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Application of clinical reasoning skills NURSING TUTOR NURSING ASSIGNMENT GUIDANCE

03 Jul 2021 250 Views Sarah

Assessment Task 2 Essay: Application of clinical reasoning skills for clinical patient scenario

1.1 Describe the pathophysiology of acute pain. How does this differ from chronic pain? Include in your answer the pathophysiological effects of narcotic analgesia as a treatment option for acute pain. Demonstrate links to Tran’s case. (400 words)

Acute pain is the result of damaged tissue and it is self-limiting. The impulses get generated in the primary sensory nerves through the chemical mediators that are released from damaged tissues. These impulses in the dorsal horn are received by the spinal cord. At this level of spinal cord, the descending inputs either reduce or amplify the impulses. Again at this spinal cord level, it is possible to modify the painful representation and other sensitivity of the surrounding areas. Further, modification occurs at the level of thalamus and brainstem. The ultimate and final pain perception is modifiable by other central phenomenon like fear and anxiety. ... states that gila’s role in the maintenance of painful states is quite evolving. The nociceptors (neurons detecting noxious or painful stimuli and sending it to spinal cord) activate the injury site. This noxious sensory data is carried by nociceptive fibres to spinal cord dorsal horn. This releases excitatory neurotransmitters and also stimulates them. This is the second order sensory neurons. This ascends to anterolateral tracts of thalamus, brainstem, midbrain and hypothalamus. This results in the symptoms of acute pain as pain sensation and localization; reduced or increased pain perception; tachycardia; and nausea.

The acute pain holds a specific cause certainly due to tissue damage, disease process or inflammation. This pain lasts for some specified time and fades when the pain trigger element is resolved or healed. It differentiates from chronic pain as chronic pain lasts for months and even years in certain cases and does not stay for predictable or specific time. Chronic pain might not have any discemible cause at all. This pain in some cases signal that disease activity is intensifying.  Acute pain can develop into chronic pain via modulation synaptic transmission. The repeated activation of C fiber nociceptors and the peripheral inflammation can result in raised expression of COX-2, iNOS and c-Fos into the microglia and secondary neuron. The peripheral injury can also generate pain hypersensitivity in uninjured and neighbouring tissues (that are secondary hyperalgesia) through central sensitization.

Narcotic analgesia or opioids are termed as the standard of care for treating moderate to severe nociceptive pain as reported in Tran’s case post ileostomy. The narcotic analgesia moderates their actions as they bind and activate receptors in the peripheral nervous system and also the ones found in the inhibitory pain circuits found to descend from midbrain to reach the spinal cord dorsal horn.  This medicine works at cellular level and the acute pain as reported in this case occurs at cellular and tissue level by activating the opioid receptors that are well-distributed across central nervous system (CNS). Thus, narcotic analgesics are the accurate treatment decision. 

1.2 Discuss THREE types of nursing assessments in order of priority that would be appropriate for Tran’s deterioration (excluding vital signs) and provide a description of each of these in the context of Tran’s complaint with rationale as to why these would be your priority. (400 words)

The three types of nursing assessments on priority basis are defined below. The first assessment necessary in this case is to ABCDE (airway, breathing, circulation, disability and exposure) approach. It is the most important post-operative monitoring tool for patients for the identification of the signs of deterioration. It is the systematic assessment conducted on an immediate basis. When the patient is in critical situation, proper assessment can be done through this assessment tool. This helps in proper assessment of patient’s airway adjunct while patient is unconscious, breathing pattern, monitoring of pulse rate, character and volume, monitoring of blood pressure, monitors blood glucose and level of disability in patient post anaesthesia, and monitoring wound sites and drain sites and conduct regular pain scoring to maintain patient comfort.  This assessment is necessary in Tran’s case as he is unresponsive and urgent clinical action is required to acknowledge his deteriorating health.

The second priority assessment is this case is the wound assessment of his surgical site post ileostomy. The accurate post-operative surgical wound care is most essential clinical protocol in avoiding the potential complications like haematomas, surgical-site infections (SSIs), and wound dehiscence. Irrespective of the wound healing mechanism, the purpose of post-operative wound care is always the same. This is to permit rapid wound healing without any complications and with best aesthetic outcomes. Ileostomy is a major concern and it demands timely and regular stoma assessment for decreasing the complication chances. The first step in this stoma assessment is inspection to acknowledge site, spout and consistency with number of lumens. The second step is palpation by gently feeling around the site of stoma for tenderness, asking patient to cough and then feeling for cough impulse for the possible parastomal hernia, and gently digitate stoma for assessing patency and stenosis. The further step is the analysis of peristomal skin for the analysis of any sign infection visible.

The third priority assessment is to conduct the Doppler imaging technique. It is necessary because Tran has Crohn’s disease that raises the bowel obstruction complication. This assessment will assist in providing data about the inflamed bowel wall. It is a form of intestinal ultrasound that will assist in determining the possibility of complications and detecting the pathologic condition linked with the gastrointestinal tract. Inflammation is identified at an early stage through this assessment and is not even harmful because it is free from radiations. It is easily accessible and most applicable in this situation.

1.3 Discuss THREE nursing interventions (may include one pharmacological) you would initiate and provide rationale as to how these would improve physiological outcomes of Tran’s problem. (400 words). Nursing interventions would include nursing activities or actions that the nurse could initiate in response to nursing assessment findings.

