Clinical Reasoning Skill Question and Answer 2022

Running head: CLINCIAL REASONING SKILL
APPLYING CLINCIAL REASONING SKILL IN A CLINICAL PATIENT SCENERIO
Name of the Student:
Name of the University:
Author’s Note:

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Table of Contents
Answer 1.1.................................................................................................................................2
Pathophysiology of acute pain...............................................................................................2
Difference of pathophysiology of acute pain from acute pain...............................................2
Pathophysiological effect of narcotic analgesia.....................................................................2
Answer 1.2.................................................................................................................................3
Rationale of three types of nursing assessment......................................................................3
Answer 1.3.................................................................................................................................4
Three nursing interventions to improve physiological outcome............................................4
Answer 1.4.................................................................................................................................5
Administration of morphine...................................................................................................5
Benefits of morphine..............................................................................................................5
Risks of morphine..................................................................................................................6
Contradiction of morphine.....................................................................................................6
Education on patient controlled analgesia..............................................................................6
Answer 1.5.................................................................................................................................6
Major side effects of intravenous morphine...............................................................................6
References..................................................................................................................................8
Table of Tables
Table 1: Nursing assessment with rationale...............................................................................4
Table 2: Nursing intervention with rationale.............................................................................5

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Answer 1.1
Pathophysiology of acute pain
Acute pain occurs due to tissue injury. This is the result of peripheral pain receptor
activation. The pain lasts usually for three to six months and it also may be the result of
damage of acute tissue. Rowe and Schiller (2020) mentioned that th4e acute pain is keen in
quality. Hence, it is necessary to treat the underlying causes first to treat the acute pain. At
the location of injury, neurochemical reactions turn on free nerve endings of nociceptors that
are the special nerves. Tis nerve enters spinal cord and pass it to the higher order neurons. By
this process pain sensation reaches to the cerebral area and afferent information occurs in
different areas. After interpreting the impulse, response signal is yielded and travelled via
descending spinal tracks and pain sensation occurs.
Difference of pathophysiology of acute pain from acute pain
Chronic pain and acute pain is not similar. Chronic pain lasts more than six months
and can continue after healing the injury. Porela-Tiihonen et al. (2017) opined that chronic
pain is related with the ongoing tissue injury. Constant activation of those fibres can cause
chronic pain. However, Gan et al. (2018) suggested that severity of the tissue injury cannot
predict the severity of pain whether it acute or chronic. Chronic pain can result from the
ongoing injury or dysfunction of central or peripheral nervous system. It can be for week or
months or years. On the other hand, acute pain lasts for six months and goes away after
healing of injury. Chronic pain can occur due to nerve pain, cancer and arthritis whereas
acute pain can occur due to surgery, burns and cut.
Pathophysiological effect of narcotic analgesia
The pathophysiological effects of analgesia principally mediated via mu and kappa
receptors in the peripheral nervous system and central nervous system (Farmer et al. 2018).
Analgesia is one type of opioids that binds ad enhances the neurotransmission. As Tran is
getting narcotic analgesia, there can be few side effects like nausea, dizziness vomiting,
respiratory depression, analgesia-induced bowel syndrome, constipation and also can affect
other body functions. However, Narcotic analgesia prevents excess pain by interfering
normal biological functions. From the vital signs of Tran, it is found that his pulse is irregular

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and blood pressure is fluctuating. In such case, the clinical practitioner needs to change the
dosage of the analgesia and start medication and useful therapies to improve the situation.
Answer 1.2
Rationale of three types of nursing assessment
Nursing Assessment Rationale
Inspection It is necessary to ask the person to expose fully the stroma site. The
best is to ask to remove the stroma bag to show the injury if the
patient is able to show. The registered nurse can do inspection the
site carefully as it is one of the vital assessments (Edwards & Sell,
2020). The complete treatment procedure depends on the assessment.
If the position of the site is left iliac fossa, it can be colostomy.
However, in case of Tran, the position of the site is right iliac fossa,
hence it is ileostomy. Due to the problem, the patient faces irregular
bowel movement. As per the casestudy, the patient has p/h/o of
crohn’s disease and ulceractive colitis, it is found that the absorption
power is poor and the patient is facing weight loss.
Palpation The stoma needs to be digitated to check the patency and also helps
in assessing if there is any stenosis. It is necessary to feel the stoma
site if any tenderness is seen. Due to illeostomy, the patient may
suffer from malnutrition and for this reason, nutrition deficiency can
occur. In such case, proper nutritious care needs to be taken. It is
necessary to make few quick tests of vitamin deficiency. This will
help to assess the further treatment process and by analysing the
report, necessary care should be taken. However, the registered nurse
needs to be careful so that fungal or bacterial infection cannot occur
surrounding the stroma (Berti-Hearn & Elliott, 2019). For this purpose,
the nurse needs to choose appropriate nursing intervention to control
the infection and spread of the stroma.
Completing
examination
It is necessary to recheck the examination process if anything
important is left to check. While completing the assessment, the
registered nurse should report the doctor about the examination
report and also should share concern regarding GI examination for

