Paper Example. The Dynamic Process of Clinical Judgment

Clinical judgment is the process of incorporating critical thought, evidence-based practices, nursing processes, and attitudes, as well as the application of the theory of practice to promote quality care and safety for patients (Mariathas & Curzen, 2019). In that regard, my clinical judgment will be essential to decide on the three scenarios depending on the level of urgency.

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The Three Scenarios

EH, a 40-year-old patient will be the first client that needs abrupt attention. The patient is experiencing acute onset severe right acute right upper quadrant pain and has been vomiting for the past 36 hours. The symptoms, as mentioned above, indicate that the individual is suffering from a gallbladder ailment. Therefore, a delay in care could have been catastrophic to the client. Thus, the concern for patients suffering from such conditions may be expedited because a delay to definitive diagnosis and treatment may subsequently lead to increased mortality and morbidity.

Additionally, the lab's ECG monitoring indicates frequent PVS (premature ventricular contractions) (Wang et al., 2013). There have been connections that relate to gallbladder ailment to cardiac disorders, which signifies the severity of the situation. Therefore, PVS accompanied by frequently vomiting and pain in the right upper quadrant can lead to chaotic, irregular, and adverse heartbeats that increase the chances of a sudden cardiac arrest and, subsequently, death.

JR, a 55-year-old patient, will be the second one that I attend to in terms of urgent attention. The patient has been admitted 8 hours before a 24-hour hold up to analyze a possible heart attack. However, the patient has Serial Troponins within the normal range, although the 12 lead ECG depicts that the patient has the right interior wall myocardial damage. The patient has Serial Troponins within the normal range of 0- 0.4 ng/ mL (Wang et al., 2013). It is an indication that the type of heart attack experienced by the patient has not caused an increase of troponin levels, which may mean that there is a potential heart attack that is above the reference range. Due to such observations, patient 2 is more stable compared to one and thus have more waiting time compared to the latter. Similarly, although the patient has a right interior wall myocardial damage, the mortality rate caused by a damaged inferior wall myocardial infarction (MI) is less than 6% when the Serial Troponins within the normal range of 0- 0.4 ng/ mL (Wang et al., 2013).

BW, a 21 old male athlete, is the last patient that I will attend to due to low-risk levels. The client has been admitted with a fever of 103, as well as the influenza diagnosis (Wang et al., 2013). However, the patient has rested well overnight, and morning chest x-ray indicates mild infiltrates in the lower left lobe. Firstly, the client has rested well overnight in a conditioned room temperature that helps to reduce the increased fever as well as ease the symptoms of influenza, thus making the patient the least likely to suffer from severe conditions compared to the rest of the patients.

Data Review of Patient, EH

In any clinical and hospital setting, there are stat tests. A nursing practitioner needs a stat test to obtain results in the shortest time possible to make a significant clinical decision. Whereas all criteria are considered essential and should be carried out with precision and as quickly as possible, stat tests supersede all others. There are a couple of stat tests, but the most common are cardiac markers, electrolytes, and glucose, among others.

For our priority patient, EH, the following are the urgent assessments that need to be done. First, serum electrolytes need to be checked. The electrolytes are comprised of Sodium, Chloride, and Potassium. EH is a classic case of hypokalemia, and this is very critical as it can lead to muscle cramps, arrhythmia, and even paralysis. Potassium is very crucial in maintaining the action pump, which is responsible for the proper functioning of the cells and nerves.

EH has a history of frequent vomiting for the last 36 hours, meaning so much of the blood's Potassium has been lost. A possible hypothesis could be the Cholelithiasis that is affiliated with the overproduction of aldosterone. Aldosterone is responsible for stimulating the kidneys to excrete Potassium. Subsequently, aldosterone levels should also be checked, and clinical correlation made with the electrolytes values. The usual range of Potassium is 3.5 to 4.5 mmol/L (Mariathas & Curzen, 2019). Therefore, this is to means that a reading of 2.9 is way below the reference range. Hypokalemia is affiliated with low levels of magnesium, and the same is exhibited in EH's results. The average magnesium levels are 1.5 to 2.5 mg/dl, and EH records indicate 1.4mg/dl. Calcium is also a stat test, but, in this case, it will not be considered much because it falls within the normal ranges.

The next assessment should be focused on amylase. The pancreas primarily produces amylase, and any alteration from the normal reference range is suggestive of a problem with the pancreas. The most probable hypothesis of EH is acute cholecystitis (Wang et al., 2013). The other supporting clinical manifestations include hyperactive bowel sounds in all the four quadrants. Likewise, the abdomen is sensitive and painful to touch. Such hyperactive sounds can be well confirmed with a stethoscope where the noises can be heard when closely monitored. The condition can lead to rupturing of the intestines, especially when the sounds subside after a given period. That being said, the fact that EH is not experiencing any diarrhea could be suggestive that the patient is suffering obstruction of the intestines. On the acute cholecystitis hypothesis, differential symptoms include fever, nausea/vomiting, and diarrhea, which are missing in EH. A confirmatory diagnosis that can be suggested on gall bladder inflammation is the lipase test.

