Case Study: Clinical Reasoning Cycle

Introduction

Case studies are integral to teaching and learning nursing. They offer an opportunity to analyze, apply and reflect on nursing theory on a given scenario with multiple perspectives. In the present assignment, a case study focusing on the provision of ethical, legal, evidence based and comprehensive person centered care is presented. The scenario entails a 42 year old mother who just delivered a baby through an elective lower uterine caesarean section and has been consequently received in the post anaesthetic recovery room (PACU). Analysis of the case follows Levett-Jones (2013) clinical decision-making framework, which details six steps including consideration of the individual’s situation, collecting and processing of information, identification of problems/nursing issues, establishment of priorities for nursing care, discussion of the care appropriate for the person, justification of care strategies and a reflection on the individual’s outcomes. 

Case Scenario

Candace Evans underwent elective lower uterine caesarean section (LUCS) at 38 weeks of gestation with spinal anaesthesia. She was diagnosed with placenta previa (which necessitated LUCS) while in her last pregnancy had issues with gestational diabetes, depression, anxiety and post natal depression. The last pregnancy had been five years earlier and this was her second. Evidently, there are problematic clinical issues to be considered with respect to the placenta previa diagnosis, the use of spinal anaesthesia and the LUCS itself. Reflecting on such issues may need a consideration of the historical issues in the first pregnancy as well.

The delivery was successful with the surgery uneventful. In addition, the baby showed no signs of clinical problems having given normal APGARS scores. However, there was need for further assessment following the determination of low blood pressure. The latter is often associated with poor fetal outcomes (Kim et al., 2015). 

The indicators following PACU assessment raises several issues. First, the Dermatone level T3 indicates clinical issues with respect to post spinal anesthesia complications while the BP reading 104/76 also adds to the same concerns. Other evident issues that deserve a close examination are the inter-operative blood loss which was given at 150ml and the soaking of blood in the vaginal pads that included clots. 

Nursing Problems

There are three nursing issues that need to be prioritized in the given case scenario. First was postpartum hemorrhage. This is often noted in cases of placenta previa diagnosis that had been made in the given case. The latter refers to the positioning of the placenta on the extremely low ends of the uterus, covering over the cervix (Brenck et al., 2009). Apart from necessitating delivery by LUCS, placenta previa often leads to postpartum hemorrhage, a possibility given the soaking of the vaginal pads with blood and the interoperative blood loss of about 150ml (Kim et al., 2015). Placenta previa implies that bleeding cannot be stopped by uterine contractions and additionally, there may be a case of placenta accreta.

The second nursing issue was hypotension. This refers to low blood pressure that had been noticed following the 104/76 BP reading in the PACU assessment. Hypotension is a common risk associated with Spinal Anaesthesia given that the block is required to reach T4 as opposed to T10 during vaginal delivery (Brenck et al., 2009). In the given case, there was already a problem with the dermatome level indicated as T3 in the PACU.  This was clearly a challenge that should be given immediate attention.

The third priority would be pulmonary embolism. This refers to the blockade of one or more pulmonary arteries in the lungs due to blood clots travelling in the blood from other parts of the body. Pulmonary embolism is a common risk in surgeries including cesarean sections like the one in the case of Candace Evans. Notably, there were blood clots in the patient’s vaginal bleeding during the PACU assessment. This means alludes to the fact that it was a nursing priority that needed to be considered.

Goals for Priority of Nursing Care

In light of the above identified problems, there are a number of nursing goals that need prioritization in care. The first goal would be to stop the bleeding. Postpartum hemorrhage is quite a serious maternal health problem and if not addressed may end up fatal (Brenck et al., 2009). Though the bleeding noted in the vaginal area together with the interoperative blood loss did not qualify as Postpartum hemorrhage yet, it was capable of attaining such threatening status if unaddressed. 

Another goal would be analyzing fetal health. This is because the presence of hypotension indicated possible poor fetal outcome and there was need to carry a more comprehensive analysis to determine if the child was fully well. 

Thirdly, there was need to focus on preventing pulmonary embolism. Surgeries commonly lead to blood clots in the arteries which end up fatal and undiagnosed. Undergoing a cesarean section increased the chances of pulmonary embolism and required urgent addressing.

