NNS5806 Nursing and the Healthcare System in Australia

Introduction: 

Clinical reasoning is an important practice in nursing for safe and effective care. Nurses need to organize their thinking process to engage in the process of clinical reasoning. The steps that health professional must take is recognizing cues about the situation, elaborate their judgment and then make appropriate reasoning (Carvalho et al., 2017). The clinical reasoning cycle developed by Tracy-Levett is an important framework for nurses to engage in the process of clinical reasoning. The aim of this report is to use the clinical reasoning cycle process to identify two nursing care priorities for Faye Richardson, a 44 year old female suffering from persistent abdominal pain. It will also provide justification regarding the two care priorities chosen based on support from research literature.

Consider patient situation:

Mrs Faye Richardson is a 44 year old female who was admitted with complain of persistent abdominal pain. She is a mother of three children and works in management position. She works for long hours and does not have any other support as her husband died last year. She developed a massive upper gastrointestinal bleeding two days after admission.

Collect cues and information:

To gain further understanding regarding the possible cause behind abdominal pain, reviewing medical history, current vital signs and laboratory report of Mrs Faye is important. Her past medical history included diagnosis of rheumatoid arthritis two years ago for which she is taking 10 mg Prednisone per day. She has a history of cigeratte smoking and irregular eating habits too. Her father also had a history of gastric incidence and incidence of hypertension was seen in paternal uncle and maternal grandmother. Her current persistent abdominal pain may be linked to her smoking and eating habits or the effect of medications too.

Other details of Faye revealed that is malnourished as her weight was 45 kg and she lost 4.5 kg weight within the last six weeks. Her blood pressure on admission was 150/88 indicated that she is hypertensive. It has been found that she has been experiencing epigastric pain since the last three months and the pain became intense one to two hours after eating. This can be linked to the quality of diet taken by Faye as epigastric pain increases due to consumption of spicy or oily food or due overeating. The possibility of digestive conditions needs to be ruled out too (Bahdi, Jeung & Bhatt, 2019).

Process information

From the information collected on past medical history and current symptoms, patient’s lifestyle may be linked to the current problems. Mrs. Faye smokes 1 pack of cigarette per day and this could be the cause behind gastrointestinal bleeding incidence. According to Li et al. (2014), cigarette smoking is an important risk factor for gastrointestinal disorders like ulcers and inflammatory bowel disease. This link has been established because of the effect of cigarette smoking on peptic ulcers and delay of ulcer healing. The pathology behind this is that cigarette contains active ingredients that can cause mucosal cell death thus inhibiting cell renewal process. It results in decreased blood flow to the gastrointestinal tract and interference with the mucosal immune system. Berkowitz et al. (2018) established the harmful effect of smoking on the gastrointestinal tract. It has been found that cigarette smoking increases the incidence of peptic ulcer disease and other digestive problem. Thus, cigarette smoking is regarded as one cause behind current symptoms of Mrs. Faye.

The link between Mrs. Faye and current medication needs to be established. She has been taking prednisone for her rheumatoid arthritis. It needs to be reviewed whether use of Prednisone is associated with any digestive side effects or not. Prednisone is a type of corticosteroids and evidence shows that use of corticosteroid increases the risk of gastrointestinal bleeding. The risk was found to be high in hospitalized patients (Butler et al., 2018). The effect of Mrs Faye’s diet on current condition needs to be explored too as her diet is irregular and this may be the cause behind the problem. Evidence has revealed relation between irregular diet and gastric problems (Lim et al., 2013).

Identify problem/issues

Based on the synthesis of Faye’s clinical information and lifestyle, key problems that has been identified for patient is poor eating habit, cigarettes consumption, presence of anxiety and recurrence of upper gastrointestinal bleeding.

Eating habit is a concern because of her current weight and dietary habit. Currently, she is irregular in her eating and this may be due to the fact that she is a single mother. Her current weight is 45 kg indicating that she is malnourished. This may exacerbate her symptoms and make her prone to complications. It is necessary to communicate to the medical team about the problem and consider about the adverse effects of prednisone drug too. This is important to prevent further damage to the intestinal epithelium (Eswaran et al., 2017).

Her cigarette consumption is regarded as one major problem too as she is consuming one pack every day. The chemical found in cigarette like aldehydes, quinone, epoxides and peroxides induce production of reactive oxygen species. It can induce tissue damage and risk of gastric diseases (Langsted & Nordestgaard, 2019). Thus, this needs to be prioritized. Currently, smoking cessation effort could be affected by Faye’s current mental stress. She is found to be restless and distressed when asked to avoid cigarette. Thus, convincing client would be an issue. Recurrence of gastrointestinal bleeding needs to be taken seriously and focusing on risk factors is essential to further prevent complications (Yasud et al., 2015).

Establish goals

The ultimate goal of care is to prevent recurrence of gastrointestinal bleeding and ensure that epigastric pain is relieved. It is planned to provide relief from pain and other symptoms within the next one week.

Take action

It has planned to focus on two care priorities for the recovery of patient. The first care priority is to prevent cigarette smoking and the second care priority is to address dietary habits of patients. The intervention that has been proposed to address dietary issues is to implement nutritional intervention for patient. This is indicated because of her symptoms of nausea and low weight. It is a sign of imbalanced nutrition in patient. Thus, with the collaboration with dietician, nutritional intervention needs to be implemented. Nutritional intervention will focus on diet counseling, revision of food habits and eliminating foods or medications that interfere with current symptoms. The main justification for implementing this intervention is that can act as supplemental care for patient and provide exogenous fuel to support client during stress response (Park et al., 2017). As currently she is hospitalized, early nutrition support may decrease severity of symptoms and shorten length of hospital stay too. Malnutrition can worsen outcome of clinical procedures and result in worse outcome. Thus, early nutritional assessment and early initiation of nutritional intervention can improve symptoms (Ukleja, 2018).  

