1. Ms. Melody presented with severe abdominal pain and was diagnosed with a ruptured appendix requiring emergency surgery. She developed post-operative peritonitis. 2. Her vital signs were abnormal and indicative of sepsis in response to the abdominal infection, as shown by elevated white blood cells and c-reactive protein. 3. Key issues identified included high pain levels, nausea, and sepsis from the peritonitis that required treatment following the hospital's sepsis protocol.

1. Clinical Reasoning Cycle Essay.
Clinical Reasoning Cycle Essay. This case study will demonstrate the care of MS. Melody by
the nursing staff using the clinical reasoning cycle, to respond to her unstable clinical
manifestation and ensure that there is a positive outcome for her as a patient, during her
hospitalization in the surgical ward (Levett-Jones, 2013).Clinical Reasoning Cycle
Essay.Consider patient situation.Ms.Melody is a 36-year old female who presents herself to
the emergency department (ED), after having 2-3 days of severe right lower quadrant
abdominal pain which is diagnosed, and she is immediately taken to theatre for an acute
appendicectomy. After the laparoscopic removal of her appendix, she develops peritonitis
which is common to patients who have had a ruptured appendix and require immediate
treatment (van Rossem, Schreinemacher, Treskes, van Hogezand & van Geloven,
2014).ORDER A PLAGIARISM-FREE PAPER HERECollect cues and information.Ms.Melody
has a relevant past medical history of asthma and depression. The staff should be aware of
what triggers her asthma and consider how often she takes the Ventolin, Seretide for
asthma and sertraline an antidepressant which is a selective serotonin reuptake inhibitors
(SSRIs), (MIMS online, 2019). These are all her regular medications. she is coming to the
ward for treatment of peritonitis which is an infection to the inner lining of the peritoneum
and needs immediate medical intervention as it is life threatening (Horvath et al., 2016).Ms.
Melody’s vital signs given are not very stable as she is hypotensive with a blood
pressure(BP) at 95/45, tachycardic at 120bpm and febrile 38.5, her respiration rate is 22
breaths per minute and shallow. She had nausea, but no vomiting is reported. Pain levels
are reported to be 7-8/10 on a scale of 0-10. Physical assessment done show a distended
abdomen which she was guarding. Pathology results show an elevated level of white blood
cells and c-reactive protein. Drake & de C. Williams, (2017), describe acute pain as the fifth
vital sign while Gélinas, (2016), explanation of pain as an uncomfortable sensory and
emotional experience which is related to an actual or potential tissue damage (Gélinas,
2016). There is a deficit of information regarding Melody which should have been included
to get a complete scenario of her situation and provide holistic care. This information
includes her social status and whether she lives alone or has family who might depend on
her during hospitalization. The obs given were not specific as no time line is given of when
they were taken.Process information.For Melody to be considered stable, her vital signs
must be within a certain acceptable range. According to Kuiken (2016), Vital signs (VS) are
used to measure a body’s physiological functioning. According to Limbe, Currey &
Considine, (2016), normal vital sign range is RR12-22 breaths per minute, oxygenation

2. above 95%, systolic blood pressure 90-139mmHg, heart rate 60-100 beats per minute for
an adult and a Glasgow coma scale of 15 to a patient who is conscious and orientated to
time, place and person. The body core temperature should be between 35-37.8c (Lambe,
Currey & Considine, 2016).Clinical Reasoning Cycle Essay.Vital signs abnormalities can be a
clear indication of a deterioration of Melody’s condition within minutes to hours (Mok,
Wang, Cooper, Ang & Liaw, 2015). Considering Ms. Melody’s age,no past medical history of
hypotension, is tachycardic and has an elevated white blood cell count and c-reactive
protein, all these vital signs are abnormal and are clear markers of a patient who has sepsis
and her body’s response to the infection (Hayden et al., 2016). Sepsis according to Cheung
et al., (2015) is a clinical condition that results from a dysregulated inflammatory response
to an infection (Cheung et al., 2015). For Melody to be considered as having sepsis, there
must be two or more vital sign abnormalities present and a culture-proven or an identified
site for infection. These include temperature above 38.3 C or below 36°C,heart rate above
90beats/minutes, a respiratory rate above 20breaths/minutes and an elevated white blood
