Scenario Overview
Neriman Tan, a 65-year-old Muslim woman who immigrated to Australia from Turkey in 2022 to be nearer to her family, is the patient in this case study. She has told her daughter that she is having a hard time adjusting to life in Australia. Three months ago, Neriman noticed a lump in her left breast. After having an ultrasound and a biopsy, her condition was discovered to be stage 1 ductal carcinoma of the breast, and she was put on the elective list for a left breast lumpectomy.
Neriman has a complicated medical background, including Type 2 Diabetes Mellitus, Obesity (BMI 34.9, Weight 95kg), Hypertension, Anxiety, and Depression, as well as Bee and Penicillin Allergies. On the day of the lumpectomy, Neriman was moved from the Post-Anesthesia Care Unit (PACU) to the surgical ward. The following day, the registered nurse discovered Neriman feeling pain and discomfort close to the surgical site.
Cues
- The patient reports experiencing pain at a level of 6/10 on the recent NRS measurement. It indicates Neriman’s level of discomfort, which can influence her ability to perform daily functions.
- The patient has a BMI of 35, indicating obesity.
- The patient has a history of uncontrolled diabetes, with blood glucose levels ranging from 10-15 mmol/L in the past measurements.
- Medication history: Metformin 1000mg tab BD, Sertraline 50 mg tab daily, Captopril 25 mg tab daily, Atorvastatin 20mg daily. Provides information on potential drug interactions.
- The patient may encounter difficulty performing ADLs due to pain in the surgical site.
- The patient may be dehydrated: Her mouth is dry, and her tongue is white; the water bottle beside her bed is empty.
- The patient has a history of hypertension, controlled with medication.
- Urine output: at 32 mL/h in the beginning and 28mL/h during the last observation. It provides information on the patient’s hydration status, kidney function, and potential complications such as urinary retention or infection.
- Nutritional status: Can influence the patient’s ability to heal and recover from surgery, and may indicate the need for nutritional support or interventions.
Explanation of 5 Priority Cues
Pain and Discomfort Near the Surgical Site
Neriman reported feeling pain and discomfort, and is currently using her hand to protect the surgery site. The discomfort has gone from 2 out of 10 to 6 out of 10, suggesting a deteriorating situation.
Dry mouth and White Tongue
This cue indicates that Neriman may be dehydrated and unable to maintain good dental hygiene following surgery. The fact that the water bottle next to her bed is empty shows that she hasn’t been getting enough fluids. Electrolyte imbalances and other consequences from dehydration can hinder healing and raise the risk of infections (Lung et al., 2023).
Tiredness and Dizziness
The presence of postoperative problems, including hypovolemia, hypotension, or anemia, may be indicated by these signals. The patient’s heart rate has jumped from 72 to 115 beats per minute, and her blood pressure has dropped from 140/75 to 102/60 mmHg, potentially signaling hypotension or anemia.
Low Oxygen Saturation
The oxygen saturation has dropped from 96% to 94%, necessitating additional observation and perhaps even treatment. According to Diehl and Pesenti (2019), a drop in blood oxygen levels might result in respiratory distress or hypoxemia.
High Blood Glucose Level
Neriman has a history of Type 2 Diabetes Mellitus, which raises the risk of infection following surgery and slows the healing process. She now has a blood glucose level of 9.5 mmol/L instead of 7.5 mmol/L, indicating that she has to have her diabetes closely monitored and managed after surgery.
Identifying the Problems
Diagnosis 1
Risk for infection related to surgical incision and compromised immune system, evidenced by a history of breast cancer and complex medical history including Type 2 Diabetes Mellitus and Obesity (BMI 34.9, Weight 95kg), and decreased urine output. These conditions can impair the immune system and increase the risk of infection.
Diagnosis 2
Risk for impaired skin integrity related to the surgical incision and immobility is indicated by pain and discomfort near the surgical site, the use of her hand to protect the surgical site, and elevated respiratory and heart rates. Impaired skin integrity can lead to issues such as infection, slow wound healing, and other complications. Shallow breathing and restricted mobility might result from elevated cardiac and respiratory rates.
Establishing SMART Goals
Goal 1
Specific: Within 48 hours, the patient’s pain level must drop from 6/10 on the Numeric Rating Scale (NRS) to 2/10 or less. Measurable: Every four hours, the pain level will be measured and recorded using the Numeric Rating Scale (NRS). Achievable: The patient will receive the appropriate analgesics to manage her pain. Relevant: Encourage patient comfort and carry out ADLs. Time: Within 48 hours.
Goal 2
Specific: Before discharge, blood sugar levels must be kept within the desired range (4–7 mmol/L) for at least two straight days. Measurable: Blood sugar levels will be checked and recorded every four hours. Achievable: The patient will receive the necessary diabetes control treatments, including insulin therapy and dietary modifications, as needed. Relevant: To avoid complications. Time-bound: Before patient discharge.