It is planned to implement smoking cessation intervention too. This is crucial because Faye is an active smoker and continuing with smoking could lead to detrimental health outcome. Nicotine replacement therapy (NRT) can be initiated for client. It is regarded as a first line therapeutic intervention for patients who find it hard to quit. Nicotine administration reduces cravings within few weeks. Moreover, NRT reduce the reinforcing effects. Nurse can also give simple advise to Faye regarding the benefits of cessation and harmed linked to continuing with smoking. Simple counseling related efforts using therapeutic communication techniques can increase abstinence rates (Aubin, Luquiens & Berlin, 2014). 

Evaluate outcomes

The evaluation of outcomes can be done by assessing for improvement in epigastric symptoms and pain score of patient. This will be done by pain assessment process. In addition, the positive effect of nutritional intervention can be understood by improvement in eating habits and weight gain. It can also lead to improvement in nausea (Ahuja, 2017). Thus, regular monitoring of food pattern and smoking status will highlight if the intervention is successful.

Reflect on action

From the evaluation, it has been found that certain important data related to vital signs post admission was missing. This could have helped to establish other effect of epigastric pain on patients. One challenge in the process is the way a nurse could convince a patient to quit smoking who is reluctant to quit. It is recommended that in future more training is needed to tackle resistive patients.

Conclusion

By the use of clinical reasoning cycle to identify care priorities for Mrs. Faye, it has been found that lifestyle and eating habit has played a major role in the development of gastrointestinal disorder in patient. The process of collecting cues and processing informed helped to identify key problems in patients which included recurrence of gastrointestinal bleeding, active smoking, irregular feeding habits and effect of drugs. The goal of care was to reduce any future incidence of GI bleeding. To achieve the goal, the intervention of nutritional support and smoking cessation was planned to address the problem. The intervention focused on restless nature and educational aspects for compliance to treatment too.

References  

Ahuja, N. K. (2017). Nutritional approaches to chronic nausea and vomiting. Practical Gastroenterology, 41(10), 34-40. https://practicalgastro.com/wp-content/uploads/2019/08/Nutritional-Approaches-to-Chronic-Nausea-and-Vomiting.pdf

Aubin, H. J., Luquiens, A., & Berlin, I. (2014). Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice. British journal of clinical pharmacology, 77(2), 324-336. doi: 10.1111/bcp.12116.

Bahdi, F., Jeung, J., & Bhatt, A. (2019). An Unusual Cause of Recurrent Epigastric Pain. Gastroenterology, 156(5), 1261-1263. doi: 10.1053/j.gastro.2018.07.055

Berkowitz, L., Schultz, B. M., Salazar, G. A., Pardo-Roa, C., Sebastián, V. P., Álvarez-Lobos, M. M., & Bueno, S. M. (2018). Impact of cigarette smoking on the gastrointestinal tract inflammation: opposing effects in Crohn’s disease and ulcerative colitis. Frontiers in immunology, 9, 74. doi: 10.3389/fimmu.2018.00074

Butler, E., Møller, M. H., Cook, O., Granholm, A., Penketh, J., Rygård, S. L., ... & Perner, A. (2018). Corticosteroids and risk of gastrointestinal bleeding in critically ill adults: Protocol for a systematic review. Acta Anaesthesiologica Scandinavica, 62(9), 1321-1326. doi: 10.1111/aas.13159.

Carvalho, E. C. D., Oliveira-Kumakura, A. R. D. S., & Morais, S. C. R. V. (2017). Clinical reasoning in nursing: teaching strategies and assessment tools. Revista brasileira de enfermagem, 70(3), 662-668. doi: 10.1590/0034-7167-2016-0509.

Eswaran, S., Farida, J. P., Green, J., Miller, J. D., & Chey, W. D. (2017). Nutrition in the management of gastrointestinal diseases and disorders: the evidence for the low FODMAP diet. Current opinion in pharmacology, 37, 151-157. doi: 10.1016/j.coph.2017.10.008.

Langsted, A., & Nordestgaard, B. G. (2019). Smoking is associated with increased risk of major bleeding: a prospective cohort study. Thrombosis and haemostasis, 119(01), 039-047. doi: 10.1055/s-0038-1675798. doi: 10.3892/ijmm.2014.1786.

Li, L. F., Chan, R. L. Y., Lu, L., Shen, J., Zhang, L., Wu, W. K. K., ... & Cho, C. H. (2014). Cigarette smoking and gastrointestinal diseases: the causal relationship and underlying molecular mechanisms. International journal of molecular medicine, 34(2), 372-380. doi: 10.3892/ijmm.2014.1786.v

Lim, S. L., Canavarro, C., Zaw, M. H., Zhu, F., Loke, W. C., Chan, Y. H., & Yeoh, K. G. (2013). Irregular meal timing is associated with helicobacter pylori infection and gastritis. International Scholarly Research Notices, 2013. doi: 10.5402/2013/714970.

Park, Y. E., Park, S. J., Park, Y., Cheon, J. H., Kim, T. I., & Kim, W. H. (2017). Impact and outcomes of nutritional support team intervention in patients with gastrointestinal disease in the intensive care unit. Medicine, 96(49). doi: 10.1097/MD.0000000000008776

Yasuda, H., Matsuo, Y., Sato, Y., Ozawa, S. I., Ishigooka, S., Yamashita, M., ... & Itoh, F. (2015). Treatment and prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy. World journal of critical care medicine, 4(1), 40.v   doi: 10.5492/wjccm.v4.i1.40 

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