NRSG125- Assessment 2 - This assignment shows the use of CRC in healthcare. this assignment demonstrates PDF

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This assignment shows the use of CRC in healthcare. this assignment demonstrates the use of CRC to identify the disease and its management. I got DI with this work...

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Clinical reasoning cycle (CRC), as proposed by Levett-Jones (2013), is the way clinicians perceive the problems they face in clinical practice. This cycle mainly encompasses two processes: clinical judgement (what is wrong with the patient) and clinical decision making (what to do with the patient). CRC is a logical process which nurses use to collect cues about the patient considering the patient situation, process the available cues to design the assessment plan, identification of the illness or issues and treat the ailment with the application of clinical reasoning. This essay aims to incorporate the CR cycle to assess a 49year-old man presented to the emergency department (ED) with acute cholecystitis (AC). In addition, the essay scopes to trigger various plausible hypotheses of pathophysiology in relation to the disease in the given case study of Mr Kasim Al-Mutar. Acute cholecystitis is an inflammatory response of the gallbladder secondary to acute obstruction of a cystic duct by cholelithiasis, also known as biliary stones. Biliary stones are caused by an alteration of chemical composition of bile and are usually made of cholesterol (80%), bile pigment (20%) or mixed composition of cholesterol and pigment (Eachempati, & Reed, 2015). Cholecystitis without any cystic obstruction due to stones or biliary sludge is known as acute acalculous cholecystitis (AAC). AAC is typically associated with high morbidity and mortality if not managed in a timely manner. Although AC is not usually a medical emergency, delay in treatment can lead to many serious and potentially fatal complications such as death of the gallbladder tissue known as gangrenous cholecystitis or perforation of the gallbladder. The development of AC begins with the formation of a stone that obstructs cystic duct. This result to sustained high pressure within the gallbladder lumen that impairs normal mucosal blood flow and subsequent ischemia. Glynn (2017) advocates that chemical meditators such as lysolecithin are released within the stagnant bile, damaging ischemic mucosa, and leading to chemical cholecystitis with the accumulation of

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inflammatory infiltrate and gallbladder wall oedema. Despite the probability of bacterial infection is very low within first two days, the risk of infection may increase up to three folds by the end of the first week (Glynn, 2017). Thus, in the case of delayed treatment, the patient is at high risk of developing bile stasis and inspissation, which may cause toxic destruction of gallbladder epithelia. The symptoms of calculous cholecystitis may vary. However, the most common symptoms of AC include pain in the RUQ (peritoneal irritation) that might radiate to the back and shoulder. According to Halpin (2014), the pain starts in the epigastric region and then localises in the RUQ. In addition, the pain is accompanied by fever, nausea and episodes of vomiting. Other symptoms include palpable gallbladder or fullness of RUQ in more than third of patients and tenderness in the RUQ often with guarding or rebound (Halpin, 2014). The patient often experiences tachycardia and a quarter of patients might reveal jaundice. If AC progresses to gangrenous cholecystitis with significant perforation of gallbladder, then the patient might experience dehydration due to the loss of body fluid (Keenan, Dhaliwal, Henderson, & Bowen, 2014). The diagnosis of AC depends upon the accuracy of clinical presentation, laboratory findings and diagnostic imaging. Halpin (2014) explains the methodological way to subclassify the abdominal pain as arising from either abdominal wall, peritoneum or peritoneal cavity, viscera or a referred pain (pain in the area due to extra-abdominal cause). The diagnostic approach to identify pain and aetiology begins with history taking (social and medical) and physical examination. Taking a person history helps in differentiating acute versus chronic pain and identify if the pain is traumatic or non-traumatic or arising from recent abdominal surgery and establishing a relationship between pain and social behaviour. For example, a sudden onset of an abdominal pain suggests a complicated intra-abdominal event such as organ perforation or ischemia or obstruction of small tubular structure such as

