Nursing Case Study: Levett Jones Clinical Reasoning Cycle

This nursing case study discusses the provision of care for a patient post-surgery for peritonitis following a ruptured appendix, using the Levett Jones clinical reasoning cycle. The essay highlights three care requirements for the patient and devises an action and evaluation plan accordingly.

Running head: NURSING CASE STUDY
Nursing Case Study
Name of the Student
Name of the University
Author Note

NURSING CASE STUDY
Introduction
According to the code of professional conduct of the nurse in Australia, it is the duty
of the nurse to practise via reflectivity and ethically (Nursing and Midwifery Board of
Australia, 2018). In the domain of explaining the nursing reflection, one of the important
frameworks is the Levett Jones clinical reasoning cycle (Levett-Jones, 2018). Via following
the Levett Jones clinical reasoning framework, this essay will discuss provision of care for
the patient, Ms Melody King. The care for the patient will be based on her current medical
situation that is post surgical condition after peritonitis from ruptured appendix. This
reflection framework will help to devise care plan for Ms Melody Kind based on the current
situation and via collection and identification of the problem. The essay will highlight three
care requirements for Melody and will devise the action and evaluation plan accordingly.
Levette Jones Clinical Reasoning Cycle
Patient Situation
Ms Melody King is a patient of peritonitis following ruptured appendix. Currently she
is in the post-surgical unit after laparoscopic removal of ruptured appendix. Her current
condition include low blood pressure (BP 95/45mmHg), high heart rate (HR: 120), high body
temperature (38.3 degree Celsius) normal oxygen saturation at room temperature (95%).
Melody has also complained of increased nausea along with high abdomen pain (7-8 on pain
scale). Current observation highlights distended abdomen and blood test examination showed
high white blood cell (WBC) and C-reactive protein count (CRP)
Collection of cues
Collected vital signs at the time of post surgical condition indicated that Ms Melody
has low blood pressure, high heart rate and high body temperature. She also has high pain

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scale in the central part of the abdomen and distended abdomen. Her high infection rate
within the blood is indicated via the high white blood cell count and high count of C-reactive
protein (CRP) (McCance & Huether, 2018). Her high heart rate may be due her previous
reported case of bronchospasm as indicated by her prescribed drug list which includes
Ventolin. High rate might also due to asthma however; she still takes anti-asthmatic
medication: Seretide (McKenna & Lim, 2012).
Processing of information
One of the main information that must be taken into consideration while designing
care plan for Ms Melody King is her asthmatic tendency. According to Forbes and Watt
(2015), asthma is the major respiratory illness that impacts on the overall health and well-
being of an individual. Asthma may cause inflammation in the airways and thereby creating
blockage in the pulmonary airways and hence increasing the heart rate and respiratory rate of
Ms Melody. Thus post surgical complications in case of Melody might include breathing
problems. Moreover, her blood reports revealed that she has high white blood cell
concentration along with high CRP. Thus indicates high rate of inflammation. This high
inflammation is still persists after the surgery then the condition might indicate pulmonary
infection. Another, vital information that must be taken into consideration in post-surgical
unit is depression of Ms Melody King. However, her oxygen saturation seems to be normal at
the time of emergency admission this might overrule the chances of asthmatic condition or
bronchospasm going severe (Reddel et al., 2015). According to Forbes and Watt (2015)
depression is the most common disorder for the patients with peritonitis and this might
further increase in case of Ms Melody King as she is already a patient of depression.
Identification of problems
The blood pressure of Ms Melody kind is low. This is something unusual taking into
consideration of her age (36 years). Moreover, Melody has asthma and this increases the

