Nursing Case Study Analysis: Mrs. Austin's Cholecystectomy, NURS10

This case study analyzes the perioperative care of Mrs. Jane Austin, a 59-year-old woman who underwent a laparoscopic cholecystectomy. The analysis utilizes the Clinical Reasoning Cycle to assess the patient's condition, identify nursing problems, establish goals, and evaluate interventions. The key issues identified include pain management, abnormal vital signs, and elevated C-reactive protein levels. The paper discusses pharmacological and non-pharmacological interventions, including pain medication, oxygen supplementation, lifestyle modifications, and patient education. The evaluation focuses on assessing the effectiveness of interventions in achieving the care goals, with an emphasis on holistic patient care, including both physical and psychological well-being. The case study highlights the importance of evidence-based practice, ethical considerations, and the cyclical nature of clinical reasoning in providing effective nursing care.

Running head: NURSING
Nursing
Name of the student:
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Author’s note

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Introduction
Clinical reasoning is an important skill in nursing that facilitates nurses to provide
safe and effective care. It is implemented in all phases of the nursing process. It includes the
step of recognizing cues from a clinical situation, elaborating judgment and reasoning to
select appropriate interventions and evaluate the outcomes achieved (Carvalho et al., 2017).
The clinical reasoning cycle is an important framework that gives guidance regarding the
stepwise process to be implemented to assess patient and develop care plan (see appendix 1).
The main purpose of this report is to analyze the case study of Mrs. Jane Austin using the
Clinical Reasoning Cycle and discuss about the provision of ethical, legal and holistic patient
centred care for patient. The paper will explore the health assessment data of patient to
understand three nursing problems, establish goal of priority and evaluate the nursing care
strategies to implement the intervention.
Consider the person’s situation:
The case study is about Mrs. Jane Austin, a 59 year old woman admitted to the theatre
for a laparoscopic cholecystectomy following severe right upper quadrant abdominal pain.
She had symptoms of uncontrolled nausea and vomiting. She has been diagnosed with
cholelithiasis and cholecystitis. Cholelithiasis is a condition associated with formation of
gallstones and cholecystitis is the inflammation of the gall bladders leading to severe pain in
the abdomen (Mohammed, Behan & Ahmed).
Collect, process and present related health information
Mrs. Jane has a body mass index (BMI) of 28 and has past medical history of
hyperlipidaemia, hypertension and smoking. Currently, she is taking her regular medications
like Lipitor and Perindopril. The review of the emergency department assessment data

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revealed she was tachcardic and febrile. The subjective data of Jane revealed upper quadrant
tenderness on palpation and intolerance to fatty foods. The preoperative chest x ray is clear.
From the above data, the key diagnosis and health problem for patient is identified.
Post-anaesthetic recovery room (PACU) assessment data gave results regarding votal
signs, pain, level of consciousness, blood culture results and operation site assessment. She
was awake and alert and had 4 incision dressings with nil ooze. Her pain score was 6/10. The
vital signs of the patient included RR 28 (normal rate 12 to 20 bpm), HR 115 (90 to 100
bpm), BP 125/70 (120/80), SpO2 89% (96 to 99%) and temp 37.5 degree Celsius (within
normal range). Fluctuation in vital signs post operatively was seen. No bowel sound on
auscultation. However, mild abdominal distension was found on abdomen palpation. The
nursing assessment implemented are relevant with current evidence based practices as
assessment of skin, operation sites and gastrointestinal assessment is critical for post
operative patients with cholecystitis.
Identify and prioritise three (3) nursing problems/issues:
From the analysis of health assessment data for Mrs. Jane, the pain score is a concern
for patient as his current pain score in 6/10. Laparoscopic cholecystectomy leads to parietal
pain and this is a source of marked discomfort and surgical stress for patient. It may be due to
the effect of the surgical procedure as the procedure was slightly longer for Jane as the
surgeon had difficulty in identifying the common bile duct (Barazanchi et al., 2017). Hence,
the first priority problem is pain and addressing this is important to provide relief to patient.
Pain management is also critical to improve post surgical outcome and promote recovery in
patient. Pain is associated with emotional distress and negative psychosocial outcomes in
patient (Svanberg et al., 2017). Hence, pain management should be prioritized to provide
holistic care to patient and improve both physical and mental health outcomes of patient.

