Clinical Reasoning Cycle - Nursing Assessment Answers

Introduction

 

In the given assessment, the clinical reasoning cycle has been used to explain the pathophysiology and causes behind the wound status of Mrs. Gina who underwent an amputation surgery. A clinical reasoning cycle is an effective tool that facilitates effective decision making and evaluation of outcomes that has been proposed by nursing professionals (Sharma, Singh amp Sharma, 2016). In the assessment, two nursing priorities care is explained including its basis and support. Additionally, the management of nursing priority interventions has been talked in brief. In the last section of the assessment, a brief reflection has been given on the process and learning that has been gathered from the case study.

Question 1: Based on the case study, critically analyze and discuss the underlying pathophysiology and causes of the patient's postoperative wound status. (650 words)

Consider the situation Mrs. Gina Bacci is a woman who is 49-year-old. In her right leg, she experienced the complications of foot ulcer. The patient experienced the surgery for halfway removal of great and first toe and forefoot pursued anesthesia. The patient has a medical history of weight with a BMI of 40.4 m2, type 2 diabetes mellitus, and fringe vascular disease. The patient has been suggested with specific medications like Pregabalin 75 mg mane, Novo rapid TDS 12 units, Paracetamol 1g and Lantus 30 units note.

Collect the cues On an examination, it has been seen that Mrs. Gina Bacci left foot was cool to touch and capillary refill rate was 2-3 seconds. The blood glucose level was 12.6mmol/L. Following are the vitals of her which has been recorded and reported
BP 120/70 mmHg
RR 18 bpm
Pulse 88 bpm
SpO2 97 on RA
Temperature 37.8C

While examining the injury of the patient, it comes to notice that there was an Island film dressing and because of serous exudates output, her incisional wound was wet. Some wound dehiscence seen along the sloughy tissues and line of the suture has also noticed. The skin around the injury was warm which was painful to touch and dark pink in color.

Process information

Mrs. Gina has undergone a surgical halfway amputation of great amp first toe forefoot were affected with anesthesia because of foot ulcers in the right foot. She has experienced a medical history of type 2 diabetes mellitus. According to Beyaz, Gler, and Bar (2017), the patients who have peripheral vascular diseases, complexities of diabetes, and obesity may arise problems like diabetic foot ulcers and for the treatment of foot ulcers amputation is required. The postoperative complication among the patients like Mrs. Gina is very common. It has been reported that increased body mass index (gt 38.0 m2), smoking and cardiovascular diseases and diabetes mellitus are certain causative factors which leads to postoperative wound complication between the patients who experienced amputation surgeries (World Union of Wound Healing Societies WUWHS Consensus Document, 2018). The exudate has been produced at the surgical site which indicates the proliferative phase of wound healing and occurs in order to prevent infections (World Union of Wound Healing Societies WUWHS Consensus Document, 2018). The vasodilatation and increase in vascular permeability result in the leakage of fluid in extravascular space because of which the wound of the patient becomes wet. The increased amount of exudates can be resulted because of infection at the site of incision (World Union of Wound Healing Societies WUWHS Consensus Document, 2018). Some dehiscence has been noticed at the site of the incision along the line of the suture along with sloughy tissues.

It has been reported that there are various reasons which can result in dehiscence like inappropriate closure of the surgical incision, mechanical stress at the incision site, and infection. According to Minossi et al. (2014), because of the diabetic condition of the patient tensile strength, morphometrical, and morphological change has occurred in the blood vessels of the patient. This results in the compromised integrity of the skin and leads to surgical wound dehiscence (Advanced Tissue, 2015). The warmth, pain, and dark pink color of the skin indicating the process of wound healing (Physiopedia, n.d.). The excessive wear and tear that has been occurred because of amputation lead to pain at the site of the incision. The inflammatory processes because of the action of immune cells have resulted in dark pink coloration and warmth at the patient's surgical site (World Union of Wound Healing Societies WUWHS Consensus Document, 2018).

