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Case Study Of Cholecystitis Question: Discuss about the Cholecystitis with Clinical Reasoning Cycle.     Answer: Introduction: Clinical reasoning cycle is one of the most important tools that are utilized by the nurses in order to perform correct assessments of the patients and plan the right interventions. Often a patient gets admitted in a hospital with huge number of symptoms. In such a scenario, it is the duty of the nurse to assess each and every symptom of the patient and then by applying her knowledge and skills, she would relate the situations of the patients with the symptoms and then apply her interventions. Clinical reasoning cycle makes the work of a nurse easier by allowing her at first consider the patients’ situation, collect information about the patient and then process the information. After properly processing the information, the nurse should then be able to identify the problems of the patients which will then make her to establish her goals (Koharchik et al 2015). These setting of goals will help the nurse to plan her interventions accordingly following which she needs to conduct proper evaluation of the results. The nurse would then be reflecting upon her own experience of handling the case by properly addressing both the negative as well as the positive points (Victor-Chmil, 2013). Therefore by this process of clinical reasoning cycle, the given case will be analyzed that will help the nurse in sequentially approaching to plan the correct set of interventions.   The first step is to consider the person situation who has been admitted to the hospitals. The patient was of 49 years of age and was suffering from the symptoms of acute cholecystitis. It was noted that he had suffered from the pain in her right upper quadrant (RUQ) of the abdomen.. Not only that he was suffering from fever as well as vomiting. Patients who usually get admitted to these hospitals due to cholecystitis are mainly women belonging to higher age cohort. Normally this disorder is mostly seen in women than in men. Moreover the age cohort that gets affected by the disorder is mainly middle age adult usually in the forties and the cases have increasing number as the age increases (Alfaro et al., 2015). In this case, although the gender criteria did not align with the occurrence of the disorder in the patient but however his age was vulnerable tp the occurrence of the disorder. He was accompanied by his daughter who was of 12 years of age and complained of severe shoulder tip pain. Not only that, he also reported that he had done vomiting just before two hours. These are the information that the nurse collected about assessing the situation of the patient. The second point is the collection of the information by assessing the situation of the patient. The nurse conducted the vital sign analysis and it showed that many of the components showed signs of concern in the patient. The first one is the heart rate which was measured to be 126. This sign showed that the heart rate of the patient was quite high and he had a vulnerability to develop tachycardia. Secondly, his blood pressure was low for about 100/45 which should be 120/80 and this showed that the nurse should immediately take precautionary measure to make his blood pressure stable to prevent him from losing his consciousness and other associated factors (Noh & Lee, 2015). His temperature was about 38.8 which was higher the normal and helped the nurse to understand that he is having fever that may be due to severe physiological condition. The nurse should also take proper interventions to make the vital signs come under control so that any severe issues may not arise (Doenges, Moorhouse & Murr, 2014).   The third point is processing the information that the nurse had gathered form the case and then relating them with the knowledge she has to spread light on the entire scenario. The patient had developed acute pain in the right upper quadrant of the abdomen and his pain from this region has spread to the tip of his shoulders. These are the symptoms that are noticeable in case of cholecystitis. This usually occurs in cases of gall bladder. Gall bladder is the small, pear shaped organ that is mainly located in the right side of the body just beneath the liver. It is mainly responsible for storing a digestive fluid released by the liver. This fluid helps in digesting lipid droplets when they are released into the small intestine after moving through the common bile duct (Ambe et al., 2016). However in many cases, it is seen that occurrences of gall stones in the gall bladder acts as barriers of the digestive fluid to enter the bile duct. This results in building up of the fluid inside the gall bladder leading to inflammation. Often there may be also other reasons that lead to the occurrence of the symptoms of cholecystitis. This may be due to the infection of the Common bile duct or CBD system along with the blockage in the CBD system (Zhang et al., 2013). Sometimes due to diabetes, less blood supply occurs in the gall bladder causing inflammation. Moreover tumors in the gall bladder may also result in the occurrence of cholecystitis. Researchers have shown that in most cases, patients who remain associated with cholecystitis have complained of constant pain as well as development of fever and vomiting (Lindseth & Denny, 2014). The fourth step is the identification of the issues in the proper way so that the nurse can then form the right goals that need to be achieved. The different symptoms that were observed like tachycardia, fever as well as pain in the epigastric region are intricately associated with the occurrence of cholecystitis. Repeated vomiting was another symptom. However in order to ensure that the diagnosis made by the nurse is on the right track, she needs to conduct different tests to be assured. Often ultrasonography is the preferred test that is recommended by every healthcare expert which is mainly based on initial imaging that helps the nurse to understand the presence or absence of acute cholecystitis. Computed tomography is another diagnosing test which helps in understanding the patients who have non-specific abdominal pain (Quian et al. 2013). Besides researchers have suggested that magnetic resonance imaging called as MRI also helps the nurse as secondary tests for confirming the presence of the disorders as cholecystitis in the patients. All the tests would help the nurse to understand the main reason for the patient suffering from the symptoms and help her in setting the goals.   