Clinical Reasoning Skills in a Patient Scenario Report

This report provides a comprehensive analysis of a clinical patient scenario involving a 33-year-old male admitted for a temporary ileostomy due to Crohn's disease. The report delves into the pathophysiology of acute pain, particularly in the context of post-surgical complications. It outlines three prioritized types of nursing assessments, including focused, admission, and physical assessments, crucial for monitoring and managing the patient's deteriorating condition. Furthermore, the report details three key nursing interventions designed to improve the patient's health, such as comprehensive pain assessments, lifestyle adjustments, and dietary recommendations. It also addresses the administration of morphine for pain management, including patient education on patient-controlled analgesia and potential side effects like respiratory depression and hypotension. The report emphasizes the importance of monitoring vital signs and providing appropriate interventions to improve patient outcomes and quality of life, highlighting the challenges of acute pain management and the need for vigilant healthcare practices.

Application of Clinical
Reasoning Skills
within a Clinical
patient Scenario

Table of Contents
INTRODUCTION...........................................................................................................................3
MAIN BODY...................................................................................................................................3
1.1 Pathophysiology of acute pain..........................................................................................3
1.2 THREE types of nursing assessments in order of priority that would be appropriate for
Tran’s deterioration................................................................................................................4
1.3 Three nursing interventions ti improve health of Tran’s and problems from which he is
suffering..................................................................................................................................5
1.4 Administration of Morphine for Tran’s pain along with explanation of the type of
education to the patient on commencement of the patient controlled analgesia....................6
1.5 Major side effects of intravenous morphine.....................................................................7
Conclusion.......................................................................................................................................7
REFERENCES................................................................................................................................8

INTRODUCTION
Clinical reasoning, also known as clinical judgment, is the process by which clinicians
collect signs, process information, understand the patient's medical situation or problem, plan
and implement appropriate medical interventions, evaluate outcomes, and learn from this entire
process. Present report is based on case study William Tran who has been admitted to the
surgical ward for temporary ileostomy. Report will describe Describe the pathophysiology of
acute pain. It wills also Discuss THREE types of nursing assessments in order of priority that
would be appropriate for Tran’s deterioration
MAIN BODY
1.1 Pathophysiology of acute pain
It has been analysed from the case study that William has past history of Chron’s disease
and is been admitted to hospital for Crohn’s related illnesses including malabsorption and weight
loss. The pathophsiology of Crohn’s related disease can have a life threatening impact on
individual suffering from it. This disease can cause pain in abdominal, fatigue, weight loss, and
nausea. This disease can be cured if detected earlier. It has been analyzed from the case study
that patient has been admitted with temporary ileostomy. This is basically been used to move the
waste out of body (Buvanendran et.al., (2018).. Acute pain basically arises suddenly and the
main reason of this type of pain that it can be caused because of the surgery.
On the other hand chronic pain can be faced by patient for months and usually arises
because of the underlying conditions such as arthritis. Tran’s condition was not well, he has the
problem related to speaking and was unable to move. The medical chart of Tran provided the
details that his body temperature was 35.8. This can be considered as normal. It means that
patient was not suffering from high chills or fever. It was also analyzed that Tran’s pulse rate
was irregular. It was noted at 110 breathe per minute. It is not normal and most of the time pulse
rate over 100 can be considered as dangerous. It means that patient can be at the risk of suffering
from Tachycardia (Schwenk et.al., (2018)..
It has also been analyzed that patient’s blood pressure was low as it was measured at 98/55. This
means that he can also be at the risk of suffering from hypotension. It has also been analyzed that
Tran’s respiratory rate was 6 BPM which was abnormal. The normal rate lies between 12 and 20.

