NRSG370 Case Study: Clinical Reasoning Cycle and Peritonitis Care

This case study, prepared for the NRSG370 Clinical Integration course, examines the case of a 20-year-old woman, Bianca Lane, admitted with peritonitis following a perforated appendix. The assignment applies the Clinical Reasoning Cycle to assess Bianca's condition, including her vital signs, symptoms (abdominal pain, nausea), and medical history (depression and asthma). The analysis identifies key issues: elevated CRP, abnormal vital signs (hypotension, tachycardia, tachypnea), and abdominal pain. The student establishes goals to reduce infection, manage pain, and normalize vital signs. Actions include antibiotic administration, pain management with opioids and antispasmodics, and interventions to manage abnormal vital signs. The effectiveness of the care plan is evaluated by monitoring vital signs, pain levels, and CRP. The reflection highlights the importance of clinical reasoning in nursing and the need for patient-centered care. This assignment is a comprehensive application of the Clinical Reasoning Cycle in a real-world clinical scenario, demonstrating the student's understanding of patient assessment, planning, intervention, and evaluation within the context of a peritonitis case.

Running head: ESSAY
NRSG370 – Clinical Integration - Speciality Practice
Student Name:
Student ID Number:
Speciality Area:
Scenario:
Total number of words:

1ESSAY
Introduction- Person-centred care refers to the process of thinking and performing
things that considers individuals who seek health and social care services as equal partners in
formulation, development, and monitoring of care. Clinical reasoning cycle encompasses the
process where nursing professionals and allied medical practitioners gather indications,
conduct data processing, and comprehend the issues that are faced by their patients (Levett-
Jones et al., 2010). This essay will be based on the eight stages of clinical reasoning cycle for
evaluating a case study that involves a 20 year old woman, Bianca Lane.
Situation- Bianca Lane had been admitted to the Emergency department based on her
presenting complaints of lower quadrant abdominal pain. A thorough and comprehensive
physical examination revealed a perforated appendix in ultrasound diagnosis and necessitated
immediate laproscopic surgical intervention. 36 hours after the operation, her vital signs are
blood pressure of 94/45 mm Hg, heart rate 136, body temperature of 38.5° C, and respiratory
rate of 24 breaths/minute. Some of her presenting complaints include nausea, feelings of
bloated, and centralised abdominal pain that increases with movement (pain score 7/10).
Moreover, a distended right abdomen has also been identified from the physical examination,
with no bowel sounds.
Process information- Peritonitis refers to inflammation of the peritoneum tissue that
lines the inner abdominal wall, thus providing covering and support to the internal organs.
Some common signs and symptoms of peritonitis are namely, fever, feeling of distention or
fullness in abdomen, tenderness, diarrhoea, vomiting and nausea, and low urine output
(Ndayizeye et al., 2016). According to Wang et al. (2018) if left untreated, inflamed appendix
subsequently perforates or bursts, thus leading to the spillage of infectious substances in the
abdominal cavity, and causing peritonitis. A perforation in the appendix might result in entry
of bacteria in the peritoneum through pores in the gastrointestinal tract, thus explaining her
health status. An analysis of her vital signs suggest that Bianca is hypotensive, tachycardic,