Question 2: Identify 2 main nursing priorities of care for this patient and provide justification and rationale for each. (350 words)

Identifying issues

From the case study, it has been found that the patient is encountering postoperative wound complications. The patient has undergone various postoperative complications like serous exudates output, pain, redness, and dehiscence. This has made the recovery of the patient difficult. Also, the loss of great and first toe and forefoot during amputation leads to physical disability and low esteem of the patient. Thus, two main nursing priorities of care that have been identified for Mrs. Gina are postoperative wound management and the provision of psychological support to her. According to Yamada et al. (2016), patients who underwent amputation surgery and have the medical complication of diabetes and peripheral vascular diseases are more vulnerable to postoperative complications. Such patients require the utmost care for the prevention of postoperative deterioration. The nursing priorities that will be included in the postoperative surgical wound care would be pain management, interventions for dehiscence, and appropriate dressing of wound (Virani, Werunga, Ewashen amp Green, 2015). The rationale for the provision of wound care is the prevention of infection, bleeding, and pain due to the incision in the patient (Virani et al., 2015). Holzer et al. (2014) stated that the process of amputation poses adverse impacts on the life of the patient dramatically. There are certain aesthetic factors like deformation of body image and low self-esteem that reduce the quality of life of the patients who underwent amputation because of any reason. This could impact the psychological and emotional well being of an individual. The nursing priority of care of psychological support to the patient would help in enhancing the self-esteem of the patient and would provide him/her the confidence to live a quality life by providing careful attention to the patient (Virani et al., 2015).

Established goals

The two established goals for the provision of care to Mrs. Gina are as follows
Provision of postoperative wound care
Provision of psychological support

Question 3: From your identified priorities, outline and justify the appropriate and safe nursing management of the patient during this time. (600 Words)

The appropriate nursing interventions that would be appropriate for the patient for the provision of postoperative wound care include topical negative pressure therapy, use of analgesia, appropriate dressing of the patient. According to Dumville et al. (2015), dehiscence occurs due to the weakening of the wound and its inability to resist the external forces. The use of topical negative pressure therapy like a vacuum-assisted closure system (VAC) can help in preventing dehiscence and can handle exudates of extensive quantities and can prevent abrasion and macerations. This can also prevent the risk of surgical site infections among the patients who underwent amputation surgeries (Dumville et al., 2015). It has been reported that postoperative pain is a common phenomenon at the site of incision among the patients who underwent amputation surgeries (Virani et al., 2015). For the management of this pain use of analgesia would be an appropriate nursing intervention. Effective analgesia can be helpful in fast recovery and reducing the pain with the help of a reduction in the responses of sympathetic nervous systems (Virani et al., 2015). In a postoperative phase, patient-controlled analgesia can also be helpful in reducing intense pain and the most effective strategy for the patient who has experienced surgeries followed anesthesia (Luo amp Min, 2017). According to Dumville et al. (2016), the appropriate wound dressing is required in order to prevent infections like the surgical site and other complications associated with the dressing. It has been recommended that the incidents of surgical site infections can be prevented by allowing the wound to be dry (Dumville et al., 2016). It has been evidently found that the use of sterile techniques, assessment of exudates, dry and clean dressing, and cleaning of the wound appropriately are certain techniques that can help in the prevention and quick halting of surgical sites (Pickering amp Marsden, 2015). Also, the dressings should not be too tight or loose because it could lead to ischemia or the conical shape of the stump (Virani et al., 2015). The interventions which can be posed for the arrangement of patients' psychological support. It includes cognitive-based therapies, counseling, and community reintegration.

Amalraj amp Viswanathan, in the year 2017 conducted research in which they concluded that one of the most psychologically impactful and life-changing events for any patient is to lose a part of his/her body. Losing a body part leads to the experience of grief, depression, anxiety, anger, and denial among the patients. Moreover, such patients require specialized nursing interventions. Counseling the suffering patient aids in the development of their psychological and emotional support system. Additionally, such interventions allow patients to accept their new condition (Virani et al., 2015). It encourages the patient to live a better quality of life because of better management of chronic illness even though in the presence of a disability (Amalraj amp Viswanathan, 2017). Cognitive therapies are useful in maximizing the patient's self-esteem and reduce negative feelings like depression, sadness, anxiety, and anger (Sharma, Singh amp Sharma, 2016). Community reintegration is a type of approach which provides support to the patient for dealing with isolation as well as facilitates successful rehabilitation to the patient (Virani et al., 2015).

Evaluation of results: The various outcomes which can be achieved after the proposition of nursing interventions for the management of priory issues include less pain, healing of the wound in a better way, no dehiscence, and increased patients comfort. Also, the enhanced better quality of life and self-esteem is other results that would get after the application of appropriate nursing interventions.
Reflection From the given clinical situation, it has been found that post-operative wound care is very important for better healing of the wound and prevention of infections at the site of surgery. In my future clinical placement, if I would encounter a situation in which I need to provide care to an amputee patient, I will take care of the effective management of surgical wounds. Also, it has been found that psychological support is very important for the amputee patient who has multiple co-morbidities. I would take care of it and will provide psychological and emotional support to the patients so that I can enhance their quality of life and self-esteem to live with a disability.