It was also been analyzed that oxygen was been delivered to Tran by making use of Hudson
mask. The medical chart provided the information that SaO2 93% 6Lt oxygen via Hudson mask.
It has also been analyzed that as patient is suffering from the acute pain, he has also been
provided with narcotic analgesia. This pharmacological therapy when provided to patient can
also have certain side effects. It has been analyzed that Morphine 60mg in 60 ml with Normal
Saline 0.9% can cause various other problem such as vomiting, headache, nausea and reduction
in bowel mobility (Kent et.al., (2017). There are several consequences of this narcotic analgesia
on an individual suffering from acute pain. Opioids are been used in order to relive the acute pain
which has been caused because of the surgical process (John and et.al., 2019).
1.2 THREE types of nursing assessments in order of priority that would be appropriate for Tran’s
deterioration
It has been analysed that in order to improve the health outcome of Tran various type of
nursing assessment will be used. This includes the following:
Focused assessment: It is a detailed nursing assessment which can be used by nurses in
order to analyse the current and past health related problem of the patient. In this nurses will be
engaged in doing Tran’s comprehensive neurological assessment. They will be engaged in
analysing the patient’s capabilities to verbal response. Nurses will also check their mobility, arm
and leg movement (Bliss et.al., (2016). It has been analysed from the report that patient was
unable to speak and also had difficulty in moving. Neurological assessment is really important in
this situation. Nurses will also be engaged in monitoring the respiratory system. They will be
involved in monitoring for oxygen saturation, tracheal position Respiratory rate. It has been
analysed that Trans’ respiratory rate was abnormal. Nurses will also be engaged in doing
cardiovascular assessment in order to analyse the problem faced by Tran.
Admission Assessment: In this type of assessment registered nurses will be engaged in
analysing and discussing the past medical history of patient. Case study has provided us with the
details that Tran has the medical history for Chron’s disease and is been admitted in hospital for
several times because of it (Helander et.al., (2017).. Nurses will also be engaged in assessing
patient’s behavioural, emotional and physical position. They will analyse their relevant past
history and allergic considerations. It was been analyse from the case study that Tran was also
been provided with narcotic analgesia for acute pain. Nurses will also be engaged in monitoring
the vital signs of patient.

Physical assessment: Registered nurses will also be engaged in analysing the physical
appearance of patient while admitting them to surgical ward. In this systematic approach will be
used by the nurses in order to analyse the problem of patient. They will be involved in making
Tran comfortable so that he can easily communicate the problem which has been faced by him.
This will assist nurses in enhancing the health outcome of patient (Eipe, Gupta & Penning,
(2016). They will also be engaged in asking the family about the problem faced by patient.
1.3 Three nursing interventions to improve health of Tran’s and problems from which he is
suffering
In the case of Tran who is 33 year old male it is stated that he is admitted for temporary
ileostomy to the surgical ward, So, from this it can be said that body part of this patient is
damaged and needs to remove or amputee and at the end of the cut, it is diverted to an artificial
opening in abdominal wall. In further investigation it is also analysed that this patient has a past
history of crohn’s disease. For solving this problem he was hospitalized because it was affecting
its body as weight loss. So, the main problem from which he is suffering is acute pain due to the
surgery and past history It is important to provide him effective healthcare services which may
include:
1. Performing a comprehensive assessment of pain which include characteristics , duration
of pain frequency, quality, severity of pain, intensity and others.
It can be considered one of the best nursing intervention in which nurse tries to identify all
factors which are associated with the by knowing duration and intensity of the pain. One of the
main aims of using this nursing intervention, knowing about patients’ pain, interacting with him
and making him feel comfortable is acute pain is a subjective experience and before giving high
dose of medicines, it is important to solve the problem at their own (Shah and et.al., 2017).
Without making use of medicines or heavy dose of medication, nurse can decrease pain of the
patient to some extent because it is a psychology of people as how much they think about the
pain, pain increases Dailey, (2017). So, changing psychology and making patient believe that he
will be alright is the main intervention.
2. Suggesting to the patient to wear loose clothing, to stop taking aspirin and using
loperamide, codeine and morphine sulphate to some extent.
One of the main reasons of suggesting about wearing loose cloths, not to consume alcohol and
taking healthy diet can increase immune of the patient and make him feel comfortable. Aspirin