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nutritious deficiency. With the permission of healthcare professional,
the registered nurse needs to arrange the GI examination and report
to the doctor. After completing the assessment, a particular nursing
intervention plan should be made and discussed with the healthcare
professional. The nurse needs to convey the intervention procedure
not only to the doctor but also other healthcare workers who are
related to the treatment procedure and the patient also (Stankiewicz et
al., 2019).
Table 1: Nursing assessment with rationale
(Source: As created by Author)
Answer 1.3
Three nursing interventions to improve physiological outcome
Nursing
Intervention
Rationale
Inspection of stoma
as well as peristomal
skin area and measure
stoma
The registered nurse needs to monitor healing process for further
assessment and intervention. The RN identifies the concern areas and
monitors the effectiveness of the appliances. As the stoma is
identified in early stage, the risk of fungal infection or stomal
necrosis is less in case of Tran. Stoma is red and skin irritation is
reported. Khachian et al., (2019) stated that in case of ileostomy, the
effluent would be rich with enzyme and the registered nurse should
be careful about the skin care as enzyme can be present in effluent
for longer time. With time, the stoma starts to shrink and size of the
stoma also changes and the area gains preventive power.
Cleaning the area
with warm water and
soap to remove sticky
stool and using a
transperant drainable
pouch that is odor
free on routine basis
with proper
It is necessary to maintain the area clean and dry, which helps to
prevent the skin breakdown. Cengiz et al., (2020) stated that the
transparent appliance allows the observation process easy during
initial 4-6weeks without irritating skin. The pouches need to be
changed without irritating skin. The process of changing pouches
with appropriate solution helps to remove bacterial and fungal
infection and odor that rose from stool and flatus around the stoma.
Moreover, it helps to deodorize the pouch so that it remains clean

5CLINCIAL REASONING SKILL
equipments and odor free. The pouch should be empty and irrigate as well as
clean on the routine basis to avoid infection.
Applying proper skin
barrier and
corticosteroid aerosol
spray by consulting
with certified nurse to
support the
surrounding skin to
wash thoroughly
The registered nurse needs to protect the skin of Tran from the pouch
adhesive. It will enhance pouch adhesiveness and also facilitates the
pouch removal when it is required. The skin barriers can be extended
wear skin barrier, karaya gun and hydrocolloid wafer or comparable
products (Hardiman et al., 2016). It will help to prevent from tissue
irritation that is associated with pulling of the pouch. If any
peristomal irritation occurs, the RN can use corticosteroid aerosol
spray with antifungal powder to avoid any fungal infection as well.
However, while using the products, precaution must be taken as the
products can have side effects. In such case, certified nurse can help
the RN to choose appropriate products.
Table 2: Nursing intervention with rationale
(Source: As created by Author)
Answer 1.4
Administration of morphine
The recent guidelines suggest morphine for the moderate as well as severe pain. It is
initiated within twenty minutes of admission in emergency department. However, it might not
be feasible. Patient with acute pain can be provided opioid drug within 60 minutes of
admission. To manage the pain oral morphine can be provided in specific cases (Leal et al.,
2017). Morphine can be administered via IV route if there is no difficulty in accessing IV
route. The nurse can place the IV catheter successfully with proper dosage.
Benefits of morphine
The efficient pain relief is important to treat a patient who has undergone surgery.
Morphine helps in pain relief that has important physiological benefits. Therefore, it is
necessary to monitor pain relief that is important for the quality measure in postoperative
situation. The aim of postoperative pain management is eliminating pain with discomfort by
minimizing side effects. This can develop the pain score and help to overcome the
postoperative complications if any. In this context, Niewiński et al. (2020) opined that the RN
should be careful about the dosage while giving morphine.

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Risks of morphine
There are few side effects of morphine which can be drowsiness and also can cause
constipation. Overdose of morphine can cause shortness of breath (Frieden & Houry 2016).
As per the case study, the oxygen saturation level and respiratory ration of Tran became low
and it is fluctuating due to overdose of analgesia. In such case, Tavenier et al., (2018) stated
that long term use of morphine can casue death or physical dependence.
Contradiction of morphine
The contradiction of morphine can include cor pulmonate, drug abuse, low blood
pressure, constipation, biliary and gallbladder problem, seizures, acute inflammation of
pancreas and shortness of breath (Farmer et al., 2018). In such case, body becomes unable to
maintain the enough blood flow and as a result the condition can be worsened. Moreover,
allergic condition can be found as a result contradiction of morphine. Hence, it should be
used carefully.
Education on patient controlled analgesia
Patient controlled analgesia is the way to provide pain medication without repeated
injection. It is given via IV slowly to treat the short-term pain. However, while using the
PCA, few necessary precautions should be taken. The nurse should be carefully so that no
one can push the button for several times and should observe the patient if any discomfort is
seen after pushing the button of IV (Nardi-Hiebl et al., 2020). The measurement of oxygen is
necessary in case of postoperative patient like Tran that can be done by using pulse oximeter.
Answer 1.5
Major side effects of intravenous morphine
The vital signs of Tran are showing that morphine has various major side effects.
Adverse effects of morphin include constipation, dizziness, nausea, vomiting, dry mouth, low
blood pressure, sleepiness, allergic reaction and respiratory problem including short
breathlessness (Chen et al., 2018). In case of Tran, his vital signs show that he has low blood
pressure, short breathlessness and respiratory problem while taking morphine. Low blood
pressure can occur due to too high dose of medication for long time. As he has experienced
short breathlessness, 6lt oxygen is given to him through Hudson mask that can help to
improve the situation.

