This is a discussion about physiology and pathophysiology and support all ideas put forward with references. For example, 'relate and infer' is the section where you provide an explanation for the data you have obtained, by discussing the physiological and pathophysiological processes and mechanisms. This careful discussion will inform the diagnoses you develop and all your subsequent decisions about care for the patient. When you consider the clinical reasoning cycle this step is directly after you have collected data (abnormal and normal cues). This step is the clustering of your cues and relating them to your patients situation to infer why you are seeing what you are seeing. This links to the patholpysicological changes occurring and why. CUES -
Mr Eddie Baker is 31 years old. He was diagnosed with Crohn’s disease in his
early 20s. Since then, the disease process has become extensive, affecting
most of his terminal ileum and ascending colon. He has experienced some
severe exacerbations which have required hospitalisation. He has used most of
the pharmacotherapies available, including immunosuppressive medications
and corticosteroid therapy for acute exacerbations.
Recently, after a colonoscopy showed progression of the disease to other
sections of his large bowel, he made the decision to undergo a total colectomy
to better manage his condition.
His initial surgery was booked for yesterday at 1000. He last ate at 1930 the
night before his surgery and last drank at a black weak tea at 0600 the morning
of surgery. Due to an emergency Eddie’s operation was delayed until the
afternoon. The surgical team were happy with the operation and reported
minimal blood loss. Eddie returned to the ward at 1900 last night.
QUESTION:
This is a discussion about physiology and pathophysiology and support all ideas put forward with references. For example, 'relate and infer' is the section where you provide an explanation for the data you have obtained, by discussing the physiological and pathophysiological processes and mechanisms. This careful discussion will inform the diagnoses you develop and all your subsequent decisions about care for the patient.
When you consider the clinical reasoning cycle this step is directly after you have collected data (abnormal and normal cues). This step is the clustering of your cues and relating them to your patients situation to infer why you are seeing what you are seeing. This links to the patholpysicological changes occurring and why.
CUES -
Normal cues Subjective
- Peripheral pulses palpable
- PQRST score = 4 which is acute pain related normally post-surgery
- Normal Objective cues
- Weight = 63kg
- BGL = 4.7mmol, (normal blood glucose levels are between 4.0–7.8mmol/L) (Diabetes Australia 2020).
- Sp02 = 96% on RA (normal level of oxygen is usually 95% or higher) (ACSQHC 2017).
- Temperature: 36.5 (The normal body temperature range is 36.5°C to 37.5°C) but is becoming to trend lower from ADDS chart (ACSQHC 2017).
- PEARL/ Motor and sensory function intact/ Alert and orientated.
- No oedema
- Clear lung fields bilaterally
- Dressing intact, nil ooze or bleeding on abdominal wound site + stoma site.
- CXRay- Nil evidence of enlarged cardiac shadow or lung changes pre-op.
- JVP not visible
- Bowel sounds not present (is expected as he is post-surgery)
Abnormal Subjective cues
- History of Crohn's disease
- Abdomen firm/swollen/tender
- Tight pressure around abdomen when moving or palpation, nothing is making it feel better
- Pulse rapid and palpable
- Dyspneic
- Increased work of breathing
Abnormal objective:
- Blood Pressure (BP) = 101/42, (for a 31-year-old a normal Systolic range is 95-135mmHg and Diastolic range is 60-80mmHg) (Amerman E. 2019). Starting to trend to low on the ADDS chart overnight (ACSQHC 2017).
- Heart rate (HR) = 118, (normal HR 60 – 100 bpm) (Amerman E. 2019).
- Respiratory rate (RR) = 20, (normal RR is 12-16 breaths per minute) (ACSQHC 2017).
- Reducing in level of consciousness GCS=13 (normal GCS score is equal to 15, which indicates a person is fully conscious) (Amerman E. 2019).
- Capillary refill 3>4 seconds (normal cap refill is 2 seconds or less) (Amerman E. 2019).
- Pale, cool to touch, clammy, dry mucous membranes
- ECG = Sinus Tachycardia
- Fluid intake since midnight is 975mL
- Urine output since midnight is 120mL (Oliguria is defined as decreased production in urine <500 ml/day in adults) (CDC 2020)
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