Clinical Reasoning and Nursing Care: Inguinal Hernia Repair Case Study

This case study presents the nursing management of a 67-year-old male, Mr. Peter Ling, who underwent an open mesh inguinal hernia repair and developed a post-operative wound infection. The assignment utilizes the clinical reasoning cycle, encompassing patient assessment, cue collection, information processing, problem identification, goal establishment, intervention planning and implementation, outcome evaluation, and reflection. The assessment reveals that Mr. Ling, who is obese, hypertensive, and has mild congestive heart failure, presents with a fever, tachypnea, hypertension, and a wound with purulent discharge, along with confusion and pain. The analysis identifies ineffective breathing, impaired tissue integrity (wound infection), and acute pain as priority nursing diagnoses. The goals are to improve breathing, reduce wound size and promote healing, and manage pain. Nursing interventions include proper body alignment, encouraging deep breaths, observing aseptic techniques during wound care, providing rest, and administering analgesics. The evaluation shows initial pain relief but persistent wound infection, necessitating antibiotic administration. The assignment concludes with a reflection on the importance of aseptic techniques and the use of the clinical reasoning cycle in providing holistic patient care.

Student’s name;
Institutional affiliation;

INTRODUCTION.
Open mesh inguinal hernia surgical procedure is a procedure that includes any of the three
procedures; Herniotomy, hernioplasty or Herniorrhaphy. The assignment describes A case
scenario of a 67-year-old man Mr Peter Ling, currently admitted to the surgical ward following
an open mesh inguinal hernia repair. Despite having started with reasonable progress post-
surgical, he later developed signs of wound infection on his second day postoperatively. The
assignment will make use of clinical reasoning cycle where the following processes will follow
sequentially. The patient will be considered; the cues will be collected; followed by information
collection and processing. The patient's problem will then be understood, planning of the
interventions and implementation, outcome evaluation and finally, a reflection from the process.
The assignment will, therefore, help the reader understand the use of clinical reasoning cycle in
managing the same case scenarios.
CONTENT
Consideration of facts from the patient/situation.
Mr. peter Ling was brought to the surgical ward for post-operative nursing management; he
underwent an open mesh inguinal hernia. He has been showing excellent progress till day
postoperatively, he has started showing signs of post-surgical wound infection. He is restless and
confused about time and place. His post-operative surgical wound dressing is oozing green
purulent discharge, and the wound is tender to touch. He had visited the emergency department
with a 6-hour history of an R non-reducible tender, inguinal mass, and post commencing a new
gym regime. He is retired, besides, he currently lives with his wife. He is obese with a BMI of
30, an ex-smoker and an ex-weight lifter. He has hypertension and hyperlipidemia disorders;

however, he is currently on medication to control the conditions, and they are both controlled
well. Besides, he has mild congestive heart failure.
Collection of cues.
Information collected during the assessment includes objective and subjective data. The
objective data collected include BMI of 30, a temperature of 39.3 degrees Celsius, respiratory
rate of 25 breaths per minute. A heart rate of 100 beats per minute. Systolic blood pressure of
170/90 mmHg. Hemoglobin of 16.5gm/dl. He also has 95% SPo2 level and a Glasgow coma
scale of score 14/15. Surgical wound dressing oozing green purulent discharge and tender to
touch was also noted. Plus, an increase in white blood cell count. His left calf seems bigger than
the right one, has a clear chest and a dry skin. The information provided by the patient (Mr Peter)
includes a history of hypertension and hyperlipidemia, pain of score 7/10, history of being an Ex-
smoker and ex weight lifter.
Processing gathered information.
The BMI of 30 is an indication of Mr Peter being obese. He has hyperthermia with a temperature
of 39.3 (it is above 37.5 degrees Celsius). Mr Peter is tachypneic, his respiratory rate of 25
breaths per minute is above the normal range supposed to be 12 to 20 breaths in a minute. He is
hypertensive with a heart rate of 100 beats in a minute. The heart rate is alarming in as much as it
is within the normal range of 60-100 breaths in a minute. He has a high blood pressure with a
systolic pressure of 170 mmHg which is above the normal range of 100 to 120 mmHg. Besides,
he has a higher diastolic pressure of 90mmHg, which us more elevated than the normal range of
60-80 mmHg. He has normal but alarming SpO2 levels despite being within the normal ranges of
95-100%. Pain Rating Scale usually used by the nurses and other healthcare professionals to

understand certain aspects of patient's pain better gives Mr Peter's pain a score of 7/10. Such a
pain score is considered very severe that requires immediate management to make Mr Peter
comfortable. He has a Glasgow coma scale of 14/15 in which the Best verbal response is given a
score of 4/5 since he is confused to time and place during the assessment (Teasdale et al., 2014).
The post-operative surgical wound dressing oozing green purulent discharge is a sign of wound
infection (Harrington, 2014). Wound infection can also be confirmed by the increase in white
blood cell count — an indication of recruitment of Neutrophils to phagocytose the microbes
causing the surgical wound infection.
Performing surgery on someone leads typically to an acute dermal wound. Normally the
cutaneous wound should progress well and heals with time. But this may not be the case,
especially when infection kicks in. Aerobic or anaerobic bacteria and fungal strains colonize the
dermal wound forming microbial communities (Bertesteanu et al., 2014). The bacteria can
originate from the skin surrounding the incision site or from an external environment; including
unsterile surgical instruments used during the surgical procedure. And, failure in observing septic
techniques, including thorough handwashing before handling the incision site. Failure in
maintaining a clean working area during wound care cleaning (Megeus et al. 2015). During
wound infection, the polymicrobial film delays the process of wound healing. Overwhelmed
natural body defence mechanism by the virulence microorganisms, i.e. bacteria and fungi lead to
wound infection (Weiss & Schaible 2015). The body’s immune system will then respond by
inducing inflammatory process and damaging the infected tissues.
After the virulence microorganisms have invaded the tissue through the incision site, they injure
the viable tissues surrounding the incision site. The cells that have been damaged, therefore,
produces chemicals in response (Artis & Spits, 2015). Such chemicals include bradykinin,

