort and decrease in SpO2. This compensatory effort of the body will ultimately lead to cardiogenic shock or septic shock depending upon the underlying condition.

These changes in the patient physiological parameters are also due to Pain. Pain activates the body’s sympathetic system. According to assessment reports, Haley is feeling pain at a moderate level which requires clinical review.

Hyperglycemia is a condition where there is abnormally large amount of glucose in blood. Due to stress on the body after surgery, there has been incidence where a sudden increase in BGL level is seen. Such glucose is quite dangerous as it slows down the healing process and further cause chance of infection (Verhoeven et al., 2011). Haley has been observed to have a high BGL level even though insulin is being infused.

Fluid imbalance:  According to her ISBAR reports, Haley passed urine prior to surgery and her fluid infusion has been clamped for transfer. She has also been given Hartmann solution that has been clamped for transfer. As mentioned in her assessment report, fluid imbalance is present. This imbalance in the body leads to accumulation of lactic acid and decrease in sodium bicarbonate.  It causes an acidic pH and leads to metabolic acidosis. Metabolic acidosis shows changes in physiological parameter that ultimately leads to shocks (Kimmoun et al., 2016). Acidosis also causes low blood pressure and increased heart rate and rapid breathing. This leads to the conclusion that an imbalance in the fluid status causing acidic pH is present that requires immediate attention.

ESTABLISH GOALS

The main role of the nurse after diagnosis is to note a list of goals that are holistic and can be easily applied to that specific patient. Through applying SMART criteria, nurses can produce an effective action plan that will try to achieve the target. After thorough analysis of Haley’s assessment report and comparison with the previous and standard observation, 3 most important goals that need to be addressed are:

  • A balanced fluid status of 65 ml/kg:

Electrolytes are within their normal range and homeostasis is maintained. Body pH is neutral and within 7.35- 7.45. This fluid balance is the average fluid status required in children Haley’s age. Her weight is normal and proper circulation is promoted (Alobaidi et al.,2018).

  • BGL level between 5 to 10mmol/l:

Normal BGL level is less than 5mmol/l but since Haley is diabetic and went through surgery, it is directed to try to achieve 5-10mmol/l. Keeping the glucose in check will prevent risks of infection in patients and further decrease the occurrence of shocks (Ambiru et al., 2008).

  • Pain level is absent or 1-3 on pain scale:

Pain is managed and absent according to pain scale (Tsze et al., 2018).  Patient’s vitals are within reference range: i.e. heart rate is within 80-120 bpm, respiratory rate is between 20 to 30, systolic blood pressure is with 90-110mmHg, capillary refill time is less than 2 seconds (Fleming et al., 2011) . Patient is alert and her fever is below 38.

TAKE ACTION

Nurse actions will be considered extremely significant in the situation. Her calm and confident demeanor will aid in keeping the patient and her caregiver calm. She should at first inform Haley’s mother about the situation and provide the strategy for coping with it.

Next step would be to call pediatrician and inform of the changes in Haley’s clinical presentation and increasing trend

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Management of fluid imbalance:

  • Inquire patient if she wants to pass urine
  • Inquire if she is thirsty
  • Take patient’s weight if possible
  • Start Hartmann’s solution at a slow rate at first
  • Check fluid status and pH every hour and adjust dose of Hartmann solution according to the pH (Yung, Leeton and Keelay, 2017).
  • Resolving acidosis
  • Turn frequently and massage gently
  • If unable to manage, consult with head nurse for guidance

Blood Glucose Level Management

  • Inquire the caregiver about patient’s normal BGL level during fasting
  • Question patient to check her conscious level
  • Calling on call- endocrine team for setting dosage of insulin for managing BGL within range.
  • Administer the required dose of insulin intravenously
  • Monitor hourly till BGL is within desired range i.e.5 to 10mmol/l

Pain Management:

  • Reassess pain and inquire the patient about her pain score
  • Observe her facial and physical signs
  • Start Morphine at 4ml/hour infusion
  • Reassess the patient pain scale hourly
  • Observe heart rate, blood pressure, respiratory rate every 1 to 2 hours till normal reading is observed.
  • Update the pediatrician and caregiver of the status and asks for further directions.

EVALUATE

After acting and going forward with the require goals following results were observed:

Pain:

  • Her heart rate is normal
  • Her capillary refill is less than 3 seconds: Proper tissue perfusion is taking place that causes capillary refill to take place in less than 3 seconds.
  • Her temperature is less than 38 and is not in red range: High fever is a body’s way of informing of some underlying illness or infection.  Post operative fever is normal after minor surgeries. If the temperature is not in normal range then further care plan is required
  • Her breathing has normalized and even breathing pattern is occurring: oxygen is being supplied properly and therefore respiratory rate becomes normal

Fluid Balance:

  • Haley is alert and is not sleepy: Due to the supply of oxygen to the brain, patient faces drowsiness and sleepiness. With the correction of her problems, blood carrying oxygen is fully supplied to brain causing alertness and consciousness. Further monitoring is required
  • Haley’s peripheries are not cold and proper blood circulation is taking place: Due to loss of proper blood circulation, blood carrying oxygen was not being supplied to the peripheries. As a result they were turning cold. Major effort is done by the body to carry blood to the central part where major organs are situated. With the fluid status normal, the blood was transported.

Blood Glucose Level:

  • BGL has decreased presently. Hourly observation is required for increasing or decreasing insulin dosage.