The creatinine and urea levels are within the normal range, and this is to say that the patient's kidneys are in perfect health. The deviation of electrolytes alone is not enough to suggest Chronic Kidney Disease. On premature ventricular contractions, I believe that they are primarily caused by the offset of electrolytes balance and cannot be necessarily used to assert cardiac arrest.

Three Hypothesis Based On Cues Provided

Based on the signals provided by EH, there are three hypotheses to the problem the patient may be suffering from which include:

• Acute cholecystitis
• Cholelithiasis
• Choledocholithiasis

The priority hypothesis that matches the cues presented by the patient is acute cholecystitis. It is the inflammation of the gallbladder that is caused when a gallstone obstructs the cystic tube. Severe cholecystitis symptoms include right upper quadrant pain that is frequently accompanied by vomiting. Based on the signals indicated above, the patient is experiencing a pain level of 10/10 (Keiji Ohota, 2014). Individuals with acute cholecystitis experience extreme pain because the patient has abnormal levels of Sodium (Na+) 147 mmol/L, Bilirubin 3.5 mg/dL, and Alkaline Phosphatase 155 unit/L that combine in the bile to form stones (Kumar, 2017). Therefore, as the stone passes from the gallbladder becomes stuck in the biliary duct when heading into the small intestine, thus leading to extreme pain in the abdominal walls. The frequent pain experienced by individuals suffering from acute cholecystitis leads to occasional vomiting because the 'stones' in the gallbladder retrograde into the stomach, thus increasing the urge to vomit. The PVS accompanied by frequent vomiting and pain in the right upper quadrant can lead to chaotic, irregular, and adverse heartbeats that increase the chances of a sudden cardiac arrest and subsequent death.

Evaluation Plan Based On Expected Client Outcomes

The patient is diagnosed with acute pain linked to inflammation and obstruction, as evidenced by self-reports of extreme pain. The expected result is pain level is symptom severity. In that regard, the evaluation plan will include oral bile therapy as well as antibiotics to manage pain in the right upper quadrant. However, there is a need for laparoscopic cholecystectomy. The procedure should be performed within 48 hours upon diagnosis of acute cholecystitis because at this stage, and there is minimum inflammation in the gallbladder (Kumar, 2017). The patient may complain of pain in the abdominal wall due to the presence of carbon dioxide; thus, the use of antibiotics will be utilized to manage the pain once again.

Actions If Satisfied With Client Outcomes

From the hypothesis generated, the best possible route of treatment is surgery. EH needs to stay dehydrated to minimize the symptoms but it is challenging considering the patient is in extreme pain. Therefore, the best way to curb dehydration is through intravenous fluids. The patient should also be put on painkillers and antibiotics to relieve him from the abdominal pains he is presently experiencing. Laparoscopy and invasive methods should be used if possible to ensure that there is no bowel obstruction (Kawamura, Tanioka, Funakoshi & Takahashi, 2017). However, if these techniques make him uncomfortable, non-invasive procedures can be chosen. The patient should be consuming food that is high in Potassium and low on fats to minimize the formation of stones in the gall bladder. Depending on the severity of acute cholecystitis, I would recommend surgery to remove the gallbladder. Cholecystectomy should be the last option in this case but very necessary. However, it should only be done after all the other clinical symptoms have been diagnosed.

References

Kawamura, H., Tanioka, T., Funakoshi, T., & Takahashi, M. (2011). Dual-ports Laparoscopy-assisted Distal Gastrectomy Compared With Conventional Laparoscopy-assisted Distal Gastrectomy. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 21(6), 429-433. Doi: 10.1097/sle.0b013e318238063c

Keiji Ohota, N. (2014). Early Laparoscopic Cholecystectomy for Acute Cholecystitis in accordance with the Tokyo Guidelines for the Management of Acute Cholangitis and Cholecystitis. General Medicine: Open Access, 02(01), 1-34. Doi: 10.4172/2327-5146.1000127

Kumar, D. (2017). Laparoscopic Cholecystectomy vs. Open Cholecystectomy in the Treatment of Acute Cholecystitis. Journal Of Medical Science And Clinical Research, 05(05), 22547-22551. Doi: 10.18535/jmscr/v5i5.206

Mariathas, M., & Curzen, N. (2019). Use of troponins in clinical practice: Evidence against the use of troponins in clinical practice. Heart, 1(3), heartjnl-2019-315765. Doi: 10.1136/heartjnl-2019-315765

Wang, L., Chang, L., Lee, I., Tang, K., Li, C., & Eng, H. et al. (2013). Clinical diagnosis of pandemic A(H1N1) 2009 influenza in children with negative rapid influenza diagnostic test by lymphopenia and lower C-reactive protein levels. Influenza and Other Respiratory Viruses, 8(1), 91-98. Doi: 10.1111/irv.12182