Selecting a Course of Action
Administering Pain Relievers as Prescribed
Intervention
The anesthesiologist or surgeon will issue an order for a painkiller, which the nurse will then administer in accordance with the hospital’s guidelines for medication administration. Before and after administering the painkillers, the nurse will evaluate the patient’s level of pain using a pain assessment tool, such as the Numeric Rating Scale (NRS).
The nurse will evaluate the patient’s pain setting, quality, magnitude, and aggravating or mitigating factors if it exceeds the targeted goal of 2/10 or less to choose the most effective pain management technique. The nurse will also monitor the patient for any side effects of the painkillers, such as drowsiness, hypotension, or respiratory depression. In the patient’s medical file, the nurse will note the pain evaluation and treatment procedures.
Rationale
Using painkillers is a critical step in helping surgery patients manage their pain. Painkillers help reduce pain intensity and improve the patient’s ability to perform activities of daily living (ADLs) with minimal discomfort (Fallon et al., 2018). The patient will experience sufficient pain relief if the drug is taken as directed, thereby lowering the risk of complications and accelerating the healing process.
Implementing Non-Pharmacological Pain Management Strategies
Intervention
The patient’s tastes, cultural assumptions, and prior exposure to non-pharmacological pain treatment modalities will be evaluated by the nurse. They include meditation, distraction, guided imagery, sound therapy, or therapeutic massage. The nurse will inform the patient and their relatives of the advantages and disadvantages of each plan, while also seeking their input in choosing and implementing it.
The patient can practice the chosen tactics in a welcoming and confidential setting provided by the nurse. The patient’s capacity to execute ADLs will be improved, and the nurse will assess how well the techniques reduced the patient’s pain level. The nurse will note the non-pharmacological treatments for pain management and their results in the patient’s medical file.
Rationale
Non-pharmacological pain management methods like guided imagery, distraction, and relaxation techniques can be used in concert with pain medication to control pain successfully. These methods can lessen the patient’s dependence on painkillers, lower the likelihood of side effects from these drugs, and increase the patient’s general level of comfort (Kia et al., 2021). Non-pharmacological therapies are a viable choice for controlling pain in surgical patients because they are also affordable and simple to implement.
Education on Insulin Delivery and Blood Glucose Monitoring
Intervention
The nurse should first evaluate the patient’s current level of knowledge and comprehension of diabetes management before implementing this intervention. This will help determine the necessary educational level. The patient can then be taught by the nurse about tracking blood glucose and insulin delivery using a range of instructional tools, including written materials, visual aids, and verbal instructions.
The nurse may also explain how to use a blood glucose meter and how to administer insulin injections correctly. The patient should be informed by the nurse about the importance of routine blood glucose testing and how to adjust insulin dosages based on the results. The nurse should clarify when to seek medical attention and what to do in the event of hypoglycemia or hyperglycemia.
Rationale
To effectively manage diabetes, it is essential to have a comprehensive understanding of the condition, its complications, and effective self-management strategies. To help the patient attain the intended outcome, it is essential to provide training and self-management support (Davis et al., 2022).
Through this intervention, the patient will acquire the knowledge and skills necessary to perform successful diabetes self-management, including blood glucose tracking, lifestyle modifications, and medication management. A patient can develop self-efficacy, a crucial factor in long-term diabetes management, by receiving education and support.
Cooperating with the Multidisciplinary Team for Glycemic Management
Intervention
To ensure that the patient receives thorough diabetes management, the nurse should collaborate with an interdisciplinary team, which includes the doctor, diabetes educator, and nutritionist. The patient’s care plan can be updated as needed by the nurse by informing the team of the patient’s blood sugar levels, medication schedule, and dietary restrictions.
To create a meal plan that meets the patient’s dietary requirements and supports glycemic management, the nurse may also consult with a diabetes instructor or nutritionist. The nurse must ensure that the patient receives routine blood glucose checks and medication adjustments as needed.
The nurse must record the patient’s blood sugar readings, any medication adjustments, and any interdisciplinary team meetings that occur. Additionally, the nurse must assess how the patient has responded to the actions and change the care strategy as necessary.
Rationale
Managing diabetes medication is crucial for achieving and maintaining ideal blood glucose levels. To help patients reach the desired outcome, collaboration with a multidisciplinary group for optimal diabetic drug administration is crucial (Conca et al., 2018). The patient will be able to obtain the correct diabetes medications, dosage adjustments, and regular monitoring thanks to this intervention, which is essential for achieving and maintaining ideal blood glucose levels.