REFLECT

As a nurse, every experience aids in providing knowledge and lesson for achieving the ultimate goal of patient care. Haley’s situation taught a list of things that needs improvement and attention.

Haley’s situation taught how diabetic patients should be provided with extra care and attention after surgery. The percentage of patients experiencing deteriorating signs is high among diabetics and therefore vigilance is required

  • Haley’s suffered from fluid imbalance due to delay supply of nutrients as a result of transport and in recovery. This should be noted for future patients as a simple delay causes a hypovolemic reaction
  • Although vitals were taken accordance with standard time, other physical aspects of the illnesses and signs and symptoms should be better known and practiced
  • Another situation like this requires prompt decision making on the nurses part along with better handling of patient care. Absence of delay and on time medication is required.
  • Hyperglycemia and hypoglycemia are two conditions that arise most definitely after surgery due to stress. It is more common in diabetic patients than non diabetics and therefore pre-management plan should be made to cater this situation effectively
  • Detail study and education is required for the effect of pain on the body

REFERENCES:

Kimmoun, A., Novy, E., Auchet, T.,Ducrocq, N., and Levy, B. 2016, ‘Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside’, Critical Care, vol 19, no. 75.

Balcı, A. K., Koksal, O., Kose, A., Armagan, E., Ozdemir, F., Inal, T. and Oner, N. 2013, ‘General characteristics of patients with electrolyte imbalance admitted to emergency department’, World Journal of Emergency Medicine, vol 4, no. 2, pp. 113-116.

Ata, A., Lee, J., Bestle, L. S., Desemone, J., Stain, and C.S. 2010, ‘Postoperative Hyperglycemia and Surgical Site Infection in General Surgery Patients.’, Arch Surg, vol 145, no. 9, p. 858–864.

Vijarnsorn, C., Winijkul,G., Laohaprasitiporn, D., Chungsomprasong, P.,  Chanthong, P., Durongpisitkul, K., Soonswang, J., Nana, A., Subtaweesin, T., Sriyoschati, S., Pooliam, J. 2012, ‘Postoperative Fever and Major Infections after Pediatric Cardiac Surgery’, J Med Assoc Thai, vol 95, no. 6, pp. 761-70.

Tsze, D. S., Hirschfeld, G., Dayan, P. S.,  Bulloch, B.,and Baeyer, C. 2018, ‘Defining No Pain, Mild, Moderate, and Severe Pain based on the Faces Pain Scale – Revised and Color Analog Scale in Children with Acute Pain’, Pediatric Emergency Care, vol 34, no. 8, pp. 537-544.

Hariri, G., Joffre, J., Leblanc, G., Bonsey, M., Lavillegrand, J.R., Urbina, T., Guidet, B., Maury, E., Bakker, J. & Ait-Oufella, H. 2019, ‘Narrative review: clinical assessment of peripheral tissue perfusion in septic shock’, Annals of Intensive Care volume, vol 9.

Verhoeven, J., Brinker, M., Hokken-Koelega, A. CN.,  Hazelzet, J. A. & Joosten, A. F.M. 2011, ‘Pathophysiological aspects of hyperglycemia in children with meningococcal sepsis and septic shock: a prospective, observational cohort study’, Critical Care, vol 15.

Wan, J.-J., Qin, Z., Wang, P.-Y., Sun, Y., and  Liu, X. 2017, ‘Muscle fatigue: general understanding and treatment’, Experimental & Molecular Medicine.

Wang, J.-J.,  Chen, K., Li, X.,  Jin, X., An, P.,  Fang, P., and Mu, Y.   2019, ‘Postoperative adverse events in patients with diabetes undergoing orthopedic and general surgery’, Medicine, vol 98, no. 14.

Mitchell, K.,  Carlbom, D., Caldwell, E., Leary, P. E., Himmelfarb, J., and Hough. C. L.  2015, ‘Volume Overload: Prevalence, Risk Factors, and Functional Outcome in Survivors of Septic Shock’, Annals of the American Thoracic Society, vol 12, no. 12.

Yung, M., Letton, G., Keeley, S. 2017, ‘Controlled trial of Hartmann’s solution versus 0.9% saline for diabetic ketoacidosis’, Journal of Paediatrics and Child Health, vol 53, no. 1, pp. 12-17.

Alobaidi, R., Morgan, C., Basu, R. K., Stenson, E., Featherstone, R., Majumdar, S. R., and Bagshaw, S. M.  2018, ‘Association Between Fluid Balance and Outcomes in Critically Ill Children’, JAMA Pediatrician, vol 172, no. 3, pp. 257-268.

Ambiru, S., Kato, A., Kimur, F.,  Shimizu, H., Yoshidome, H., Otsuka, M., and Miyazaki, M. 2008 ‘Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: a prospective study in a high-volume institute in Japan’, Journal of Hospital Infection, vol 68, no. 3, pp. 230-233.

Shao, S., Shen, K., Wilder-Smith, P. E., and Li, X. 2011, ‘Effect of pain perception on the heartbeat evoked potential’, Clinical Neurophysiology, vol 122, no. 9, pp. 1838-1845.

Fleming, S., Thompson, M., Stevens, R., Heneghan, C., Plüddemann, A., Maconochie, I., Tarassenko, L., and Mant, D.  2011, ‘Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies’, The Lancet, vol 377, no. 9770, p. 19–25.

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