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In such case, being a graduate nurse, it is necessary to report the doctor about the
findings. This is necessary because the dosage of medication needs to be changed and also he
needs emergency medical attention. In this context, Rowe and Schiller (2020) suggested that
to maintain patient safety, a clear communication is necessary between the doctor, nurses and
other healthcare staffs. The doctor will check the report of vital signs and will do to other
necessary check up and communicate with the patient or the family members for further
treatment. Hence, it is vital to inform the doctor about patient status.

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References
Farmer, A. D., Holt, C. B., Downes, T. J., Ruggeri, E., Del Vecchio, S., & De Giorgio, R.
(2018). Pathophysiology, diagnosis, and management of opioid-induced constipation. The
Lancet Gastroenterology & Hepatology, 3(3), 203-212.
Porela-Tiihonen, S., Kokki, M., & Kokki, H. (2017). Sufentanil sublingual formulation for
the treatment of acute, moderate to severe postoperative pain in adult patients. Expert review
of neurotherapeutics, 17(2), 101-111.
Gan, T. J., Epstein, R. S., Leone-Perkins, M. L., Salimi, T., Iqbal, S. U., & Whang, P. G.
(2018). Practice patterns and treatment challenges in acute postoperative pain management: a
survey of practicing physicians. Pain and therapy, 7(2), 205-216.
Edwards, D. M., & Sell, L. R. (2020). Early identification of dehydration with orthostatic
blood pressure monitoring in high-output ileostomy patients. Gastrointestinal Nursing, 18(2),
28-32.
Berti-Hearn, L., & Elliott, B. (2019). Ileostomy Care: A Guide for Home Care
Clinicians. Home healthcare now, 37(3), 136-144.
Stankiewicz, M., Gordon, J., Rivera, J., Khoo, A., Nessen, A., & Goodwin, M. (2019).
Clinical management of ileostomy high-output stomas to prevent electrolyte disturbance,
dehydration and acute kidney injury: a quality improvement activity. Journal of Stomal
Therapy Australia, 39(1).
Khachian, A. L. I. C. E., Fazeli, M. S., Sabour, H., Haghani, H. A. M. I. D., & Akhoondian,
G. (2019). Effects of Smartphone-based Nutritional Education on the Biochemical Indicators
of Patients with Ileostomy. Iran Journal of Nursing, 32(118), 72-85.
Cengiz, B., Bahar, Z., & Canda, A. E. (2020). The Effects of Patient Care Results of Applied
Nursing Intervention to Individuals With Stoma According to the Health Belief
Model. Cancer nursing, 43(2), E87-E96.
Hardiman, K. M., Reames, C. D., McLeod, M. C., & Regenbogen, S. E. (2016). Patient
autonomy–centered self-care checklist reduces hospital readmissions after ileostomy
creation. Surgery, 160(5), 1302-1308.

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Leal, W. P., Carregaro, A. B., Bressan, T. F., Bisetto, S. P., Melo, C. F., & Sladky, K. K.
(2017). Antinociceptive efficacy of intramuscular administration of morphine sulfate and
butorphanol tartrate in tegus (Salvator merianae). American journal of veterinary
research, 78(9), 1019-1024.
Niewiński, G., Figiel, W., Grąt, M., Dec, M., Morawski, M., Patkowski, W., & Zieniewicz,
K. (2020). A Comparison of Intrathecal and Intravenous Morphine for Analgesia After
Hepatectomy: A Randomized Controlled Trial. World Journal of Surgery, 1-10.
Frieden, T. R., & Houry, D. (2016). Reducing the risks of relief—the CDC opioid-prescribing
guideline. New England Journal of Medicine, 374(16), 1501-1504.
Tavenier, A. H., Hermanides, R. S., Ottervanger, J. P., Ter Horst, P. G. J., Kedhi, E., & van‘t
Hof, A. W. (2018). Risks of opioids in ST-elevation myocardial infarction: a review. Drug
safety, 41(12), 1303-1308.
Nardi-Hiebl, S., Eberhart, L. H. J., Gehling, M., Koch, T., Schlesinger, T., & Kranke, P.
(2020). Quo Vadis PCA? A Review on Current Concepts, Economic Considerations, Patient-
Related Aspects, and Future Development with respect to Patient-Controlled
Analgesia. Anesthesiology Research and Practice, 2020.
Chen, A., Shariati, F., Chan, T., & Lebowitz, D. (2018). A review of adverse outcomes
following intravenous morphine usage for pain relief in acute coronary
syndrome. Cureus, 10(9).
Rowe, K. M., & Schiller, L. R. (2020, January). Ileostomy diarrhea: Pathophysiology and
management. In Baylor University Medical Center Proceedings (pp. 1-9). Milton Park:
Taylor & Francis.