NRSG370 Assessment: Bianca's Case Study, Clinical Reasoning Cycle

This case study focuses on Bianca, a 20-year-old female admitted to the emergency department with severe abdominal pain and diagnosed with a perforated appendix, which subsequently led to peritonitis. The assignment utilizes the Clinical Reasoning Cycle to analyze Bianca's situation, including cue collection (symptoms like pain, fever, and hypotension), processing health information related to peritonitis, and identifying three priority nursing issues: infection control, centralized abdominal pain, and deficient fluid volume. Goals are established for each issue, and the assignment discusses comprehensive nursing care strategies, such as monitoring vital signs, pain management, fluid replacement, and infection control measures. The evaluation of nursing strategies and reflection on Bianca's outcomes and learning are also included, emphasizing the importance of the Clinical Reasoning Cycle in guiding ethical, evidence-based, and holistic person-centered care. The conclusion reinforces the clinical reasoning cycle's value in minimizing errors and promoting methodical nursing care.

Assessment task 3

Table of Contents
Introduction......................................................................................................................................3
Bianca’s situation.............................................................................................................................3
Collection of cues............................................................................................................................3
Processing of related health information.........................................................................................4
Identification and prioritization of three nursing issues..................................................................5
Establishment of goals for priority of nursing care.........................................................................5
Discussion of the nursing care of the person...................................................................................6
Evaluation of the nursing care strategies.........................................................................................8
Reflection on the Bianca’s outcomes and learning..........................................................................8
Conclusion.......................................................................................................................................9
References........................................................................................................................................9

Introduction
It is observed that when nurses possess effective clinical reasoning skills, they influence the
health outcomes of the patient positively. On the other hand, when nurses do not possess
adequate clinical reasoning skills or have poor skills, they fail to identify forthcoming patient
deterioration which sometimes results in “failure-to-rescue”. Clinical reasoning cycle denotes the
clinical judgements and clinical decision-making that are abstracted as a progressive and logical
process that involves eight different and important stages (Levett-Jones, 2013). In this
assignment Clinical Reasoning Cycle will be used as a framework to plan and evaluate person-
centered care for the case study of Bianca. It will discuss the delivery of ethical, legal, evidence-
based, holistic person-centered care.
Bianca’s situation
Bianca Lane is a 20 year old female who was brought into the Emergency department on having
severe pain in right lower quadrant abdominal region for last 2-3 days. She also complained of
nausea, fever and poor appetite. She has a history of asthma and depression. Currently, she is on
prescription of salbutamol, seretide and sertraline. She is compliant with the medicinal regime.
When her abdomen was physically examined and an ultra-sound was done, a perforated
appendix was diagnosed. And emergency laparoscopic surgery was done. 36 hours post
operatively Bianca was diagnosed with peritonitis following ruptured appendix.
Collection of cues
After 36 hours of operations, her blood pressure was reported to be 94/45 mmHg which indicates
that blood pressure was sinking and not under control. Heart rate was 136. Temperature was

recorded to be 38.5°Celcius, respiratory rate 24/min and shallow and SpO2 95% on room air.
Bianca complained of gradually progressing nausea, ‘bloated’ feeling and enhancing centralized
abdominal pain. Pain worsened with any movement and respiration. On scale, pain score was
7/10. On physically examining, a distended rigid abdomen was identified with generalized
abdominal guarding and absence of bowel sounds. Results from the pathological investigations
revealed elevated levels of white blood cell (WBC) count and CRP. Reports of blood cultures are
pending. The abdominal X-ray identified an oedematous and gaseous distention of the small and
large bowel. All these signs and symptoms indicated towards the probable diagnosis of
peritonitis after perforated appendix (Schietroma, et al., 2012). It means that Bianca’s appendix
would have developed a tear, which leaked the contents into the rest of the abdomen and led to
severe inflammation of the intestinal lining.
Processing of related health information
Normally, the peritoneum is sterile but when GI tract is perforated, peritonitis develops. It means
that when Bianca developed peritonitis, the peritoneum which is the membrane that lines the
abdominal cavity and covers the visceral organs got inflamed (Pietrangelo, 2017).
Peritonitis usually lowers the intestinal motility and leads to intestinal distention with gas as
observed in Bianca’s case. It is essential that peritonitis is diagnosed at early stage including the
identification of underlying cause and remove it which in Bianca’s case is ruptured appendix.
Steps must be taken to monitor Bianca’s condition regularly and prevent further complications
and infection spread.

