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NRSG370 - Case Study on Clinical Integration

   

Added on  2020-03-13

12 Pages2386 Words32 Views
Running head: CLINICAL INTEGRATIONClinical IntegrationName of the studentName of UniversityAuthor’s note

1CLINICAL INTEGRATIONTable of ContentsIntroduction:....................................................................................................................................2Reflection based on clinical reasoning cycle:..................................................................................2Identification of 3 nursing problems based on the health evaluation data-.....................................4Nursing goals or key care priorities.................................................................................................5Discussion on nursing care..............................................................................................................6Evaluation of care............................................................................................................................8Conclusion.......................................................................................................................................9References......................................................................................................................................10

2CLINICAL INTEGRATIONIntroduction:The clinical reasoning cycle is the process by which the nurse collects cues,process information, analyze the nursing situation, construct plan. Developinterventions and then evaluate the effects and reflect on the learning. This reportanalyses the case of Ms Melody, who is having Peritonitis followed by rupturedappendix. The reflection on the patient-care approach used for the patient isprovided here by the application of clinical reasoning cycle (Adams, Maben &Robert, 2014). The phase or process used in clinical reasoning cycle is alsodescribed here for Ms. Melody to determine appropriate interventions and outcomefor her.Reflection based on clinical reasoning cycle:Description of person’s conditions, collection of information, process andpresentation of the informationThis will be reflecting on the condition of Ms Melody who is suffering fromperitonitis followed by ruptured appendix. It is found out that she was presented inthe Emergency department with 2-3 days of severe left lower quadrant abdominalpain. She needed emergency laparoscopic surgery on removal of the rupturedappendix. The following is the current information that was collected aboutMelody. Then it can be reviewed that her information on past medical history

3CLINICAL INTEGRATIONwhich showed that she had asthma, depression. The present medical cues werefollowed on the medicaments like ventolin, seretide, straline. It is also observed hercurrent observations which included blood pressure 95/45 mm Hg, heart rate of120, temperature 38.3 Celcius, RR of 22/ min and shallow, spO2 of 95% on roomair. It is also noted that she complained of increasing nausea, abdominal painwhich was found to be 7-8 on a scale of 0to10. Her physical evaluation reflectedon distended abdomen and generalized abdominal guarding. Then it was found thatshe had her raised white blood cells (WBC ) count and CRP. After all the possible cues and the situations of Ms Melody, followinginformation can be processed. On the basis of information, it could be interpretedthat she has low blood pressure. She is also facing higher heart rate than theoptimal. Her body temperature is moderately increased it was about 100.94Fahrenheit. Her respiratory rate is within the normal range but she is havingtachypnea because of shallow breath . Her SPO2 reading suggests that her oxygenlevel in the blood is almost normal. While processing her complaints it could besaid that she is facing acute Peritonitis. She is suffering from abdominal painwhich is high in the scale of 0-10. The abdominal pain mainly presented hersituation of peritonitis (Grace, 2017). The nausea that she is having is also due to herpresent condition.

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