Question No. 1- 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.
The clinical reasoning cycle (CRC) has many stages, and the first stage is “Consider the patient situation.” According to this stage, the biophysical, spiritual, and cultural aspects of patient care are in the following. These aspects have emerged from the surgery experienced by the patient, Ted.
Biophysical Aspects:
Biophysical aspects of Ted include that he has gone through bowel resection and colostomy surgery. His age is 82 years and is in the hospital for the last four days. The investigation underway is regarding biopsy and colonoscopy. He is experiencing a distended abdomen. This physical and biological information is helpful to note that the patient is not living at home, and he is an old patient as well. More about the situation can be reflected using the cultural and spiritual aspects of the patient (Jakobs, O’Leary, Cormack, & Chong, 2010).
Spiritual Aspects:
There is not enough information about the spiritual aspect of the patient. However, he is with his partner because his wife has died. His partner, Gwen, is 78 years old and has been assisting him in life. It is the spiritual aspect of the patient that he wants companionship from his partner. Though he is living alone in the retirement village and now is feeling alone (Jakobs, O’Leary, Cormack, & Chong, 2010).
Cultural Aspects:
Cultural aspects form using the family and context in which he is living. He has a family, but his sons are not near to him. He has to live in a retirement village where he has found a new partner. He feels lonely and does not feel well. He is on medication continuously.
Question No. 2- 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.
The CRC has the second stage to collect cues and information. It is present in the case study, with the help of this information, a nurse may respond to stages three and four of the CRC that are “process the information” and “identify problems,” respectively.
Processing the Information:
The processing of information reveals that a stay follows surgery in the hospital for a week or more. Ted should be aware of this fact. He can feel bowel cramps that incision or cut may cause pain. The patient can experience the feeling of the flue that is along with a low fever. The medication and its side effects may cause nausea and tiredness in the patient. Meanwhile, the nurse has to gather more information for processing, and in so doing, it has to remain in close contact with the patient. It would help Ted to get instant and relevant treatment from the nurse.
Traditional surgery takes six weeks to recover. Ted has undergone bowel surgery that causes pain for him. Side effects of bowel resection should also be in mind. They include pain, blood clots, constipation, diarrhea, and bowel obstruction. The patient can also face infection after the surgery.
Identification of the Problem:
With the help of the case study, some problems are identified. The patient has a medical history of heart failure, obesity, gout, stomach, and type 2 diabetes melilites. The problems are also related to the bio-psycho-social aspects of the patient. He is living alone and does not have consistent care at home. He is living in a retirement village. He has the NBM diet.
The past medical history of the patient is written in the case study. The information includes bowel resection and the emergence of colostomy temporarily. Other problems include inspiratory coarse crackle on the right side and experiencing a cough producing a moist. For the pain regulation, he has PCA morphine. He is also having pain in his abdomen. Upon palpation, the pain gets worse, and the abdomen gets distended (Jakobs, O’Leary, Cormack, & Chong, 2010).
Pathophysiology of Past History Diseases of Ted:
Ted has a past history of heart failure. The cause of the disease is when the heart does not provide tissues having an adequate quantity of blood. It is worth mentioning that blood is needed for the metabolic needs of the patient. Organ congestion happens where there is cardiac-related elevation of pulmonary or systemic venous pressures. It is the result of abnormalities of diastolic or systolic function or both. A change in the cardiomyocyte function can cause primary abnormality. However, changes in the collagen turnover of the extracellular matrix can also cause abnormality. Other causes of heart failure include cardiac structural defects and high metabolic demands (Putko, et al., 2014).
Ted experiences another disease called type 2 Diabetes Mellitus. It is called a heterogeneous disorder, and its prevalence is different in different ethnic groups. The most affected ethnic groups from this disease in the United States are native Americans, Hispanics, and Asian Americans. Characterization of type 2 Diabetes Mellitus is by impaired regulation of production of hepatic glucose and resistance of peripheral insulin. As a result, beta-cell function declines and leads to its failure (Becker, Langer, & Leidl, 2011).