Identification and prioritization of three nursing issues
After assessing Bianca’s health data, three nursing issues have been identified and prioritized in
order of their urgency of performance
1. Infection control- Bianca’s peritoneum has been infected which manifested through pain,
nausea, distension and led to leakage. The cause of the infection was possibly the
perforated appendix which led to abdominal leakage. This is the primary cause which led
to this postoperative complication and therefore, it must be addressed on priority basis to
avoid further complications which may prove to be fatal.
2. Centralised abdominal pain- Bianca complained of abdominal pain which on scale scored
7/10. The possible cause of pain is fluid accumulation in peritoneal cavity which was
shown in the X-ray as abdominal distension. Pain aggravated with respiration and
movement and was continually progressing, so management of pain is essential to reduce
Bianca’s suffering and relax her.
3. Deficient fluid volume- Another important aspect is deficiency in fluid volume which is
manifested as hypotension, fever and tachycardia. It could due to shift of fluid from
extracellular, intravascular, and interstitial compartments into peritoneal space
(Bennington-Castro, 2018)
Establishment of goals for priority of nursing care
1. Infection-control- To control infection, the goal would be to attain timely healing through
medical or surgical management as instructed by the doctor and achieve afebrile state.
2. Centralised abdominal pain- Second goal would be relief in reported pain.
3. Deficient fluid volume- Final goal would be to improve fluid balance.

Discussion of the nursing care of the person
1. Infection control- Nurse must check the vital signs timely and make notes of unresolved
or progressing hypotension, tachycardia, fever, tachypnea as these are signs of
impending septic shock which may further deteriorate Bianca’s condition. Nurse must
also check for altered mental state such as confusion or disorientation. It is required as
hypotension, and acidosis may lead to worsening of mental status. Nurse must maintain
strict aseptic regime while caring for abdominal drains, dressings, and invasive sites. She
must cleanse with suitable solution and prevent accessibility or limit the spread of
organisms which may cause infection and cross-contamination. She must provide
assistance with peritoneal aspiration, if needed as it can be performed for removal of fluid
and identification of the causal organisms in order to give relevant antibiotic therapy.
Nurse must also administer antimicrobials. She must also make preparations for surgical
intervention if needed.
2. Centralised abdominal pain- Nurse must assess pain reports, note the location, duration,
severity and characteristics of the pain. It is required as alterations in location or severity
may indicate towards development of complications. Generally pain becomes constant,
more severe, and can be felt over whole abdomen as inflammatory process accelerates
however, localization of pain may occur if abscess develops. Nurse must keep semi-
Fowler’s position, if needed as it would enable drainage by gravity, lower abdominal
pressure and help in lowering pain. Nurse must also offer comfort measures to Bianca
which include massage, deep breathing, instructions for relaxation and visualization
exercises. She can also engage her in diversional activities. These strategies will promote
relaxation and may increase Bianca’s coping capabilities by changing her attention. As

indicates, she must administer analgesics and narcotics which will aid not only in pain
relief but will also promote healing. Since Bianca’s pain is severe, it may need narcotic
control.
3. Deficient fluid volume- Nurse must monitor the vital signs and record the hypotension
levels along with postural changes, tachycardia, and fever. These signs will help in
assessing the level of fluid deficiency or efficacy of fluid replacement therapy and
medicinal response. She must maintain precise I&O and relate with everyday weights.
She must include measured losses and measurements from gastric suction, drains and
dressings. It will indicate the overall hydration state. She must check urine specific
gravity which indicates hydration status and alterations in renal function, which can be a
sign of development of acute renal failure due to hypovolemia and impact of toxins.
Nurse should take care to remove any noxious sights and smells from environment.
Nurse must also investigate and review laboratory studies including Hb, electrolytes,
albumin, BUN, etc. It will give information regarding hydration and functioning of organ.
Due to fluid shifts, hypovolemia, hypoxemia, circulating toxins, and necrotic tissue
products, changes in these reports with substantial outcomes on Bianca’s systemic
function is possible. She must administer plasma or blood, fluids, electrolytes, diuretics
as required as it will restore the circulating volume and electrolyte balance. She must
administer antiemetics which will decrease the nausea and vomiting. It will also help in
pain relief as nausea, vomiting cause increase in abdominal pain. She must administer
antipyretics in order to decrease the discomfort related to fever.