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tendency of high blood pressure (Chung et al., 2013). However, her blood pressure is low and
this may cast threat to in her post operative condition. Her body temperature is high (38.3
degree; normal body temperature: 37 degree C). This is how ever not that alarming in
comparison to that of low blood pressure because increase in the body temperature is
regarded as the preliminary symptom of inflammation (as indicated by white blood cells) and
might decrease during the post-operative condition. Furthermore, use of antibiotics will
further help to decrease the body temperature (Meier & Lee 2017). But low blood pressure
along with high heart rate (normal range: 100 beats per minute) are alarming and might pose
threat to Melody after laparoscopic removal of the fractured appendix (McCance & Huether,
2018).
Recovery from surgery for a perforated appendix is longer and this is because, the
spread of infection resulting out the ruptured appendix must be treated affectively (McCance
& Huether, 2018). The test result indicates high WBC count and high concentration of CRP.
According to McCance & Huether (2018), increase in the WBC or CRP count can be
regarded as the direct indicator for blood infection or sepsis. This can be a problem during the
post-operative condition results in the development of hypersensitivity shock. Melody is
more vulnerable in encountering hypersensitivity shock because she is physically weak after
surgery as indicated by nausea.
Another problem in case of Melody is her shallow respiratory rate, According to
Forbes and Watt (2015) respiratory rate is a preliminary indicator for hypoxia. According to
Trayhurn (2013), hypoxia is a pathological condition of the body is characterised as the lack
of adequate oxygen supply in the tissue. Hypoxia can be localised or general. In case of Ms
Melody King, the chances are high for generalised hypoxia (Semenza, 2014). Since Ms
Melody is a patient of asthma and also suffers from bronchiospasm, her tendency of
developing hypoxia is further high.

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Distended abdomen is another problem that can be highlighted in case of Melody.
According to McCance and Huether (2018) distended abdomen is mainly used to refer
swelling of the abdomen and not solely of the stomach. The possible cause for distended
abdomen may include increase in the accumulation in the abdomen resulting from water
retention or may be due to gas accumulation due to indigestion. Kothadia, Katz and Ginzburg
(2015) highlighted that one of the most common cause of appendectomy is indigestion, which
may give rise to distended abdomen.
High level of pain is also a problem for Melody as it might hamper her health and
well-being. Her pain might be the reason for the distended abdomen or due to high level of
blood spcesemia as evident from high WBC count and CRP (McCance & Huether, 2018).
Proper assessment of the reason behind the pain and effective intervention is mandated in
case Melody.
Establishment of goals
Goal 1: Relief from pain
Comfort of the Patient is important (Forbes & Watt, 2015). In case of Melody, acute
pain might be the reason behind inflammation or abdominal distension. The importance of
this goal is, if pain is not managed properly, it can lead to depression and thus should be
avoided. The reason behind this, Melody has previous reported case of depression and is on
anti-depressive medication.
Action: I will notify doctor about the high pain level of Melody and will ask doctor to
chart pain medication in order to help Melody with effective pain management. Proper
positioning also important in order to manage pain and I will do it accordingly under the
supervision of doctor (Forbes & Watt, 2015). If the patient is on NG (naso-gastric tube) tube
in order to decrease gastric distension then I will check the placement of the nasograstic tube.

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This is because, improper placement of NG tube can lead to pain due to leakage of bowel
contents into the peritoneum (Nguyen et al., 2016).
Goal 2: Controlling high infection rate
Infection, raised temperature, distended abdomen and high WBC and CRP count are
main indicators of infection and this internal infection should be resolved. According to
Kothadia, Katz and Ginzburg (2015), Infection after appendectomy is very common. At least
7 out of 10 cases of appendectomy are associated with high infection rate. If infection is not
resolved it can also lead to sepsis as this might be the case of Melody as she has high WBC
and CRP (McCance & Huether, 2018).
Action: My action in the domain of nursing intervention will be to notify doctor about the
increase in body temperature and other signs of infection and requirement for re- assess
patient. If medication (antibiotic therapy) is prescribed and charted, then it will be my duty as
a registered nurse to give medication on a timely manner as antibiotics are required to be
given at specified dose, time and rate/mode of administration (Yu et al., 2013).
Goal 3: Checking the condition of hypoxia
To ascertain the chances of breathing problem via checking hypoxic condition. The
rationale behind this goal is, Melody is patient of asthma and at present suffering from
nausea. McKenna and Lim (2012) highlighted that decrease in the oxygen saturation in the
body increases the tendency of developing nausea. Moreover, such hypoxic condition leading
to breathless is extremely relevant in case as asthmatic patient under post surgical condition
(Reddel et al., 2015). O'reilly (2014) reported that maintenance of proper breathing cycle
with adequate oxygen saturation helps to reduce pain sensation in the pain scale.
Action: O'reilly (2014) stated that monitoring of the oxygen saturation level is usually
done with the help of pulse oximetry. According to Chan, Chan and Chan (2013) pulse