Nursing Care for Candice Evans

There are various steps that need to be taken in order to provide person centered care for Candice Evans. First, she needed a blood transfusion to compensate for the blood lost through the surgery as well as the vaginal bleeding. The transfusion will ensure stability and balance as efforts are made to stop the bleeding (Brenck et al., 2009). The latter involves first identifying the reason behind the bleeding. If it is due to contractions of the uterus, then medication is given to put that to a stop. Notably, bleeding due to placenta previa cannot be ended by contractions given that the placenta is located too low to experience the impact of contractions. On the other hand, if there is placenta accreta, hysterectomy would have to be performed for correction (Hasanin et al., 2017). Either way, the bleeding must be stopped in addition to offering a blood transfusion.

Secondly, there is need to offer anti-coagulants that clear off blood clots. These are necessary in reducing the chances of pulmonary embolism or even thrombosis. For the child, there should be a comprehensive analysis to determine the possibility of any birth complications such as low birth weight or breathing problems resulting from the hypotension. The latter should also be addressed with respect to the mother to ensure that she had normal blood pressure. 

Finally, there should also be deliberate efforts to avoid or fight infection. Surgery opens up the possibility of infections in the operated area as well as in the vaginal region where bleeding had been reported (Hasanin et al., 2017). The appropriate antibiotic treatment as well as proper wound care techniques should therefore be put in place to ensure that the mother was safe from infections following surgery.

Justification of Nursing Care Strategies

There are various justifications for the above care methods proposed for the patient in question. First, it is notable that the care model highlighted encompasses both the mother and the child, which is with respect to patient centered care paradigms. The mother would not have received comprehensive care covering all her needs if there was no focus on the well being of her child (Brenck et al., 2009). This necessitated the recommendation to perform a rigorous assessment of the newborn to unearth any complications that may have arisen from the hypotension following spinal anesthesia. In the end, the proposed care regime was centered on the patient’s clinical and psychological needs.

Elsewhere, the proposal to take note of infection was added on top of the others directed towards the primary nursing goals earlier-listed due to the commonality of infections in Cesarean sections and other blood related procedures. There was a huge chance of emerging infections following the surgery more so in the operated areas, while the same was possible with respect to the vaginal bleeding (Hasanin et al., 2017).  It was therefore necessary to take care of the same to avoid complications other than the ones associated with the clinical history and data collected during patient assessment. 

More importantly, stopping the bleeding, blood transfusion and the use of anticoagulants were justified measures that directly addressed the identified nursing issues and further resonated with the listed priority nursing goals. Stopping the bleeding and blood transfusion would help to prevent postpartum hemorrhage while anticoagulants were meant to prevent pulmonary embolism (Kim et al., 2015). Also proposed was treatment for hypotension, whose impact was not only probable on the newborn, but direct on maternal health.

Reflection on Patient Outcomes

With the above measures in place, it is apparent that positive outcomes would be realized both for the patient and her child. If the child would have no complications, it would be a great relief while in their presence, diagnosis would be made early and hence pave the way for subsequent care. The prevention of postpartum hemorrhage would also be addressed through transfusion of blood and stopping any further losses (Hasanin et al., 2017). This would effectively ensure that maternal health is secured from associated risks. Elsewhere, the treatment for hypotension and use of anticoagulants was in direct address to identified clinical problems, which would have further prevented postoperative risks on maternal health (Brenck et al., 2009). The measures, taken together with prevention of infection, would guarantee maternal health long after delivery. 

References

Brenck, F., Hartmann, B., Katzer, C., Obaid, R., Brüggmann, D., Benson, M., … & Junger, A. (2009). Hypotension after spinal anesthesia for cesarean section: identification of risk factors using an anesthesia information management system. Journal of clinical monitoring and computing, 23(2), 85-92.

Hasanin, A., Mokhtar, A. M., Badawy, A. A., & Fouad, R. (2017). Post-spinal anesthesia hypotension during cesarean delivery, a review article. Egyptian Journal of Anaesthesia.

Kim, J. H., Joung, E. J., Lee, S. J., Kwack, J. Y., & Kwon, Y. S. (2015). Intraoperative bleeding control during cesarean delivery of complete placenta previa with transient occlusion of uterine arteries. Obstetrics & gynecology science, 58(6), 522-524.

Levett-Jones, T. (Ed.), (2013). Clinical reasoning: Learning to think like a nurse. Sydney, Australia: Pearson Education.