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The PACU assessment reveals abnormal findings for vital sign assessment. Most of
the vital sign parameter was found to be abnormal for Mrs. Jane. His respiratory rate was too
high and heart rate was abnormal too. Since, Mrs. Jane was tachycardic even during
preoperative assessment, restoring normal heart rate is critical. In addition, SpO2 value was
also abnormal which can increase risk of respiratory distress for patient (Jaber et al., 2016).
Hence, the second priority problem identified is abnormal vital signs and identifying
appropriate interventions to maintain vital sign is critical to early identify clinical
deteriorating and take proper response regarding the same. Frequent monitoring and
management of vital sign is important to avoid adverse events. This can save medical team
from unanticipated adverse events and take proper response to clinical deteriorations too
(Kyriacos, Jelsma & Jordan, 2014). Hence, vital signs needs to be prioritized based on current
diagnosis and health condition of Jane.
The third negative vital heath concern identified for John is elevated C-reactive
protein. Elevation of this protein is generally a sign of inflammation and it is the most
common marker to diagnose patients with cholecystitis. The CRP level is high after surgery
and peak is obtained after 48 hours. The value is significantly higher in patients with major
complications compared to those with minor complications (Straatman et al., 2018). Having
elevated levels of the protein even after the surgery is an indication that inflammation is still
present and most important post operative goal is reduce the level of C-reactive protein
(CRP). CRP is an inflammatory protein that plays an important role in inflammatory
processes and host response to infection such as phagocytosis, releases of nitric oxides and
production of cytokines. CRP levels can increase because of age, smoking status, weight and
blood pressure too (Sproston & Ashworth, 2018). Mrs. Jane’s BMI was 28 which indicate she
is overweight. Her medical history shows includes history of smoking and hypertension.

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Hence, the impact of these factors must be considered while planning interventions to reduce
CRP level of patient.
Establish goals for priority of nursing care
Based on the identification of above three problems, the following goals have been
prepared to provide effective nursing care to Mrs. Jane:
 To provide pain relief to patient and achieve positive physical and psychological
outcome
 To manage CRP level of patient to reduce inflammation due to surgery and other
factors such as weight and surgery
 To maintain vital signs of patient and prompt manage early signs of clinical
deterioration
 To engage in evidence based nursing care to avoid adverse event and promote holistic
recovery of patient.
Discuss the nursing care of the person:
After establishing the goal of care, the next step is to select from available treatment
options and decide the most relevant actions to achieve the goals. This will depend on
critical thinking regarding key problems of patient and the evidence based strategies to
manage them. The first high priority problem is pain and to engage in pain management, it is
necessary to implement both pharmacological and non pharmacological intervention
considering the health assessment data of patient. Post operatively , Jane’s pain score was six
which means high pain score. The evidence based pharmacological nursing intervention that
can be given to Mrs. Jane includes providing paracetamol infusion to patient along with
NSAID drug and surgical site local anaesthesia infiltration. Paracetamol and NSAID should
be started before and after the operation as part of preoperative care. Evidence based studies

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report continuation of both the drugs after operation to achieve pain relief (Barazanchi et al.,
2018). Hence, it is planned to deliver multimodal regimen of postoperative analgesia to
patient following Laparoscopic cholecystectomy. Other non pharmacological intervention
that will be necessary for the management of pain and it’s associated discomfort for Mrs.
Jane includes promote bed rest of patient and engage patient in relaxation techniques to
provide relief from pain. Ju et al. (2019) gives the evidence regarding the efficacy of
relaxation therapy by reducing anxiety and distracting attention of patient from current pain.
Nurse can also engage in patient education to explain Mrs. Jane that current pain is due to the
process used during surgery and this will subside after one or two days of analgesic
treatment.
To address the problem of abnormal vital signs of Jane following Laparoscopic
cholecystectomy, it will be necessary to provide supplemental oxygen to patient. This is
because Jane’s SpO2 value was 89% which is an indication of hypoxemia. Hence, unless this
is treated, it may lead to complications in body tissue and organs and respiratory arrest. To
treat hypoxemia during perioperative care, it will be necessary to provide oxygen
supplementation to patient. This will help to treat the condition as well as promote healing of
the surgical wounds (Sun et al., 2015). Nurse need to involve Jane in deep breathing too so
that normal oxygen saturation value is obtained. Continuous monitoring of patient is also
planned to promptly recognise change in vital signs and implement timely and proper nursing
interventions.
To reduce the level of CRP protein, it will be necessary to modify risk factor of Mrs.
Jane. From her preoperative assessment data, it has been found that she is an obese patient
with smoking habits. As weight and smoking related factors contribute to high CRP level, it
will be necessary to implement educational and lifestyle intervention for patient. This will
involve giving education regarding quitting smoking (Rojano-Rodriguez et al., 2014).