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oximetry is a non-invasive method that is used for monitoring oxygen saturation of an
individual. It mainly provides the reading via denoting the peripheral oxygen saturation
(SpO2). Proper supply of the external oxygen in case of drop in SpO2, will help to maintain
normal oxygen level in the body and thereby helping to control hypoxia (O'reilly, 2014). I
will also call in a professional physiotherapy in order to promote active breathing in addition
to external oxygen supply if needed (Reddel et al., 2015).
Actions
The main actions that I will take while monitoring Ms Melody King under post
operative condition include thorough monitoring of her oxygen saturation through pulse
oximetry. If I find that her oxygen level below 95 to 90%, I will immediately call in the
concerned doctors. The doctor will determine the exact amount of oxygen that will be
required by Melody externally. Once the doctor devises the external oxygen supply care plan,
I will monitor the supply of oxygen along with the change in her oxygen saturation level.
While controlling her infection within the body I will also monitor her white blood cell count
and her CRP level in the blood serum. If I find that her inflammation rate is not decreasing
even during the post operative condition, I will further inform the doctor so that he can take
the necessary action. Lastly I will also make sure that Ms Melody Kind may not pass into
depression while her stay in the post-operative unit. This is as per the previous reported case
history; Ms Melody suffers from depression and also takes anti-depressive medication.
Hence, I will converse and encourage her to fight back with her problem and will give her
positive source of hope and inspiration while discussing her care plan and rate of progress.
According to Rathert, Wyrwich and Boren (2013) discussing the care plan with the patient,
increases patient involvement. This helps to reduce the unwanted apprehension and
improvement of the overall health outcome.

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Evaluation of outcomes
In order to evaluate the outcome of her overall rate of recovery in the post surgery
unit, I will monitor the blood pressure, heart rate, respiratory rate and oxygen saturation. This
monitoring of the vital signs of Ms Melody Kind will help to get an overview of her current
health condition. I will also monitor her infection rate in the blood from her white blood cell
count and CRP concentration in the blood serum.
Reflection of process and new learning
From the analysis of this case study, I emerged in new learning in the professional
role of registered nurse. One of my new learning highlights that it is the duty of the nurse to
involve patients in the health care plan via discussing the possible outcome and the
importance of the therapy imposes. This goes with the competency standards of the Nursing
and Midwifery Board of Australia (2013). According to the standard 9, it is the duty of the
registered nurse to help patient to participate in the informed decision making and this in turn
helps to improve the overall quality of care. In my new learning, I have also understood the
importance of the consultation with the other healthcare professionals in order to improve the
patient outcome and the value of the evidence-based practice in nursing care.
Conclusion
Thus from above discussion based on clinical reflection, it can be concluded that
controlling and coordinating the internal inflammation is curial for patient who have ruptured
appendix, even after undergoing laparoscopic surgery. Apart from proper monitoring of the
oxygen saturation is also importance. Since Ms Melody King is a patient of asthma,
monitoring her oxygen saturation further holds additional importance. Lastly, it can be said
that it is the role of the nurse to involve patient in the care plan and practice via following the
evidence based guidelines. This help to improve the overall outcome of the care along with
the promotion of patient’s health and well-being.

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