Ted is obese as well, and obesity is also a disease. Exaggeration of normal adiposity causes obesity that also makes the pathophysiology of diabetes. Largely due to the secretion of excessive adipokines, hypertension, atherosclerosis, and dyslipidemia also occur (Tsai, Cheng, & Pan, 2014).
Gout is another disease present in Ted that is simple, a disorder of metabolism. It leads to accumulating uric acid and urate in blood and tissues. Ultimately, the formation of crystals happens when urate salt precipitation occurs after the supersaturation of tissues (Stevenson & Pandor, 2011).
Question No. 3- Using stage Ŝve of the CRC Establish goals outline and justify (5) nursing care interventions/strategies and the rationale the registered nurse would implement to provide care for a patient with right sided inspiratory coarse crackles and moist productive cough. Justify your thinking with links to current peer reviewed evidence and literature
Stage five of the CRC is “Establish goals,” and in the following, there is the guidance of how nurses can plan against five goals.
Assessment:
Nurses should establish a goal to treat Ted by assessing him according to different perspectives. These perspectives include physiological, psychological, sociocultural, economic, and spiritual. These would help assess the condition of the patient. Assessment is the first step, but it is the most important.
Diagnosis:
Clinical judgment of nurses is crucial because good and perfect diagnosis would help nurses ascertain the potential and actual needs and requirements of the patient. Ted is feeling pain, but true diagnoses would not treat or cure pain only. It would also treat other problems emerging from this painful problem (Jakobs, O’Leary, Cormack, & Chong, 2010).
Planning:
Assessment and diagnoses would allow nurses to take steps in a calculated manner. In so doing, a nurse would go for developing short term and long-term goals for the patient’s treatment.
Implementation:
Care follows the planning stage, where suitable care is provided to the patient. The care fits the patient, whether he is in the hospital or in the planning to discharge.
Evaluation:
This stage is an evaluation that focuses on evolution and assessment of the status of care provided to the patient. Evaluation is a continuous process that should keep going.
The patient has right-sided inspiratory coarse crackles, and the cough is producing moisture. Therefore, the following are nursing interventions and their justifications for Ted.
| Nursing Interventions | Rationale |
| 1. A nurse should help and teach Ted to take a deep breath. He should be in a proper propped up position to take a deep breath (Fu, et al., 2017). | Deep breathing is helpful for Ted in this condition because it would give his extra body oxygen and a sitting position would provide him with relief and comfort. |
| 2. Now, the nurses should let Ted take deep breaths and cough twice or thrice in different successions. | This intervention is called controlled coughing that is caused by closing the glottis. The use of abdominal and chest muscles expels air from the lungs. |
| 3. The nurse should encourage and teach him to use incentive spirometry. | It would help Ted in breathing exercises with the maximum possibility of ventilation. |
| 4. A nurse would use a stethoscope and would hear breath sounds and examine it. It would help note the area of absent ventilation and adventitious sounds. | It would help the nurse to assist Ted because the nurse would note changes in his body. |
| 5. The nurse should start administering respiratory therapy treatments. For example, a nurse may recommend using the nebulizer. | Respiratory therapies can help open constricted airways and help secretions take the form of liquid. |
| 6. The nurse should start systemic fluid hydration | An adequate amount of fluid intake would help Ted to get liquid pulmonary secretions, and it would facilitate him in the expectoration of mucus. |
| 7. The nurse should take steps to note and examine the rate of respiration. He can also note the depth, effort consumed, and rhythm of the respirations (Basic & Conforti, 2005). | Through these interventions, nurses can note and evaluate the appropriateness of ventilation. |
Here, one thing is to note that these nursing interventions are easy to follow if five goals are pursued in nursing. Five golden goals have been explained above. They start from the assessment and diagnoses further increase the level of assessment. Then, there is the planning because diagnoses help guide to take suitable steps. Then, it comes to the implementation of the planning. However, evaluation should be the end of these interventions because it would help note any required process further. If there is no need for change, the previous treatment will continue. In another case, change in interventions would be inevitable (Jakobs, O’Leary, Cormack, & Chong, 2010).