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renal pelvis or a ureter due to stones, whereas more gradual onset of a pain might indicate an infection or inflammation of a bodily organ such as liver or obstruction of a large tubular structure (colon) (Jandoo, & Lawrence, 2013). Presence of any intra-abdominal therapeutic devices might link the pain to intra-abdominal infection. Moreover, questioning the patient about the nature of pain might reveal the origin of a pain. Biliary colic radiating to back, for instance, suggest cholecystitis, whereas burning pain is often linked with peptic ulcer disease (Keenan et.al, 2014). The patient might reveal activities that make pain aggravating or relieving. For instance, if taking antacid lessens pain then it might suggest peptic ulcer disease, whereas if sitting up and leaning forward relieves pain, then the pain might relate to acute pancreatitis (Jandoo, & Lawrence, 2013). Similarly, pain in inspiration or coughing might suggest a pulmonary cause of RUQ pain. Jaundice with RUQ pain makes an immediate suggestion of hepatic diseases such as hepatitis and biliary obstruction as in acute cholecystitis (Paradox, 2013). Enquiring a patient about his social history such as drinking, smoking or use of other illicit substances may reveal different story of the pain. For instance, chain smokers might have the pulmonary cause of RUQ pain, whereas druggist and alcoholic might have a hepatic cause. Likewise, physical examination (PE) begins with checking vital signs and pulmonary condition. This helps to establish patient stability and a working diagnosis to guide further evaluation. PE manoeuvres that are likely to be useful in diagnosing the cause of the problem follows IAPP (inspection, auscultation, percussion and palpation) instead of IPPA (Estes, 2010). The physiology behind this procedure owes to the fact that doing percussion and palpation before auscultation might alter the bowel sounds and produce false results (Estes, 2010). Inspection begins with eyes looking for scleral icterus and pallor, abdominal movement in accordance with respiration, colour and texture of the skin, checking for any scars (surgical or injuries), sign of oedema or symmetricity of the abdomen. Percussion and

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palpation assess firmness and tenderness of the abdomen. Palpation and percussion of the RUQ are especially executed for hepatomegaly (Cole, Lynch, & Cugnoni, 2016). In most of the cases, positive Murphy’s sign hints acute cholecystitis. Positive Murphy’s sign refers to the pain on inspiration in RUQ while palpating, however, has no pain in LUQ (Cole et. al, 2016). In acutely inflamed gallbladder, the patient will wince with sudden “catch” in their breath as the inflamed organ hits the examining hand at the height of inspiration (Chandra, 2013). Chandra (2013) acknowledges that absence of RUQ tenderness on palpation indicates “referred pain” that might be felt in the RUQ from extra-abdominal causes. Following the prognosis, radiographic imaging and pathology serve as the doorway to the treatment. Ultrasound (US) scan of the abdomen is the primary choice in the diagnostic evaluation. Researches show that sensitivity of ultrasound for stones is more than 82%, for AC diagnosis (Katabathina, Zafar, & Suri, 2015; Zhang, Han, Zhang, Li, & Yao, 2014). Moreover, ultrasound is helpful revealing the thickening of the gallbladder wall and distension of the lumen (Zhang et. al, 2014). It may also point other cause of the RUQ pain such as liver neoplasm or renal lesions. The presence of cholelithiasis and thickened gallbladder wall may not always be diagnostic and hence require other diagnostic tests. Hepatobiliary scintigraphy by hydroxyminodiacetic acid (HIDA) scanning provides the highest diagnostic accuracy among all imaging techniques, with a sensitivity of more than 95% (Katabathina et.al, 2015). It provides a good functional assessment of a gallbladder excretion, which is evidently impaired with AC. CT scan and MRI scan are also useful; however, CT scan is less preferable than ultrasound and MRI is mostly used for patients with suspected biliary obstruction of a common hepato-pancreatic duct (choledocholithiasis) or Mirizzi syndrome (Zhang et. al, 2014). Moreover, laboratory findings may reveal leucocytosis, mild elevation in serum concentration of bilirubin, and in some cases, elevated amylase level (Sartin, 2013). Patients are usually subjected to have a urinalysis to eliminate