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Perioperative prophylaxis is planned to as high CRP level is an indication of postoperative
infection and antibiotic prophylaxis can reduce this risk for patient. However, this should be
continued for short period as current evidence suggests the need to avoid implementing such
intervention in low risk surgical patient (Chauhan et al., 2018). Hence, the intervention can be
stopped once CRP level reaches normal value.
Evaluate your nursing care strategies:
To evaluate the effectiveness of the above nursing care strategies, it will be necessary
to assess whether care goals has been achieved following treatment or not. The key goal was
to address three identified problems and promote holistic recovery of patient. To address this,
it will be necessary to assess vital sign of Jane to assess restoration of vital signs. In addition,
conducting pain assessment using PQRST method will be necessary to identify reduction in
pain and anxiety. The effect of educational intervention will be reviewed by monitoring
anxiety level in patient and use of positive coping style to deal with current symptoms.
Reflect on the person’s outcomes/your learning
The key reflections from analysis of patient problem and development of care plan for
Mrs. Jane is that vital sign fluctuation is an effect of postoperative surgical process. As Jane
had a long surgery, this was the reason for her pain. However, as pain is associated with
anxiety and mental stress in patient, including non pharmacological and educational
intervention for patient suggest the significance of these care strategies in providing holistic
care to patient.
Provide a conclusion
The paper gave a summary about the use of clinical reasoning cycle to engage in
collecting cues about patient, identify patient problem, develop goals based on care priority,

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take actions for recovery and evaluate the interventions proposed. By using this process, three
major health problem identified in patient included high pain level, high CRP value and
abnormal vital signs. Both pharmacological and non pharmacological intervention along with
patient education was implemented to promote recovery of patient. Emphasizing on mental as
well as physical health is critical to promote holistic care and recovery of patient.

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References:
Barazanchi, A. W. H., MacFater, W. S., Rahiri, J. L., Tutone, S., Hill, A. G., Joshi, G. P., ...
& Lirk, P. (2018). Evidence-based management of pain after laparoscopic
cholecystectomy: a PROSPECT review update. British journal of anaesthesia, 121(4),
787-803.
Carvalho, E. C. D., Oliveira-Kumakura, A. R. D. S., & Morais, S. C. R. V. (2017). Clinical
reasoning in nursing: teaching strategies and assessment tools. Revista brasileira de
enfermagem, 70(3), 662-668.
Chauhan, V. S., Kariholu, P. L., Saha, S., Singh, H., & Ray, J. (2018). Can post-operative
antibiotic prophylaxis following elective laparoscopic cholecystectomy be completely
done away with in the Indian setting? A prospective randomised study. Journal of
minimal access surgery, 14(3), 192.
Jaber, S., Lescot, T., Futier, E., Paugam-Burtz, C., Seguin, P., Ferrandiere, M., ... &
Pottecher, J. (2016). Effect of noninvasive ventilation on tracheal reintubation among
patients with hypoxemic respiratory failure following abdominal surgery: a
randomized clinical trial. Jama, 315(13), 1345-1353.
Ju, W., Ren, L., Chen, J., & Du, Y. (2019). Efficacy of relaxation therapy as an effective
nursing intervention for post-operative pain relief in patients undergoing abdominal
surgery: A systematic review and meta-analysis. Experimental and therapeutic
medicine, 18(4), 2909-2916.
Kyriacos, U., Jelsma, J., & Jordan, S. (2014). Record review to explore the adequacy of post-
operative vital signs monitoring using a local modified early warning score (mews)

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chart to evaluate outcomes. PloS one, 9(1), e87320.
doi:10.1371/journal.pone.0087320
Mohammed, A. T., Behan, R. B., & Ahmed, A. C-Reactive Protein in Patients with
Diagnoses of Cholecystitis. Annals of PIMS ISSN, 1815, 2287.
Rojano-Rodriguez, M. E., Valenzuela-Salazar, C., Cardenas-Lailson, L. E., Loera, L. R.,
Torres-Olalde, M., & Moreno-Portillo, M. (2014). C-reactive protein level in
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Peet, D. L. (2018). C-reactive protein in predicting major postoperative complications
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Appendices:
1. The steps of the clinical reasoning cycle :