and other medicines taken before surgery can have several and severe side effects on the body
after some times so preventing the patient is one of the main reason of suggesting this. lope
amide, codeine and morphine sulphate can help the patient in increasing blood level and also
reduce side effects pf other medication along with decreasing acute pain.
3. Discussing about possible need to decrease salt intake.
One of the reason is salt can increase ileal output as well as risk of dehydration. So, making
patient heal improve it is important for him to reduce salt intake Seres & Gonzalez, (2019).
1.4 Administration of Morphine for Tran’s pain along with explanation of the type of education
to the patient on commencement of the patient controlled analgesia
It is stated that patient is being given and prescribed Morphine with a continuous infusion rate of
3ml/hr. It is considered as an effective dose but on the flip side it has side effects. This medicine
is being given to the patient by injection into a vein, muscle and under the skin (Drake and
Williams, 2017). In this context, it can be said that given dose depend upon the weight and
intensity of the disease and as per the type of disease and weight of the patient which is 55kg,
given dose of this medicine is somehow ok. But it can be said that stopping to use this medicine
immediately can cause several problems for the patient Murphy, P. B., & Barrett, M. J. (2019). It
may improve health of the patient and relief pain but continuous dose can create several
problems which include:
Respiratory depression, headache, urinary retention. miosis, hypotension etc. One of the main
effects which this medicine and taking continuous dose of morphine can have is respiratory
effects.
Contradictions
Contradiction to this is same for as intravenous morphine which is acute bronchial
asthma, obstruction and other etiologic of severe hypotension. This morphine use requires
cautions in the patient with injuries. Miosis from this medicine may interfere with the monitoring
as well as diagnosis of pathology. It may also create problems of tension which can create other
problems like diabetes, heart disease and others. High and continuous dose of this medicine can
be worst for the patient after sometimes. It can help patient in decreasing pain and improving
health only when it takes this medicine but gradually it has adverse impacts on the body which
lasts for the long run Hein, A. (2018). Morphine continuous use also requires caution in patients
who have decreased respiratory reserve, obesity and it is stated that patient is suffering from

weight loose and this continuous dose can be harmful to some extent. Elimination half-life may
be prolonged in patients with reduced metabolic rates (Mello and et.al., 2016).
1.5 Major side effects of intravenous morphine
Intravenous morphine is been provided to patient in order to treat acute pain which has been
faced by Tran because of temporary ileostomy. It has been analysed that this medication can
cause problems such as nausea, vomiting, constipation, dizziness (Zaccagnino et.al., (2017). It
can reduce the health outcome of Tran and also can reduce their quality of life. Health care
professional needs to be considered when there are changes in skin, pain, redness or swelling.
The doze related Morphine must be taken by patient only after consulting pharmacist or health
care professional (Reid et.al., (2017). It has also been analysed that while consuming this
medication Tran must not be involved in taking alcohol. This can cause severe side effect. It can
lead to reduction in bowel movement, constipation worsening the health outcome of patient.
There are various precautions which can also be taken when in-taking these medications. Patient
needs to tell health care professionals about if he is allergic to certain type of medication (Gilron
et.al., (2019).
Conclusion
From the above study, it has been summarised that patient has been suffering from acute pain
which can be because of the temporary ileostomy faced by Tran. It has also been analysed from
the report that Tran was also suffering from Chron’s disease. The temperature recorded of Tran
while admitting to surgical ward was normal. Various interventions has been used by nurses in
order to enhance the health outcome of patient. They have made use of evidence based approach
so that health outcome of patient is been improved.