cell and c-reactive protein (Cheung et al., 2015).Kuiken (2016) recommends that the
nursing staff in Melody’s care, should assess, identify, monitor and document her
physiological status and report all vital signs abnormalities to the treating physician
(Kuiken,2016).The elevated White Blood Cells and C-reactive Protein are inflammatory
markers (Gans et al., 2015).Melody’s pathology results are indicative of an acute abdomen
infection and inflammatory response(Gans et al.,2015) ……. also argues that elevated levels
of white blood cells and c-reactive protein are not very specific and their diagnostic
precision for a specific diagnosis is low, but they are still used to triage patients who may
require urgent imaging to determine cause for elevation(Gans et al., 2015).Clinical
Reasoning Cycle Essay.Identify problems /issues.1.pain-Gélinas (2016), describes pain as an
unpleasant emotional and sensory experience which is associated with potential or actual
tissue damage. Melody reports 7-8/10 pain levels using the 0-10 numerical pain assessment
tool. The Royal Children’s Hospital(RCH)2015, concurs that, any changes in physiological
indicators of any patient should be incorporated when assessing pain. These changes
include an increase or a decrease in heart rate, changes in respiratory rate and pattern,
observed work of breathing and shortness of breath. Melody is also observed to be guarding
her abdomen which is a clear indication that she is in a lot of pain and the pain location.
Different tools of pain assessment should be used to assess and reassess her pain levels to
identify onset, duration, severity, location, quality, quantity and provocation so that there is
accurate documentation and appropriate pain interventions given to Melody (Levett-Jones,
2013).2.Nausea– Post-operative nausea and vomiting (PONV) is often the cause of anxiety
and great distress to patient (Bhakta et al., 2016). Excessive post-operative nausea and
vomiting (PONV) may lead to dehydration, electrolyte imbalance and feared complications
such as pulmonary aspiration syndrome. Nausea and vomiting may have financial
implications in that, day procedures may turn into hospitalization of a patient if nausea and
vomiting is not resolved at the expected time of discharge (Brown & Edwards, 2013). A
patient may express dissatisfaction with the surgical process in instances where there is
prolonged nausea and vomiting after the surgical procedure (Brown & Edwards,
2013).Factors that predispose Ms. Melody to post-operative nausea and vomiting (PONV)

3. include her gender, anesthetic agents used during the removal of her appendix, time she
took during surgery and the location of the surgical incision which in her case is abdominal
and any past history of having motion sickness or nausea and vomiting(Brown & Edwards,
2013).Clinical Reasoning Cycle Essay.3.sepsis-Melody is febrile, her abdomen appears
distended, tachycardic and has ongoing nausea. These are clinical manifestations of a
peritonitis which is fatal. Ms. Melody is being admitted because of peritonitis which is more
than likely to have been caused by a ruptured appendix and releases harmful enzymes, bile
and bacteria into the sterile peritoneum. The intestinal contents produce an immediate
chemical peritonitis followed by a bacterial peritonitis in a few hours (Brown & Edwards,
2013). Establish goalsResolve the abdominal pain being experienced by Ms. Melody or at
least ensure pain levels are minimized to a comfortable level so that she can resume and
undertake activities of daily living without much discomfort as soon as possible.Resolve
nausea and vomiting episodes so that Ms. Melody can tolerate fluids intake to restore her
blood pressure to normal parameters within an hour.Treat the cause of the infection and
inflammation as per the hospital sepsis protocol, ensure the white blood cell count and the
c-reactive protein is back to the normal limits.Take actionPoor acute pain management can
lead to adverse consequences (Levett-Jones, 2013). These include postsurgical
complications and prolonged hospital stays, which increase health care costs and patient
suffering (Drake & de C. Williams, 2017).As the primary nurse, the main role after receiving
Ms. Melody back into the ward is to manage her abdominal pain levels and ensure that she
is comfortable (Drake & de C. Williams, 2017). This will work if there is proper pain
assessment and dispensing nurse-initiated analgesia (Levett-Jones, 2013).Russo et al.,
(2016) advocates for continuous use of intravenous (IV) infusion of opioids for
postoperative pain as the best pain relief option for a patient like Ms. Melody who is a high -