It is visible from assessment that Tran’s blood pressure is low at 98/55 mmHg and he is potentially at risk of being hypotensive making Tran more at deteriorating health. Thus, Tran needs to be administered with Orvaten to increase his blood pressure. It is the most effective treatment procedure that will also reduce his discomfort. This is the alpha-1 selective adrenergic agonist that is found to increase the peripheral vascular resistance; increases arteriolar and venous tone and this leads to increase in the systolic and diastolic blood pressure while sitting, supine and standing. This medicine constricts blood vessels and raise blood pressure. This medicine stimulates nerve ending directly related to blood vessel and raises blood pressure.

The second intervention is to educate Tran about proper stoma care as it will help him at home also and will reduce the possibility of dependency on others. He should be educated about how to clean the stoma pouch, change it and inspect it daily and skin care to assure when to call the doctor to avoid infection and complications. Self-care management needs to be inculcated before the discharge period. He will be educated that the skin around stoma must be moist and pink or red and small amount of bleeding might be present while cleaning stoma. Its size should reach the normal size within 8 weeks. He needs to call doctor if the bowel movements are bloody or black, stoma bleeds, too weak to stand up, fever, foul odour from stoma bag, stoma size changes abnormally and have severe abdominal pain. He should e provided with a booklet and a handy kit to get knowledge and be aware of proper caring techniques and regimen.

The third intervention is the proper nutrition therapy. Special diet is proposed to people with crohn’s disease to avoid any complications. Bowel needs rest and healing to avoid inflammation. Thus, nutrition plays the major role. The low-fiber or low-residue diet is necessary to decrease the intestinal blockage risk. The dairy products should be eliminated, fried and greasy food must be avoided, food causing gas like cruciferous begetables must be avoided and the diet must be limited to well-cooked vegetables only.

1.4 Discuss the administration (including administration, benefits, risks and contraindications) of Morphine for Tran’s pain. Include in your explanation what education you should provide to Tran’s on commencement of the patient controlled analgesia (PCA). (400words)

Administrationà Morphine comes in the form of a solution (liquid) to be injecting intramuscularly (in the muscle) or intravenously (in the vein). Morphine is generally injected every 4 hours once as per requirement. The morphine injection needs to be used or administered at the same times daily. The dose is to be adjusted as per the pain severity, patient’s underlying disease, patient age, and occurrence of adverse events.  

Benefitsà Morphine is an opioid agonist that is indicated for managing pain that is not responsive towards the non-narcotic analgesics. This medicine works in the brain for altering how the body feels and makes response to pain. It relieves pain as it works through the process of binding with the opioid receptors into the spine, brain and other body organs that are sensitive to pain. Such an interaction creates a blockage for pain and dopamine flood is initiated in the body. This drug is also a narcotic that means it also helps the patient to get induced with sleep and potentially result in coma if it is taken excessively that is a factor to consider.

Risksà If morphine is used for longer period than a few days, it should not be stopped using suddenly. It is because it can make patient experience withdrawal symptoms like teary eyes, restlessness, anxiety, irritability, sweating, chills, muscle or joint pain, weakness, loss of appetite, fast breathing or tachycardia. It also causes side effects like headache, mood changes, dizziness, lightheadedness, seizures, slow breathing, breathlessness, hallucinations, nausea/vomiting, rashes, hives menstruation issues, itching and reduced sexual drive.

Contradictionsà Morphine is contradicted if Tran has allergy to morphine or known hypersensitivity; upper airway obstruction or bronchial asthma; paralytic ilieu; and respiratory depression in the absence of resuscitative equipment.

PCA is given intravenously (IV) means inside the vein. Tran should be educated that medicine is put in the vein in his arm via a plastic tube or a small needle called a catheter. The PCA pump gets connected with his IV into the recovery room post surgery. The pump provides pain medicine via the IV if the button is pushed. Tran will hear the beep on pressing the button. It means pain medicine is being received. Tran should be informed that when pain starts becoming uncomfortable, button should be pressed. He should not wait till it becomes bad. It is good to take it prior doing things that can make you pain like physiotherapy, breathing or coughing exercises. PCA medicine takes 5-10 minutes to work.

1.5 Report the major side effects of intravenous morphine apply your findings to Tran’s case. Explain why this finding would need to be reported immediately to the Doctor. (200words)

The major side effects of intravenous morphine to Tran could be nausea, vomiting, drowsiness, dizziness, constipation, dizziness, lightheadedness, increased sweating, or dry mouth. It is possible that he might experience swelling, redness or pain at the injection site and it is possible because his immunity is weak post surgery. If this persists or worsens, doctor needs to be reported immediately. If this is not reported, these side effects can convert into causing interrupted breathing, mood swings, and signs of his adrenal glands not working properly by causing unusual tiredness, weight loss and loss of appetite. It major side effect is respiratory depression that is strong in causing respiratory arrest and hypoxia to Tran if not managed well. Train is in the recovery phase and his condition is really weak to tackle these side effects. Another key side effect is nausea and vomiting that increases the patient discomfort on direct note. The other side effects possible are increased dry mouth and sweating with sedation, confusion, constipation and dizziness. If these side effects persist, it raises the complication rate and level and make patient feel highly uncomfortable. These side effects can worsen his health and can elongate his hospital stay and more financial burden.