Deliverable 7 - The Dynamic Process of Clinical Judgement

Based on the three case scenarios, patient two, E.H is a priority for urgent medical management and care. E.H. is a 40-year-old female who presents with acute onset of severe right upper quadrant pain and vomiting. The pain and vomiting have lasted for the past 36 hours. Besides, the ECG monitoring shows occasional premature ventricular contracts (PVCs). The insidious vomiting is severe and may lead to dehydration and electrolyte imbalance. Also, the severity of pain indicates the underlying issue is serious requiring urgent attention. The second priority patient is BW, a 21-year-old male athlete with a fever of 103 and a diagnosis of influenza. Despite resting well overnight, a morning chest x-ray reveals mild infiltrates in the left lower lobe, which indicates a likelihood of pneumonia. He needs medical attention but not as urgent as E.H. The third priority patient is JR, a 55- year-old male admitted 8 hours prior for a 24-hour hold to evaluate for possible myocardial infarction.  The laboratory results show serial Troponins within normal range, and the 12 lead ECG indicated evidence of prior right anterior wall myocardial damage. He needs continuous monitoring and follows up.

Priority client data

 E.H has underlying problems that require immediate attention. From the list, the priority includes pain, potassium levels, and abnormal liver functions. First, E.H rates the pain in the abdomen as 10/10, which indicates she is experiencing severe pain. Also, from physical examination, her abdomen is tender on all four quadrants. Therefore, it is paramount to manage pain, improve her comfort, and evaluate the source of pain afterward. The severity and location of pain point towards a diagnosis of what she could be suffering from, and managing the cause relieves the pain.  The second priority data is the client has electrolyte imbalance. Her potassium levels are 2.9 mmol, which is low; hence she suffers from hypokalemia. Hypokalemia occurred due to vomiting and needs to be collected urgently with infusions of potassium and fluids (Kardalas et al., 2018). Finally, liver function test results show an elevation in most of the parameters. For instance, the bilirubin levels are 3.5mg/dl, elevated three times the normal range. The reference range is 0.3-1.2mg/dl (Wehbi, 2020).

Hypotheses: Nursing diagnosis

Risk for electrolyte imbalance related to severe vomiting as evidenced by low potassium levels and abnormal ECG

Acute pain related to abdominal cramping evidenced by abdominal tenderness reported upon palpation of the abdomen, and the client verbalize pain level at 10 out of 10

Risk for impaired liver function evidenced by elevated liver function panel and the client verbalize right upper quadrant pain

Evaluation Plan

Mrs. E.H has three significant issues; the priority issue to address involves managing the electrolyte imbalance. Due to constant vomiting, the patient has fluid volume deficit, low potassium levels, and elevated sodium levels. The management consists of the administration of intravenous fluids.  Hypokalemia, if not managed, can cause heart arrhythmias and lead to respiratory failure due to muscle weakness. Correcting the potassium is critical to prevent cardiovascular collapse

 

 

Next steps in the Clinical judgment model

The indications of good outcomes are improved potassium levels to levels above 3.5 mmol/l and patient verbalizing reducing pain levels. The client rates her pain at ten which is the highest possible rank. Before a definitive diagnosis is identified, administration of analgesics will be done to improve comfort (Mayumi et al., 2015). If the patient stabilizes, the other clinical step will be to complete a full assessment for diagnosis. From the clinical data, the client has a possible impairment of the liver. The bilirubin, alkaline phosphate, protein, and amylase levels are elevated. As definitive diagnosis is identified, vital monitoring is also essential and will be performed to assess the patient's progress and stability.

The Dynamic Process of Clinical Judgement outline

Based on the three case scenarios, patient two, E.H is a priority for urgent medical management and care. E.H. is a 40-year-old female who presents with acute onset of severe right upper quadrant pain and vomiting.

Priority client data

 E.H has underlying problems that require immediate attention. From the list, the priority includes pain, potassium levels, and abnormal liver functions.

Hypotheses: Nursing diagnosis

Risk for electrolyte imbalance related to severe vomiting as evidenced by low potassium levels and abnormal ECG

Evaluation Plan

Mrs. E.H has three significant issues; the priority issue to address involves managing the electrolyte imbalance.