NRSG370: Clinical Integration Case Study - Bianca Lane Scenario

This case study analyzes a 20-year-old female patient, Bianca Lane, admitted with abdominal pain, vomiting, and fever, later diagnosed with peritonitis following a perforated appendix. The assignment applies the clinical reasoning cycle to assess the patient's condition, process information, and identify priority problems, including tachycardia, abdominal pain, and fever. The study details the pathophysiology of peritonitis and outlines a comprehensive plan of care, including interventions like positioning, oxygen therapy, medications (digoxin, naproxen, morphine, acetaminophen), and non-pharmacological approaches like heat/cold compress. The goals of care focus on stabilizing vital signs, managing pain, and reducing fever. The evaluation assesses the effectiveness of the interventions, and the reflection emphasizes the importance of critical thinking in nursing practice. The case study emphasizes the importance of understanding the pathophysiology of the presenting complaints, assessing the patient, and formulating care strategies to address the patient's health abnormalities.

Running head: NURSING
NRSG370 – Clinical Integration - Speciality Practice
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Introduction- Clinical reasoning cycle comprises of the procedure that helps nursing
staff and other healthcare personnel obtain vast extent of information about patient
indications, following which they are able to process the data and identify the health issues
that the patients encounter (Levett-Jones et al., 2010). This essay will elucidate a case study
involving Bianca Lane, a 20 year old female, using the clinical reasoning cycle. The eight
different stages of the cycle will be extensively discussed in the essay where the
pathophysiology will be deliberated, and three priority issues will be identified for the
patient, for which a definite plan of care will also be formulated. The final step will comprise
of a reflection on the entire scenario.
Consideration of facts- Bianca Lane is a 20 year old woman who had taken admission
at the Emergency department after she reported persistent pain in her lower quadrant
abdominal region. Three of her presenting complaints were vomiting, fever and nausea.
Following her admission, she was subjected to an extensive physical assessment that lead to
the detection of a perforated appendix from the ultrasound results. This was immediately
followed by a laparoscopic surgery. 36 hours after completion of the surgery, Bianca was
examined for her vital signs and was found to be hypotensive (blood pressure 94/45 mm Hg),
febrile (body temperature 38.5° C), with tachypnoea (respiratory rate 24 breaths/minute), and
tachycardia (heart rate 136). Her breathing is also found to be shallow. Nonetheless, she
reported a normal oxygen saturation (SpO2 95% on room air). Following the operation, some
of her complaints include feelings of being bloated or full, nausea, and gradually worsening
centralised pain in the abdomen that worsens with breathing and any kind of movement. On
analysing her pain severity, it was found to be 7/10, thus indicating a high pain score. Results
from the physical examination also suggest presence of a distended and rigid abdomen, with
no bowel sounds. Laboratory investigations have also been performed and they revealed an

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increase in CRP and WBC count. X-ray reports also suggested a gaseous and oedematous
distention of the bowel.
Process information- Peritonitis is a health condition that occurs when the peritoneum
tissue, surrounding the inner walls of the abdomen get inflamed. The principal function of the
peritoneum tissue is to offer support and protection to the internal organs (Capobianco et al.,
2017). Peritoneal fluid generally circulates inside the abdomen, in relation to variations in
abdominal pressure. The presenting complaints of Bianca can be cited as a direct
consequence of peritonitis owing to the fact that some of the most prevalent symptoms of the
condition include distended feeling in the abdomen, high body temperature, diarrhoea,
tenderness, nausea, less urine production and vomiting (Ndayizeye et al., 2016). In the words
of Zhou et al. (2018) bacterial infection and its rapid multiplication results in inflammation of
the appendix that gradually becomes swollen with pus, often leading to rupture. With the
leakage of the substances inside the appendix, anaerobic and gram-negative bacteria, along
with common gut flora, like Klebsiella pneumonia and Escherichia coli enter the peritoneal
cavity (Haugan et al., 2018). Endotoxins that are generated by gram-negative bacteria trigger
the immediate release of cytokines that eventually stimulate humoral and cellular cascades,
thus resulting in septic shock, cellular damage, and multiple organ dysfunction syndrome
(MODS). In peritonitis that occurs due to bacterial infection, the physiologic response is
generally determined by more than a few factors, together with the virulence of pathogen,
immune status, inoculum size, and complete health condition of the host. It was necessary to
analyse the vital signs since they are imperative for predicting major bacterial infections and
provide an indication for the routine physiologic functioning (Bonnez et al., 2019).
Bianca’s medical history report presence of asthma and depression. Shallow breathing
can be correlated with her asthmatic condition since asthma brings about a constriction in the
diameter of the airways that are located in the lungs, thus causing a disturbance in ventilation