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and febrile. Moreover, her respiratory rate also demonstrated signs of tachypnoea. Bianca
reports a history of depression and asthma. Tachypnoea can be attributed to her asthmatic
condition since asthma leads to narrowing of the airways located in the lungs, thereby leading
to imbalance in ventilation perfusion, and increasing the work of breathing (Radhakrishnan &
Almaddah, 2017). This might have eventually resulted in fatigue of the ventilator muscles.
Bianca’s current medications comprise of sertraline, seretide, and salbutamol. While
sertraline is a selective serotonic reuptake inhibitor and used for the management of
depression, anxiety, panic or obsessive compulsive disorder, seretide is administered for the
treatment of asthma and is a combination of inhaled corticosteroid and long- acting β2
agonist (Fann et al., 2017; Bender et al., 2016). Likewise, salbutamol is also used for opening
up the large and medium airways, particularly for the treatment of asthma (Bennett et al.,
2019). An analysis of Bianca’s pathological examination revealed elevated WBC count and
CRP. While high WBC count indicates functioning of the immune system for destroying an
infection, elevated CRP level acts as a marker of inflammation, thus increasing the risk of
heart attack.
Prioritisation- On thoroughly analysing the case study, the three major problems
identified were namely, (i) increased CRP as a result of bacterial infection, (ii) abnormalities
in vital signs as a result of peritonitis, and (iii) abdominal pain as a result of laparoscopic
surgery.
Often it has been found that CRP levels demonstrate an increase during the initial
week after a significant surgery, nonetheless to a larger extent amid infected patients, when
compared to their non-infected counterparts (Shrivastava et al., 2015). Persistently increased
CRP following a surgery demonstrates the onset and progress of postoperative infection, and
damage of tissues. It has also been found by researchers that people with increased CRP
levels demonstrate a greater likelihood of having a heart attack, than those with decreased

3ESSAY
CRP (Ridker, 2016). Thus, with the aim of reducing infection rate and protecting Bianca
from cardiovascular complications, her CRP needs to be decreased. Vital signs have also
been identified as a significant component of patient care since they facilitate determination
of the treatment protocols that need to be followed, and also provide important information
required for making life-saving clinical decisions (Bonnez et al., 2019). Owing to the
importance of documented and accurate vital signs in nursing, presence of abnormalities offer
a clear indication of clinical deterioration. Thus, the vital signs must be normalised in order to
ensure patient health and safety. Additionally, postoperative pain has a range of components
such as, hyperalgesia at the site of incision, central neuronal sensitisation, and local ischemia
(Rawal, 2016). Poorly managed pain following a surgery often results in prolonged
rehabilitation and other complications. Moreover, it is also correlated with a reduction in the
quality of life. Not only does appropriate relief from pain shorten the length of
hospitalisation, but also decreases healthcare associated costs, besides increasing patient
satisfaction. Hence, another priority would be to decrease the severity of abdominal pain
reported by Bianca.
Establishing goals- Goals of care refer to the objectives behind care of a patient, as
agreed between the patient, carers, family members and healthcare team. Discussing about
goals of care is imperative under circumstances when patients suffer from serious or life-
threatening illnesses, and encompass involving and informing the patients in the entire
process. The primary goal in this case scenario is to avert further deterioration of Bianca’s
health condition. The first goal would encompass reducing the level of elevated CRP thus
helping in cardiovascular risk reduction. The second goal would focus on decreasing
abdominal pain and providing comfort to the patient. Owing to the fact that improving patient
safety helps in minimising harm caused to them and saves health costs, it is imperative to
immediately identify and respond to the worsening clinical symptoms of the patient (World

4ESSAY
Health Organization, 2017). The third goal would be to rapidly evaluate and treat Bianca with
unanticipated clinical deterioration that are predominantly characterised by a deterioration in
the vital signs. This will help in decreasing chances of cardiac and/or respiratory arrest and
also enhance patient outcomes.
Take action- With the aim of restoring CRP levels to normal values, the first action
would comprise of administration of antibiotics to the patient. Some of the most common
antibiotics that can be used for the purpose are namely clarithromycin, doxycycline, and
azithromycin. Clarithromycin will decrease CRP levels by working in the form of a protein
synthesis inhibitor, and will eventually prevent multiplication of bacteria. Its binding to the
23s rRNA will lead to peptide translation inhibition (Moj et al., 2017). Likewise, bacterial
protein synthesis will also be inhibited by doxycycline by its binding to the 30s ribosomal
subunit. This drug will exert its bacteriostatic activity and decrease the CRP levels
(Chukwudi & Good, 2019). Similarly, bacterial growth will be prevented by azithromycin,
which will also interfere with the process of protein synthesis (Jelić & Antolović, 2016). The
successful relief of pain is of prime significance to any patient who has been subjected to a
surgery. Taking into consideration the fact that pain relief exerts important physiological
benefits, it is imperative to monitor the relief during postoperative stages.
Relief from abdominal pain can be provided by both pharmacological and non-
pharmacological means. The mainstay of postoperative management of pain is administration
of opioids. Bianca will be administered opioids that will bind to receptors located in the
central nervous system and exert an impact on the influence of nociceptors. The opioids
fentanyl and hydromorphone can be administered in this case scenario. Both the
aforementioned drugs are morphine derivatives and have a lesser onset of action. The drugs
will act as mu-selective opioid agonists. Activation of the kappa and mu-receptors will
eventually generate analgesia (Schug & Ting, 2017; Bernstock et al., 2016). However, opioid