Question No. 4- Select two classes of drugs that would be used to manage Ted’s post operative condition. Please provide a rationale for why that drug class would be suitable for Ted. Provide a detailed description of the pharmaco-dynamics of each of the selected class of drug as well as the potential side effects and the nursing implications for administration.
The two classes of drugs suitable for Ted are PPI that stands for proton pump inhibitors and analgesics.
Pharmacodynamics of proton pump inhibitors:
The drug is suitable for Ted because it would lower the gastric acid secretion that is the outcome of bowel resection. Once activated, it controls and limits the gastric hydrogen-potassium adenosine triphosphatase enzyme to develop at the surface of the secretion of gastric parietal cells. It helps to block gastric acid secretion. The PPI makes a covalent bond with H+, K+-ATPase, via the disulfide bond. The drug is suitable for Ted because it treats symptoms faced by him (Vandoros, 2014).
Side Effects:
Side effects of the drug include nausea, flatulence, vomiting, dizziness, upper respiratory infection, abdominal pain, diarrhea, and others. Some side effects are large, and some are minimal.
Pharmacodynamics of Analgesics:
Analgesics are necessary and helpful to treat a patient like Ted as he is a post-operation patient. It helps to reduce pain caused by the operation. PCA or patient-controlled analgesia is a delivery system that can control and minimize the pain experienced by a postop patient. It acts by influencing opioid receptors in the body that cause relief from pain, and it affects the central nervous system to relieve the whole body. Opioid receptors have two basic functions to perform: these functions are related to recognition and biological action. There is a correlation between binding affinity and analgesic potency. The measurement of binding affinity is possible through using the equilibrium inhibition constant or Ki (Rhee, Kim, & Kim, 2012).
Side Effects:
Side effects of analgesics include nausea, constipation, drowsiness, dizziness, and vomiting. It also causes the risk of abuse or addiction.
References
Basic, D., & Conforti, D. A. (2005). A prospective, randomized controlled trial of an aged care nurse intervention within the Emergency Department. Australian Health Review, 29(1), 1-9.
Becker, C., Langer, A., & Leidl, R. (2011). The quality of three decision-analytic diabetes models: a systematic health economic assessment. Expert Review of Pharmacoeconomics & Outcomes Research, 11(6), 751-62.
Fu, T.-c., Lin, W.-c., Wang, J.-s., Wang, C.-h., Chang, C.-t., Tsai, C.-l., . . . Lin, K.-p. (2017). Detection of exercise periodic breathing using thermal flowmeter in patients with heart failure. Medical and Biological Engineering and Computing, 55(8), 1189-1198.
Jakobs, O. M., O’Leary, E. M., Cormack, M. F., & Chong, G. C. (2010). A working model for the extraordinary review of clinical privileges for doctors and dentists in the Australian Capital Territory. Australian Health Review, 34(2), 170-179.
Putko, B. N., Wang, Z., Lo, J., Anderson, T., Becher, H., Dyck, J. R., . . . Oudit, G. Y. (2014). Circulating Levels of Tumor Necrosis Factor-Alpha Receptor 2 Are Increased in Heart Failure with Preserved Ejection Fraction Relative to Heart Failure with Reduced Ejection Fraction: Evidence for a Divergence in Pathophysiology. PLoS One, 9(6), 1-10.
Rhee, Y. O., Kim, E., & Kim, B. (2012). Assessment of Pain and Analgesic Use in African American Cancer Patients: Factors Related to Adherence to Analgesics. Journal of Immigrant and Minority Health, 14(6), 1045-51.
Stevenson, M., & Pandor, A. (2011). Febuxostat for the Management of Hyperuricaemia in Patients with Gout. PharmacoEconomics, 29(2), 133-40.
Tsai, Y.-t., Cheng, P.-c., & Pan, T.-m. (2014). Anti-obesity effects of gut microbiota are associated with lactic acid bacteria. Applied Microbiology and Biotechnology, 98(1), 1-10.
Vandoros, S. (2014). Therapeutic substitution post-patent expiry: the cases of ace inhibitors and proton pump inhibitors. Health Economics, 23(5), 621-630.