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perfusion. This makes the person exert more force during breathing, thereby drawing minimal
breath inside the lungs (Radhakrishnan & Almaddah, 2017). Greater heart beat or tachycardia
was also a direct result of the infection, in the form of a systemic response of the body to
stress (Nirei et al., 2017). This physiologic mechanism during infection increases cardiac
output and delivery of oxygen to the tissues, thus providing an indication for hypovolemia,
and the requirement of intravascular fluid repletion. Furthermore, post-operative tachycardia
can also be accredited to the release of catecholamine, in relation to surgical stress and the
laparoscopic surgery (Haskins et al., 2016).
Likewise, tachypnea was also a feature of peritonitis since it indicated pulmonary
dysfunction that occurred due to endotoxin mediated activation of the medullary ventilatory
centre. The respiratory rate might have increased to compensate for metabolic acidosis, which
in turn is concomitant with peritonitis (Chin et al., 2018). Her current list of medications
include seretide, sertraline, and salbutamol. Administration of sertraline helps in management
of anxiety, panic disorder and depression and might have been prescribed for her
psychological distress. However, both salbutamol and seretide are medications for asthma
management. While seretide contains a combination of long- acting β2 agonists and inhaled
corticosteroids, salbutamol clears the narrow airways of the lungs (Bender et al., 2016). High
WBC count, as evidenced from the pathology report also provide an indication for a well-
functioning immune system that fights against pathogen. Additionally, a rise in acute phase
reactant CRP also hint at the presence of inflammation.
Identify the problem- Three central problems identified from the case study are
namely, (i) tachycardia as a result of peritonitis, (ii) abdominal pain as a result of surgery, and
(iii) fever as a result of peritonitis.

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Establish goals- The first goal would be to help the patient demonstrate sufficient
cardiac output, as observed by pulse rate and blood pressure within normal parameters. The
second goal would be to record a pain score less than 4 on a rating scale ranging from 0-10.
The third goal would be to restore the body temperature of the patient below 38°C.
Take action- In order to address the issue of tachycardia, Bianca will be positioned in
semi-Fowler or high-Fowler position. This position will facilitate relaxation of the tension
existing in the abdominal muscles and will improve the breathing rate as well. The position
will also promote maximum expansion of the chest and help in oxygenation, thus preventing
respiratory distress and improving blood circulation throughout the body of the patient
(Costa, Almeida & Ribeiro, 2015). The second intervention would encompass administration
of hyperbaric oxygen therapy (HBOT) where oxygen gas will be administered at an ambient
pressure that is greater than atmospheric pressure. The therapeutic principle of this
intervention lies in the significance of the intervention in bringing about a drastic increase in
the oxygen partial pressure in the cells and tissues. The partial pressure of oxygen attainable
using HBOT are considerably greater than those attainable while inhaling pure oxygen
under normal atmospheric pressure (normobaric condition). This impact will therefore be
obtained by an upsurge in the oxygen carrying capacity of bloodstream (Bennett, Lehm &
Jepson, 2015). Administration of digoxin will encompass the third intervention. The drug is
commonly used for the treatment of heart failure, atrial flutter and atrial fibrillation and exerts
its action by inhibiting the sodium potassium adenosine triphosphatase (Na+/K+ ATPase) in
myocardium (Laursen et al., 2015). The aforementioned inhibition would result in an
elevation in the intracellular levels of sodium, thereby decreasing the sodium-calcium
exchanger activity, which generally helps in influx of three sodium ions and efflux of one
calcium ion (Ziff & Kotecha, 2016). The exchanger reversal would upsurge the intracellular

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concentration of calcium, thus lengthening phase 0 and phase 4 of cardiac action potential,
eventually decreasing heart rate.
The first intervention for addressing abdominal pain would encompass administration
of naproxen, a nonsteroidal anti-inflammatory drug (NSAID). The drug would act in the form
of a nonselective inhibitor of cyclooxygenase (COX) enzyme, and would trigger an inhibition
of both cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes. Under
normal circumstances, COX enzyme stimulates the formation of thromboxane and
prostaglandings from arachidonic acid. Hence, by blocking the production of prostaglandin,
the medication will help in providing pain relief (Friedman et al., 2015). The second
intervention would consist of administering the opioid analgesic morphine. Morphine will
primarily interact with the μ–δ-opioid (Mu-Delta) receptor heteromer located in the central
nervous system (Yadlapalli et al., 2017). This presynaptic action of the opioid drug will
inhibit release of neurotransmitters and produce an analgesic effect. A non-pharmacological
intervention for treating abdominal pain would involve heat or cold compress. While heat
therapy will reduce pain by improving the flow of blood to the area and decreasing pain
reflex, cold compress will decrease muscle spasticity and inflammation, by lowering pain-
inducing chemical release (Arankalle, Wardle & Nair, 2016).
High body temperature will be managed by administering antipyretic medication like
acetaminophen (Young et al., 2015). The drug will block the release of prostaglandin that
creates an impact on the hypothalamus and will decrease the body temperature. The room
temperature will also be adjusted to the patient’s normal body temperature and lines and
blankets will be provided for restoring the body temperature. The third intervention would
comprise of intake of adequate fluids that will prevent dehydration, owing to the fact that loss
of fluid significantly contributes to fever.

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Evaluation- Efficacy of the care plan can be determined if the heart rate is less than
100 beats/minute, body temperature is less than 38°C, and pain score is not more than 4.
Reflection- Upon conducting a reflection of the case study, I realised the importance
of critical thinking in nursing practice and was also able to identify the skills and expertise
that are required for the same. I understood that applying clinical reasoning while caring for a
patient helps in appropriate identification of the health concerns that are encountered by the
patients, thereby providing assistance in reaching a judgment or conclusion about plan of
care.
Conclusion- Thus, it can be concluded that considering the intended health outcomes,
nursing staff are expected to gain a sound understanding of the pathophysiology of the
presenting complaints, following which they conduct an assessment of the patient and
formulate comprehensive care strategies. The case study was based on peritonitis that occurs
due to bacterial infection, after a ruptured appendix and resulted in several health
abnormalities in the patient. Hence, the three major issues that were addressed in the care
plan were high heart rate, fever, and severe abdominal pain.

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