Nursing: Clinical Reasoning Cycle Application in Post-op Pain Care

This report employs the clinical reasoning cycle to address post-operative pain in a 38-year-old patient, Lisa, who underwent emergency surgery for a perforated bowel. The primary problem identified is intractable post-operative pain, which was inadequately managed with fentanyl PCA. The goal of care is to minimize Lisa's pain through effective pain management strategies. Nursing interventions include thorough documentation, escalating analgesics to morphine, employing multimodal analgesia, and providing patient reassurance. Frequent monitoring of pain levels and vital signs is crucial. The report emphasizes the importance of addressing pain to prevent chronic conditions and improve patient outcomes. The clinical reasoning cycle guides the assessment, planning, intervention, and evaluation of care to ensure adequate patient management and achieve the desired goal of pain reduction.

RUNNING HEAD: CLINICAL REASONING IN NURSING CARE 1
CLINICAL REASONING CYCLE IN NURSING CARE
Students name
Institutional affiliation

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The clinical reasoning cycle involves collecting cues and information regarding the
patient, processing, and interpreting the information with a view of prioritizing relevant and
irrelevant information, identifying the problem and a definitive diagnosis, setting goals of care,
taking action to remedy the problem, and evaluating the outcomes (LeMone et al, 2011). The
present paper will focus on the use of the clinical reasoning cycle in the approach to patient
management.
Cues and patient information
Lisa is a 38-year-old athlete who presented to the emergency department with acute
abdomen. A diagnosis of perforated bowel due to suspected diverticulitis was made and
emergency surgical repair done. In the ward, she had intractable pain despite being on patient-
controlled anesthesia (PCA) with fentanyl. Pain was relieved by intrawound catheter anesthesia
to 2/10 but it soon increased to 7-8/10. On assessment her pain was at 6/10 and increasing. Her
abdomen was tender to touch. She also had short periods of atrial fibrillation.
Identification of the problem
The main problem with Lisa is post-operative pain. This can be rationalized from her
history showing intractable pain in the ward after her laparotomy for repair of perforated
abdomen. Her pain was severe to 7-8/10 and was not being relieved by fentanyl PCA. On
assessment her pain was still severe at 6/10 and was increasing. With inadequate pain
management she could end up developing chronic pain, lengthen her hospital stay, and worsen
her psychological status due to anxiety and feeling of helplessness (Livingstone, 2012).
Goals of care

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The main nursing care goal in Lisa’s case is to reduce her pain to a minimum by
appropriate pain management. Aim to reduce her pain to below 2/10 on a verbal rating scale.
Nursing care
The first nursing action is thorough documentation of the findings of the assessment,
changes and any actions taken. According to Blair & Smith, (2012), in nursing something not
documented is not done. This is for competency, continuity and quality assurance. It will also
facilitate a smooth handover once the shift is done.
Choice of an effective analgesic is paramount in refractory pain (Chou et al, 2015). Lisa
is currently on fentanyl PCA and boluses, paracetamol, tramadol and ropivacaine. Changing the
medication with consultation with Lisa’s primary care physician could be helpful (Byrne et al,
2017). A stronger opioid for example morphine should be started. Use of multimodal analgesia
should be employed as it maximizes the effects of narcotics while minimizing the side effects
(Ahmed, Latif, & Khan, 2013). This will ensure adequate pain management.
Patient reassurance is as important as drug therapy in pain management. The patient
should be reassured to alleviate anxiety and hopelessness (Traeger, Hübscher, Henschke,
Moseley, Lee, & McAuley, 2015). According to Pincus et al, (2013) patient education and
reassurance was shown to help in pain alleviation as they reported satisfaction with management.
Patient monitoring should be done as frequently as possible with pain measurement using
verbal rating scale to measure outcomes of medication change, monitoring of blood pressure,
respiratory rate and heart rate as they are all affected by pain. Due to pain, patient’s mobility is
limited and they may develop pressure sores. Encouraging mobility and use of pressure friendly
beddings is helpful in this regard.

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In conclusion, using the clinical reasoning cycle identified post-operative pain as the
main problem. The goals of care were aimed at alleviating the pain by nursing care strategies.
Nursing care included documentation, monitoring pain scale and vitals, escalating narcotics used
to morphine, employing multimodal analgesia and patient reassurance. These strategies should
ensure adequate patient care according to the goal of care.

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