The next step is detailing the assessment that the nurse has conducted in order to derive to a conclusion. From the ultrasound, the nurse can understand that whether any gall bladder stones are present or not that often results to a condition which is called the cholelithiasis. This may remain in combination with the sonographic Murphy sound. Moreover the presence of the wall thinking of the gall bladder about greater than 3 mm along with pericholecystic fluid can be considered by her as the secondary findings. Besides, the nurse can also find gallbladder distention as well as the sludge. CT is however less sensitive than the ultrasound and helps to find the presence of cholelithiasis, gall bladder wall thickening, gall bladder distension, inflammatory fat stranding, mucosal hyperenhancement and others 9Le & Finleyson, 2016). The nurse may also notice the advancement of the adjacent liver parenchyma which may be due to reactive hyperaemia. Tensile gall bladder fundus sign is also noted by nurses in such condition. Once the nurse becomes sure after a thorough assessment that the patient is suffering from the disorder, she may develop a plan where urgent surgical removal of gall bladder can be included as a necessary intervention. This is called the cholecystectomy.  Otherwise, the management can be done by the nurse by allowing the patient to fast so that stress may be released off from the inflamed gall bladder and prescribing IV fluids as temporary food for cells (Shuling et al., 2013). Moreover the nurse may also help in restoration of the hemodynamic stability as well as the antibiotic coverage of the gram negative bacteria. Moreover the nurse may also help in gall bladder stimulation where IV cholecystokinin may prevent the occurrence of gall bladder sludge. Nursing assessment should also include the assessment of the integumentary system that helps in assessment of the skin as well as the mucous membrane. She will also assess the circulatory system with properly assessing the peripheral pulses and refilling the capillary. Her gastrointestinal system should also be assessed for abdominal distension, guarding, and frequent belching and others. Following proper assessment, the nurse should set out goals and then perform the activities to provide proper interventions so that the condition of the patient can be developed and also to relieve her form this condition. This may include managing pain and assessment, promoting bed rest, encouragement the use of relaxation techniques, proper communication with patients along with proper food planning, promoting appetite and others. This would be followed by proper evaluation and a refection forms the nurse on her experience (Bonatti et al., 2016).   Conclusion: Following the clinical reasoning cycle, the nurse can effectively assess the symptoms of the present. With proper assessment of each and every symptom and relating with the pathophysiology and with the present satiation, the nurse can effectively set goals and thereby develop the best interventions that would bring the best effect on the patient. Correctly assessing the different symptoms with the right diagnostic tools and tests are important in order to be sure that whether the guesses made after initial diagnosis are correct or not. Thereby an individual by following the five important steps of assessment can be sure that her  approach towards the case are moving through the right direction and therefore quality care for the patient can be confirmed.   References: Alfaro-LeFevre, R. (2015). Critical thinking, clinical reasoning, and clinical judgment: A practical approach. Elsevier Health Sciences. Ambe, P. C., Kaptanis, S., Papadakis, M., Weber, S. A., Jansen, S., & Zirngibl, H. (2016). The Treatment of Critically Ill Patients With Acute Cholecystitis: A Systematic Review and Meta-analysis Comparing Percutaneous Cholecystostomy and Cholecystectomy. Deutsches Ärzteblatt International, 113(33-34), 545. Bonatti, H., Tierney, J., Kanaya, E., Crislip, Z., Tarpley, J., & May, A. (2016). Acute Cholecystitis Caused by Vancomycin-Resistant Enterococcus faecium in a Morbidly Obese Patient with Multiple Co-Morbidities. Surgical Infections Case Reports, 1(1), 115-119. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing care plans: Guidelines for individualizing client care across the life span. FA Davis. Koharchik, L., Caputi, L., Robb, M., & Culleiton, A. L. (2015). Fostering clinical reasoning in nursing students. AJN The American Journal of Nursing, 115(1), 58-61. Le, S. T., & Finlayson, E. (2016). Surgical vs Non-Surgical Management of Acute Cholecystitis in Nursing Home Patients. Journal of the American College of Surgeons, 223(4), S118. Lindseth, G. N., & Denny, D. L. (2014). Patients’ Experiences with Cholecystitis and a Cholecystectomy. Gastroenterology nursing: the official journal of the Society of Gastroenterology Nurses and Associates, 37(6), 407. Noh, H. K., & Lee, E. (2015). Relationships Among NANDA?I Diagnoses, Nursing Outcomes Classification, and Nursing Interventions Classification by Nursing Students for Patients in Medical?Surgical Units in Korea. International journal of nursing knowledge, 26(1), 43-51. Qian, C. H. E. N. (2013). The Analysis of the Effect of Laparoscopic Cholecystectomy in Patients with Nursing Intervention [J]. Guide of China Medicine, 14, 336. Shuling, L., Huixuan, L., Ling, Z., Huannv, W., & Xuefen, Z. (2013). Experience of nursing 23 pregnant women with acute cholecystitis and gallstones. Modern Clinical Nursing, 8, 018. Victor-Chmil, J. (2013). Critical thinking versus clinical reasoning versus clinical judgment: Differential diagnosis. Nurse educator, 38(1), 34-36. ZHANG, J. X., LIN, Y. X., & ZHAN, Y. C. (2013). Characteristics of cholecystitis patients with infections and intervention countermeasures. Chinese Journal of Nosocomiology, 14, 049.

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