Evaluation of the nursing care strategies
Constant monitoring of pain, fever, blood pressure and electrolytes is essential in Bianca’s
condition to ensure that any developing complication is identified early so that further
deterioration of Bianca’s health can be prevented. Timely administration of analgesics and
antipyretic would help in eliminating the pain and fever which will reduce Bianca’s suffering.
Likewise comfort measures may also prove to be beneficial for Bianca in regaining calm. Strict
aseptic regime would prevent worsening of secondary infection or worsening of Bianca’s
condition. In such situations, it becomes vital that nurse remain calm and provide assistance to
doctor, when indicated.
Reflection on the Bianca’s outcomes and learning
Deterioration of Bianca’s condition was unexpected and could have led to panic, but I told
myself that I need to remain calm in such situation in order to fulfill my responsibilities as a
nurse and be of use to the patient and doctor. It was difficult to prioritize nursing goals for
Bianca as she was in pain, hypovolemic along with leakage. Monitoring of Bianca’s vital signs
and laboratory studies which demonstrated improvement built my confidence. I aimed at
providing holistic nursing care to Bianca based on person-centered care delivery. I put efforts to
build an individualized relationship with Bianca by being more empathetic towards her suffering
(Rogers & Rogers, 2012). I obtained consent from Bianca’s at prior to every session, therapy or
procedure after providing explanation in order to abide by the legal obligations. Furthermore, I
ensured that I involve Bianca at every step of decision-making (Capuzzi & Stauffer, 2016).

Conclusion
Levitt-Jones clinical reasoning cycle is a methodical framework which can help the nurses at
every step of nursing care (Tracy Levett-Jones a, Dempsey, Jeong, & Noble, 2010). In Bianca’s
case study, utilization of clinical reasoning cycle assisted the nurse in decision-making regarding
Bianca’s care requirements. Utilization of cycle also helped the nurse in identifying and
prioritizing the nursing issues of Bianca’s condition. It also helped in care planning, stating the
goals of nursing care, evaluate the outcomes of nurse’s action and finally reflect on the overall
case. So, it can be inferred that utilization of the cycle, minimizes the likelihood of error while
nursing care. Rather it makes nursing care more methodical, evidence-based and holistic.
References
Bennington-Castro, J. (2018, May 30). What Is a Ruptured Appendix? Causes, Treatment, and
Complications. Retrieved from
https://www.everydayhealth.com/appendicitis/guide/appendix/ruptured/
Capuzzi, D., & Stauffer, M. D. (2016). Counseling and Psychotherapy: Theories and
Interventions. John Wiley & Sons.
Levett-Jones, T. (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.
Pietrangelo, A. (2017, December 18). Peritonitis. Retrieved from
https://www.healthline.com/health/peritonitis#symptoms
Rogers, C., & Rogers, N. (2012). CARL ROGERS ON PERSON-CENTERED THERAPY.
Psychotherapy.net.

Schietroma, Piccione, Carlei, Clementi, Bianchi, Vita, d., & Amicucci. (2012). Peritonitis from
perforated appendicitis: stress response after laparoscopic or open treatment. Am Surg.,
78(5), 582-90.
Tracy Levett-Jones a, *. K., Dempsey, J., Jeong, S. Y.-S., & Noble, D. (2010). The ‘five rights’
of clinical reasoning: An educational model to enhance nursing students’ ability to
identify and manage clinically ‘at risk’ patients. Nurse Education Today, 30, 515–520.
doi:10.1016/j.nedt.2009.10.020