5ESSAY
administration might result in respiratory depression thus causing respiratory arrest and
hypoxia. Therefore, Bianca must be monitored at regular intervals during the postoperative
period. Another plan of care that would help in reducing pain severity is administration of
antispasmodics. Also referred to as anticholinergics, this group of drugs will exert action on
the acetylcholine neurotransmitter and block it, thereby preventing the transmission of
impulse from the parasympathetic nervous system to the smooth muscles. This in turn will
prevent the occurrence of any cramps, spasms or contractions in the abdomen (Stanos, Yang
& Aronoff, 2016). One non-pharmacological interventions that will be administered for
management of pain is heat therapy. Heat therapy will be applied using hot water bottle or
hydrocollator packs and will increase blood flow, thereby reducing inflammation and pain
and relieving spasms (Passmore & Gold, 2019).
In order to manage the abnormal vital signs, Bianca will be administered ipratropium,
together with her current medications that will open up the lung airways and prevent shallow
and rapid breathing (Saab & Aboeed, 2019). Moreover, she will also be subjected to anti-
arrhythmic medication like flecainide that will help in restoring her heartbeat. This drug will
block the Nav1. 5 sodium channel, thereby decreasing cardiac action potential upstroke and
reducing electrical impulse conduction within the heart (Amarouch et al., 2016).
Acetaminophen will act as both antipyretic (decrease fever) and analgesic (reduce pain) by
decreasing prostaglandin production in the brain. It will also reduce the elevated body
temperature by exerting its action on the brain’s heat regulating centre (Young et al., 2015).
Bianca will also be advised to drink more water and fluids for preventing dehydration and
will be prescribed medication like fludrocortisone that will constrict the blood vessels and
increase the blood volume, thus managing hypotension (Veazie et al., 2017). Regular
monitoring of her vital signs is also essential for detecting any changes in health status.

6ESSAY
Evaluation- Effectiveness of the care plan can be assessed by observing the vital signs
of the patient. Presence of normal body temperature, blood pressure, pulse and respiratory
rate will prove efficacy of the medications. A pain severity less than 4 and decreased level of
CRP will also characterise relief from pain and absence of inflammation.
Reflection- While reflecting on the case scenario, I comprehended that nursing is a
challenging profession and requires extreme commitment and dedication. I realised that
clinical reasoning cycle forms a core component of nursing profession since it helps in
determining the patient outcomes. I understood that poor clinical reasoning skills would lead
to a failure in delivering satisfactory and accurate healthcare to patients like Bianca who
suffer from perforated appendix and peritonitis. In future practice, I would like to address the
issues of elevated WBC as well, in order to enhance patient outcomes.
Conclusion- Depending on patient outcomes, nursing professionals plan and
implement interventions, followed by assessment of the outcomes, and reflecting on the
entire process. Peritonitis typically occurs owing to a fungal or bacterial infection and might
also occur due to perforation or rupture of the abdomen. The reasoning cycle identified three
issues of elevated CRP, abnormal vital signs, and severe abdominal pain, and proposed a plan
of care for addressing the issues.

7ESSAY
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