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pyelonephritis and renal calculi. Similarly, females of child bearing age are expected to undergo pregnancy test to rule out the reproductive cause of the pain. Treatment of AC depends on the severity of symptoms and the patient’s clinical status. The initial treatment includes pain management, bowel rest and IV hydration. Sartin (2013) asserts that the benefit of antibiotics remains still unclear, however administration of broad-spectrum antibiotics is generally used in the case of AC. Antibiotics are used for alleviating pain and to prevent bacterial growth. Patients with symptoms of dehydration are administered IV fluids to maintain electrolyte and fluid balance in the body. Surgical intervention of AC includes percutaneous catheter drainage with stent placement to relieve obstruction, particularly for surgical risk patients and if infection is present (Sartin 2013, p.747). Advanced AC requires surgical intervention: laparoscopic or open cholecystectomy. Laparoscopic cholecystectomy remains the treatment of choice for asymptomatic gallstones because it leaves less scars, minimal hospital stay and less postoperative pain (Eachempati, & Reed, 2015). This is performed through four small incisions through which the gallbladder is freed by electrosurgical or laser breakdown (Katabathina et.al, 2015). According to Campion et. al, (2015), open cholecystectomy remains safe with low morbidity and mortality. In open cholecystectomy, the surgeon removes the gallbladder through a single large incision either under the border of the right rib cage or in the middle of the upper part of the abdomen (Campion et.al, 2015). This leaves a big scar and possesses increased postoperative pain. Therefore, it is usually done after doctors identify complications to remove the gallbladder by laparoscopic procedure. There might be various ways to approach a patient and the above literature is one of them. The notion of this essay is to use CRC to distinguish various possible sources of an illness to identify the most likely cause and to establish a platform for further evaluation.

NRSG125- Assessment 2 Therefore, in the case of Mr Kasim, the primary objective of a health professional would be the management of pain followed by the diagnosis of a cause and treatment.

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Campion, E., Baron, T., Grimm, I., & Swanstrom, L. (2015). Interventional Approaches to Gallbladder Disease. New England Journal of Medicine, 373(4), 357-365. http://dx.doi.org/10.1056/nejmra1411372 Chandra, R. (2013). Right-upper quadrant abdominal pain. The Journal of Family Practice, 66(5), 35-42. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC314041/ Cole, E., Lynch, A., & Cugnoni, H. (2016). Assessment of the patient with acute abdominal pain. Nursing Standard, 20(38), 56-64. http://dx.doi.org/10.7748/ns.20.38.56.s52 Eachempati, S., & Reed, I. (2015). Acute Cholecystitis (1st ed.). Cham: Springer International Publishing. Estes, M. (2010). Health assessment & physical examination (4th ed., pp. 580-599). Clifton Park, NY: Delmar, Cengage Learning. Glynn, M. (2017). Cholelithiasis and Cholecystitis. In T. Buttaro, Primary care (5th ed., pp. 635-638). Missouri: Elsevier. Halpin, V. (2014). Acute cholecystitis. BMJ Clinical Evidence, 14(0411), 25-34. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4140413/ Jandoo, R., & Lawrence, M. (2013). Assessment of patients with acute abdominal pain. Innovait: The RCGP Journal for Associates in Training, 6(6), 355-361. http://dx.doi.org/10.1177/1755738013481208 Katabathina, V., Zafar, A., & Suri, R. (2015). Clinical Presentation, Imaging, and Management of Acute Cholecystitis. Techniques in Vascular and Interventional Radiology, 18(4), 256-265. http://dx.doi.org/10.1053/j.tvir.2015.07.009

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Keenan, C., Dhaliwal, G., Henderson, M., & Bowen, J. (2014). A 43-Year-Old Woman with Abdominal Pain and Fever. Journal of General Internal Medicine, 25(8), 874-877. http://dx.doi.org/10.1007/s11606-010-1372-3 Levett-Jones, T. (2013). Clinical reasoning: Learning to think like a nurse. Frenchs Forest, NSW: Pearson Australia Paradox, P. (2013). Gallstones. In The Gale Encyclopedia of Alternative Medicine. Detroit: Gale. Sartin, J. (2013). Alterations in Function of the Gallbladder and Exocrine Pancreas. In L. Copstead & J. Banasik (5th ed.), Pathophysiology (pp. 743-747). St. Louis: Elsevier. Zhang, L., Han, Q., Zhang, H., Li, D., & Yao, K. (2014). Significance and clinical applications of ultrasound score in assessing the clinical severity of acute cholecystitis in the elderly. Aging Clinical and Experimental Research, 27(1), 21-26. http://dx.doi.org/10.1007/s40520-014-0236-9...