histamine and prostaglandins (Artis & Spits, 2015). These chemicals recruit more white blood
cells into the incision site, thus increasing the white blood cell count in return. The produced
prostaglandin also leads to pain at the incision site. Pain rated as 7/10 by Mr. peter, making him
uncomfortable and agitated. The infection makes this exudate abnormal and becomes purulent
with a green colouration.
Problem identification.
The ABCDE assessment tool will be used in prioritizing the assessed cues to help in prioritizing
implementation of the prioritized interventions derived from prioritized cues. It involves
assessment done on airway patency, breathing normality, blood circulation, disability and
exposure (Kram et al., 2015).
Peter has an ineffective breathing pattern related to decreased energy and pain as evidenced by
tachypnea and change in respiratory rate (Gordon, 2014; Gulanick & Myers, 2016). Impaired
tissue integrity related to the open mesh inguinal hernia repair (health condition) as evidenced by
the signs of wound infection. According to Doenges et al. (2016), impaired skin integrity means
the destruction of the mucous membrane, skin or the subcutaneous tissue. The third nursing
diagnosis is acute pain related to the actual tissue damage during the surgical procedure as
evidenced by patient complaining of pain 7/10 and patient agitation (Gordon, 2014).
Establishing goals.
Ineffective breathing pattern is managed to bring the following outcome; Mr Peter will maintain
an effective breathing pattern throughout the entire time he will be in the clinical setting. This
should be evidenced by relaxed breathing, a respiratory rate remaining within the established
limits; 16 to 20 breaths in a minute for an adult (Caruana et al., 2015). Mr Peter will report

feeling rested each day throughout his hospital admission time. The goals for impaired tissue
integrity include; a decrease in Mr Peter's wound size and increased granulation tissue in two
days of nursing interventions implementation (Gulanick& Myers, 2016). Mr Peter will be in a
position of explaining the features of a healing wound and protection of the infected wound. The
goals for acute pain include, Mr. peter will describe satisfactory pain control to a level of less
than three on a rating of 0 to 10. That Mr Peter will display improvement in mood coping two
hours after implementation of interventions for acute pain.
Taking action.
The following nursing interventions for ineffective breathing pattern are considered. Mr Peter is
placed in with proper body alignment. The rationale for this is that this kind of sitting position
permits maximum lung excursion (Gulanick & Myers, 2016). The patient is encouraged to
sustain deb breaths by utilizing incentive spirometer or requiring the patient to yawn.
Encouraged sustained breaths aid in slowing respiration in patients who are tachypneic (Mr
Peter). The nursing interventions for impaired tissue integrity include observing aseptic
techniques during wound dressing and wound caring done by teaching Mr Peter and his family
on the importance of aseptic techniques while caring for his wound. This can be implemented by
ensuring that anyone visiting the patient performs thorough handwashing to prevent the risk of
asepsis (Cohen et al., 2012). The second intervention is ensuring that the nurse observes aseptic
techniques during wound dressing and inspect the surgical site at least once in a day. Application
of aseptic techniques reduces the chances of bacterial infection at the incision site (Lynn, 2018).

Nursing interventions for pain include providing rest periods to promote relief, sleep and
relaxation. Pain may lead to fatigue and lead to exaggerated pain. A peaceful and quiet
environment, therefore, may facilitate rest (Gulanick & Myers, 2016). The second nursing
intervention is administering non-opioids, such as Aspirin. These medications block the
synthesis of prostaglandins that are responsible for stimulating nociceptors (Gulanick & Myers,
2016).
Evaluation and reflection.
Two hours after the administration of the non-opioid analgesic (Aspirin), Mr. peter rates the pain
as 4/10. The intervention is therefore effective and goal met. However, it could have been better
if COX 2 selective non-opioid analgesic was used to manage the acute pain. This is because
COX 2 selective NSAIDS have minimal side effects as compared to the non-selective cox
inhibitors (Katzung, 2017; Rang, 2014). Implementation of the nursing interventions for
ineffective breathing pattern is effective as it has resolved the issue. Two days after application
of the aseptic techniques and a thorough wound cleaning but still, the exudate is still abnormal.
The wound has increased in size. Antibiotics are to be administered to manage and prevent
further bacterial infection (Najjar & Smink, 2015). Sterility should have been observed during
the intraoperative phases and post-operatively to prevent an invasion of the microbes through the
incision site (Allegranzi et al., 2016; Famakinwa et al., 2014).
Conclusion.
Concluding, the assignment has applied the use of clinical reasoning cycle consistently. A
description of the case scenario has been done; information has been collected through physical
assessment and clinical assessment. Analysis of the information is done, problems identified, and

goals established. The action was taken to implement the nursing interventions of the identified
nursing problems. Lastly, the evaluation of the outcome is done to check on the prognosis and
reflect on what is to be done in a different way to bring effective results.

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