risk patient and needs intensive postoperative care. The most commonly used drugs are
fentanyl and morphine (Russo et al.,2016).Nausea-antiemetics such as
intravenous(IV)ondansetron may be prescribed by the physician and administered to
prevent and resolve nausea and vomiting episodes (MIMS online, 2019). Fluids may be
charted and given to Ms. Melody to replace any lost fluids through vomitus and resolve the
hypotension (Bhakta et al., 2016). Nursing care should include, weaning her with sips of
water and dry foods as much as she can tolerate (LeMone, 2014). Maintaining an accurate
fluid balance chart to monitor fluid intake and output and then use it to establish the
necessary fluid replacement therapy. Ms. Melody should be encouraged to do deep
breathing exercises which assist in voluntary suppression of the vomiting reflex (LeMone,
2014).Ms. Melody vital signs are consistent to a patient who has sepsis and therefore a
sepsis treatment protocol should be initiated as per the hospital policy as it is life
threatening and a time-dependent process (Hayden et al., 2016). Van Rossem,
Schreinemacher, van Geloven & Bemelman, (2015), describes the first 12hours as the most
crucial in a patient like Melody who presents to the ED with the mentioned vital signs. She
should have a very quick and accurate prognosis, diagnosis and then appropriate
antimicrobial therapy commenced without delay.The Antimicrobial Prescribing clinical
guideline, (2018) warns that, if sepsis is detected too late, and there is delay in initiating
antibiotic treatment, Ms. Melody’s condition may worsen and could lead to serious sepsis or

4. even septic shock (The Antimicrobial Prescribing clinical guideline,2018). Hayden et al.,
(2016) recommends that antibiotics are to be administered within the first 30min
postdiagnosis or within the first 9-12hours (Hayden et al., 2016). Hayden et al., (2016)
expresses how sepsis causes high death rates in patients who present to the Emergency
department. Flum (2015), explains how having a complicated laparoscopic appendectomy
as Ms. Melody has had, is associated with an increased risk of surgical-site infection and a
much slower recovery time(Flum,2015). Ms. Melody will be receiving a 3-5days course of
antibiotics such as cephazolin and metronidazole (Hayden et al.,2016). Fluid resus is also
recommended to resolve the hypotension which may be due to vomiting and fluid loss. If
not resolved a peritoneal drainage is recommended to prevent further post-appendectomy
infection and remove all the purulent fluid leakage from the peritoneum(Cho et al.,
2016).Clinical Reasoning Cycle Essay.Evaluate outcomesMelody should be assessed and
reassessed on pain levels and until she reports comfortable pain levels which enable her to
undertake her daily activities of living (Levett-Jones, 2013).Ms. Melody’s self-report on pain
remains the best option to identify whether the pain has diminished but the nursing staff
should also use behavioral pain scale and critical-care pain observation tool to evaluate
outcome of analgesics, other therapeutic options used and establish effectiveness(Gélinas,
2016).Repeat blood cultures to establish whether the infection has resolved by showing a
normal reading to white blood cell count and the c-reactive protein. Recheck the vital signs
which should be normalizing as the infection is resolved (Gans et al., 2015).Ms. Melody
should be reassessed for signs of nausea and vomiting which is subjective and continuous
monitoring of fluid intake and output adhered. Abdomen distension should be reassessed to
ensure it has gone back to normal as it is a common stimulus for nausea and more
antiemetics administered if needed (Le Mone, 2014).ReflectionNext time I will ensure that
there is proper handover of the patient as there is missing information about Ms. Melody
which is important in providing holistic care such as the other set of vital signs since her
admission to the hospital.I should have asked for all the necessary documentation related to
her nursing care for referrals to the relevant multidisciplinary health team workers who
should have been in her care.In conclusion, I quite understand how as a graduate nurse,
time management and timely interventions are important in an acute setting. Proper and
accurate documentation, team nursing and proper communication would distinguish
between life and death to a patient (Levett-Jones, 2013).Clinical Reasoning Cycle
Essay.Clinical reasoning and critical thinking ensures that nurses will develop some positive
attributes which ensures that patients are safe and provided with holistic care by nurses
who are open minded and safe to practice (Levett-Jones, 2013).Clinical Reasoning Cycle
Essay.