Conclusion

From the assessment, it has been concluded that diabetes is a chronic illness which can also result in amputation and foot ulcers. It also examined that the prevalence of different co-morbidities like obesity, peripheral vascular diseases, and diabetes also affect the healing of the post-operative wound. In the assessment, the pathophysiology of wound and patients status has been talked about as well as the causative determinants. Toe nursing priorities are identified and these priorities were psychological support to the patient and post-operative wound care. The various interventions for the management of nursing priorities are discussed. Also, in the assessment, a brief reflection about major learning has been given.

References

Advanced Tissue. (2015). How to prevent dehisced wounds. Retrieved from HYPERLINK quothttps//advancedtissue.com/2015/06/how-to-prevent-dehisced-wounds/quot https//advancedtissue.com/2015/06/how-to-prevent-dehisced-wounds/
Amalraj, M. J., amp Viswanathan, V. (2017). A study on positive impact of intensive psychological counseling on psychological well-being of type 2 diabetic patients undergoing amputation.International Journal of Psychology and Counselling,9(2), 10-16.
Beyaz, S., Gler, . ., amp Bar, G. . (2017). Factors affecting lifespan following below-knee amputation in diabetic patients.Acta orthopaedica et traumatologica turcica,51(5), 393-397.
Dumville, J. C., Gray, T. A., Walter, C. J., Sharp, C. A., Page, T., Macefield, R., ... amp Blazeby, J. (2016). Dressings for the prevention of surgical site infection.Cochrane Database of Systematic Reviews, (12).
Dumville, J. C., Owens, G. L., Crosbie, E. J., Peinemann, F., amp Liu, Z. (2015). Negative pressure wound therapy for treating surgical wounds healing by secondary intention.Cochrane Database of Systematic Reviews, (6).
Holzer, L. A., Sevelda, F., Fraberger, G., Bluder, O., Kickinger, W., amp Holzer, G. (2014). Body image and self-esteem in lower-limb amputees.PLoS One,9(3), e92943.
Hunter, S., amp Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement Clinical educators perceptions.Nurse Education in Practice,18, 73-79.
Luo, J., amp Min, S. (2017). Postoperative pain management in the postanesthesia care unit an update.Journal of Pain Research,10, 2687.
Minossi, J. G., Lima, F. D. O., Caramori, C. A., Hasimoto, C. N., Ortolan, . V. P., Rodrigues, P. A., amp Spadella, C. T. (2014). Alloxan diabetes alters the tensile strength, morphological and morphometric parameters of abdominal wall healing in rats.Acta cirurgica brasileira,29(2), 118-124.
Physiopedia. (n.d.). Complications post amputation. Retrieved from HYPERLINK quothttps//www.physio-pedia.com/Complications_post_amputationquot https//www.physio-pedia.com/Complications_post_amputation
Pickering, D., amp Marsden, J. (2015). Techniques for aseptic dressing and procedures.Community Eye Health,28(89), 17.
Sharma, R. K., Singh, B., amp Sharma, S. (2016). Efficacy of cognitive behaviour therapy and quality of life in the amputees. International Journal of Indian Psychology,3(3), 151-166.
Virani, A., Werunga, J., Ewashen, C., amp Green, T. (2015).Caring for patients with limb amputation. Nursing Standard, 30(6), 5160.
World Union of Wound Healing Societies WUWHS Consensus Document. (2018). Surgical wound dehiscence Improving prevention and outcomes. Retrieved from HYPERLINK quothttps//www.woundsinternational.com/uploads/resources/79558b78096b68f856e0fce6485b6381.pdfquot https//www.woundsinternational.com/uploads/resources/79558b78096b68f856e0fce6485b6381.pdf
Yamada, K., Yasunaga, H., Kadono, Y., Chikuda, H., Ogata, T., Horiguchi, H., amp Tanaka, S. (2016). Postoperative outcomes of major lower extremity amputations in patients with diabetes and peripheral artery disease analysis using the Diagnosis Procedure Combination database in Japan. American Journal of Surgery,212(3), 446-450.

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