Evaluating the Desired Outcomes
Evaluation of Pain Management
The Numeric Rating Scale (NRS) can be used to compare the patient’s degree of pain before and after interventions to determine the efficacy of pain management strategies. The success of the interventions will be determined by the pain level on the NRS dropping from 6/10 to 2/10 or below within 48 hours. It is also possible to evaluate and record the patient’s capacity for ADLs with the least amount of discomfort.
Diabetes Control Evaluation
By tracking the patient’s blood glucose levels, it is possible to assess how well the interventions are controlling the patient’s diabetes. Before being discharged, the patient’s blood glucose levels must remain within the desired range of 4 to 7 mmol/L for at least two consecutive days. By probing the patient about her regimen for monitoring her blood sugar levels and her comprehension of her diabetes medications, the doctor can determine whether the patient is aware of the value of these measures.
Regular evaluation of the individual’s vital signs, laboratory results, and overall health is necessary to determine the success of the interventions. Nursing measures should be updated and reevaluated if the anticipated results are not obtained. It’s also important to communicate with the patient’s family and the interdisciplinary team.
Reflection
Situation
The patient’s case posed a challenging healthcare scenario that required cautious evaluation and efficient management. The patient was in for surgery but also had acute pain and poorly controlled diabetes, among other comorbidities.
Problem
Poor diabetes control and inefficient pain treatment were the main issues found. These issues may hinder the patient’s postoperative recovery and raise the possibility of complications.
Reflection
The process of clinical reasoning helped identify the issues and develop the most effective nursing interventions to address them. The patient’s demands were effectively satisfied thanks to the application of person-centered care and guidelines for evidence-based practice.
Outcome
By the end of the hospital stay, the patient had successfully managed their pain and demonstrated improved control over their diabetes.
Understanding
This task highlighted the importance of a person-centered approach and effective collaboration with the multidisciplinary healthcare team. According to Royce et al. (2019), clinical reasoning assists in the development of critical thinking abilities and the capacity to effectively apply evidence-based practice standards, which I have acquired.
Summary
This experience will benefit my future practice by highlighting the value of applying person-centered care and evidence-based practice guidelines. To achieve the best patient outcomes, this task has also highlighted the importance of effective interaction and collaboration with the multidisciplinary medical team (Shellenberger & Weber, 2018). To provide my patients with the best care possible, I will continue to focus on patient-centered care, adhere to evidence-based practice recommendations, and collaborate effectively with the healthcare team. These insights will enable me to deliver improved treatment to my patients.
References
Conca, T., Saint-Pierre, C., Herskovic, V., Sepúlveda, M., Capurro, D., Prieto, F., & Fernandez-Llatas, C. (2018). Multidisciplinary collaboration in the treatment of patients with type 2 diabetes in primary care: Analysis using process mining. Journal of Medical Internet Research, 20(4), e127.
Davis, J., Fischl, A. H., Beck, J., Browning, L., Carter, A., Condon, J. E., Dennison, M., Francis, T., Hughes, P. J., Jaime, S., Lau, K. H. K., McArthur, T., McAvoy, K., Magee, M., Newby, O., Ponder, S. W., Quraishi, U., Rawlings, K., Socke, J., Stancil, M., & Villalobos, S. (2022). 2022 National standards for diabetes self-management education and support. Diabetes Care, 45(2), 484–494.
Diehl, J. L., Mercat, A., & Pesenti, A. (2019). Understanding hypoxemia on ECCO2R: back to the alveolar gas equation. Intensive Care Medicine, 45(2), 255–256.
Fallon, M., Giusti, R., Aielli, F., Hoskin, P., Rolke, R., Sharma, M., Ripamonti, C. I., & ESMO Guidelines Committee (2018). Management of cancer pain in adult patients: ESMO clinical practice guidelines. Annals of Oncology: Official Journal of the European Society for Medical Oncology, 29(Suppl 4), iv166–iv191.
Kia, Z., Allahbakhshian, M., Ilkhani, M., Nasiri, M., & Allahbakhshian, A. (2021). Nurses’ use of non-pharmacological pain management methods in intensive care units: A descriptive cross-sectional study. Complementary Therapies in Medicine, 58, 102705.
Lung, B., Callan, K., McLellan, M., Kim, M., Yi, J., McMaster, W., Yang, S., & So, D. (2023). The impact of dehydration on short-term postoperative complications in total knee arthroplasty. BMC Musculoskeletal Disorders, 24(1), 15.
Royce, C. S., Hayes, M. M., & Schwartzstein, R. M. (2019). Teaching critical thinking: A case for instruction in cognitive biases to reduce diagnostic errors and improve patient safety. Academic Medicine: Journal of the Association of American Medical Colleges, 94(2), 187–194.
Shellenberger, T. D., & Weber, R. S. (2018). Multidisciplinary team planning for patients with head and neck cancer. Oral and Maxillofacial Surgery Clinics of North America, 30(4), 435–444.