REFERENCES
Books & Journal
Bliss, T. V., Collingridge, G. L., Kaang, B. K., & Zhuo, M. (2016). Synaptic plasticity in the
anterior cingulate cortex in acute and chronic pain. Nature Reviews Neuroscience, 17(8),
485.
Buvanendran, A., Kroin, J. S., Rajagopal, A., Robison, S. J., Moric, M., & Tuman, K. J. (2018).
Oral ketamine for acute pain management after amputation surgery. Pain
Medicine, 19(6), 1265-1270.
Dailey, M. (2017). Promoting quality outcomes: keeping patients safe and promoting quality
outcomes. wound, ostomy, and continence care management [editorial]. Patient Saf
Qual Healthc. Patient Saf Qual Healthc.
Drake, G. and Williams, A.C.D.C., 2017. Nursing education interventions for managing acute
pain in hospital settings: a systematic review of clinical outcomes and teaching
methods. Pain Management Nursing. 18(1). pp.3-15.
Eipe, N., Gupta, S., & Penning, J. (2016). Intravenous lidocaine for acute pain: an evidence-
based clinical update. Bja Education, 16(9), 292-298.
Field, J. J., Ballas, S. K., Campbell, C., Crosby, L. E., Dampier, C., Darbari, D. S., ... &
Zempsky, W. T. (2019). Analgesic, anesthetic, and addiction clinical trial translations,
innovations, opportunities, and networks–American Pain Society–American Academy of
Pain Medicine Pain Taxonomy Diagnostic Criteria for Acute Sickle Cell Disease
Pain. Journal of Pain.
Gilron, I., Carr, D. B., Desjardins, P. J., & Kehlet, H. (2019). Current methods and challenges for
acute pain clinical trials. Pain reports, 4(3).
Hein, A. (2018). Pain relief during labour and following obstetric and gynaecological surgery
with special reference to neuroaxial morphine. Inst för kliniska vetenskaper, Danderyds
sjukhus/Dept of Clinical Sciences, Danderyd Hospital.
Helander, E. M., Menard, B. L., Harmon, C. M., Homra, B. K., Allain, A. V., Bordelon, G. J., ...
& Kaye, A. D. (2017). Multimodal analgesia, current concepts, and acute pain
considerations. Current pain and headache reports, 21(1), 3.
John, E.B. and et.al., 2019. Acute Pain. In Academic Pain Medicine (pp. 167-175). Springer,
Cham.
Kent, M. L., Tighe, P. J., Belfer, I., Brennan, T. J., Bruehl, S., Brummett, C. M., ... & Edwards,
D. (2017). The ACTTION–APS–AAPM Pain Taxonomy (AAAPT) multidimensional
approach to classifying acute pain conditions. Pain Medicine, 18(5), 947-958.
Mello, B.S. and et.al., 2016. Applicability of the Nursing Outcomes Classification (NOC) to the
evaluation of cancer patients with acute or chronic pain in palliative care. Applied
Nursing Research. 29. pp.12-18.
Murphy, P. B., & Barrett, M. J. (2019). Morphine. In StatPearls [Internet]. StatPearls Publishing.
Reid, J., Scott, E. M., Calvo, G., & Nolan, A. M. (2017). Definitive Glasgow acute pain scale for
cats: validation and intervention level. Veterinary Record, 108(18).
Schwenk, E. S., Viscusi, E. R., Buvanendran, A., Hurley, R. W., Wasan, A. D., Narouze, S., ... &
Cohen, S. P. (2018). Consensus guidelines on the use of intravenous ketamine infusions

for acute pain management from the American Society of Regional Anesthesia and Pain
Medicine, the American Academy of Pain Medicine, and the American Society of
Anesthesiologists. Regional Anesthesia & Pain Medicine, 43(5), 456-466.
Seres, M., & Gonzalez, K. A. S. (2019). U.S. Patent Application No. 16/263,555. Murphy, P. B.,
& Barrett, M. J. (2019). Morphine. In StatPearls [Internet]. StatPearls Publishing.
Shah, K. and et.al., 2017. Durapain in symptomatic treatment of severe acute pain: a post-
marketing, prospective, multicenter, observational study–PRIME study. Journal of pain
research. 10. p.1273.
Zaccagnino, M. P., Bader, A. M., Sang, C. N., & Correll, D. J. (2017). The perioperative surgical
home: a new role for the acute pain service. Anesthesia & Analgesia, 125(4), 1394-1402.

1

3