Clinical Reasoning Cycle

Interpret:
In the following table, list the data that you consider to be normal/abnormal (not included in word count)
Normal (Subjective & Objective) Abnormal (Subjective & Objective)
Observations from 0600hrs to 0730hrs

Respiratory rate ranging from 15-19 breaths/minute. SpO2 ranging around 98% on room air.
Pulse ranging at 80-90 beats per minute (bpm). Temperature ranging at 36.0℃ to 36.9℃.
GCS 15 at 0700hrs.
Blood pressure (BP) at 0600hrs, 0630hrs and 0730hrs ranging around 130/80mmHG.
Colour on her left limb was normal at 0630hrs. It was warm to touch, and the capillary return time was <3 seconds. Observations from 0800hrs Temperature: 36.6℃ GCS: 15 SpO2: 97% Observations from 0600hrs to 0730hrs Patient had grazed left shoulder. BP at 0700hrs was ranging at 150/95mmHG. The colour of her left limb turned pale at 0700hrs. Patient had mild to moderate pain ‘at rest’ ranging from 3 to 5 from 0600hrs to 0700hrs, and moderate to severe pain ‘on movement’ ranging at 7 to 9 from 0600hrs to 0700hrs. Observations from 0800hrs Jane tells her blood pressure is normally “quite low”. BP for an adult should not be low and it should range around 120/80mmHG (Estes et al. 2015, p. 153). Blood Pressure: 155/90 mmHg (Hypertension). Normal range of blood pressure for an adult is 120/80mmHg (Estes et al. 2015, p. 153). Pulse: 107bpm (Tachycardia). Normal pulse rate for an adult is 60-100bpm (Estes et al. 2015, p. 146). Respiratory Rate (RR): 22 breaths/minute (Tachypnoea). Normal RR for an adult is 12- 20 breaths/minute (Estes et al. 2015, p. 143). Capillary return: >3seconds. Normal capillary refill may vary with age, but colour should return to normal within 2 to 3 seconds (Estes et al. 2015, p. 250).
Pain score (left leg): 9/10 on movement. 8/10 on rest. Pain score (shoulder): 4/10 at rest.
Complaining of tingling in the toes.
Increased pain at rest and upon passive movement of limb. Left leg appears more pale than right leg.
Patient anxious regarding her mother’s welfare.

Relate & Infer (450 words): Make it 550 words (excluding intext citation)
In the given scenario, Jane may be suffering from acute compartment syndrome (ACS). The most common cause of ACS is trauma, usually after a fracture (Porth 2014, p. 1090). Jane’s out of proportion pain to the injury despite appropriate medication, and pain on passive muscle stretch are the most effective clinical observations that suggest an ACS (Ali, Santy-Tomlinson & Watson 2014). ACS is defined as a collection of symptoms such as pain, pallor, paraesthesia or paresis that signal increased pressure in a closed muscle compartment resulting in compromised circulation and tissue perfusion (Pechar & Lyons 2014). It is based on arteriovenous pressure gradient theory that suggests ACS is a venous obstruction rather than an arterial infarction and is mainly characterised by its intense ischemic pain and neurological deficits. Our body maintains an equilibrium between venous outflow and arterial inflow and when the compartmental pressure rises all the veins within the compartment are compressed and venous outflow is blocked. Since venous outflow is blocked, perfusion of the tissues within the compartment ceases subsequently resulting in tissue ischemia alongside increased inflammation, arterial spasm, disrupted capillary flow, increased osmotic pressure, proteinaceous exudate, muscle fibre swelling and oedema (Pechar & Lyons 2014). Furthermore, the lower leg consists of four compartments and Jane’s inability to perform ankle dorsiflexion and plantarflexion and lost sensation in lower arch of the foot suggest an ACS involving anterior, lateral and deep posterior compartments that are largely responsible for decreased sensation and weakness of foot dorsi and plantar flexion (Nudel, Dorfmann & deBotton 2016). Similarly, the decrease of venous outflow and arterial inflow result in decreased oxygenation of tissues causing ischemia ultimately leading to pallor and paraesthesia as nerve conduction slows in hypoxic /ischemic conditions. Jane’s complaint of tingling in the toes could be because of the motor neurons associated with the compartment starting to dysfunction because of the compression and hypoxic conditions (Porth 2014, p. 1090).

Likewise, the initial traumatic fracture would lead to a localised swelling in the muscle compartments due to the stimulation of inflammatory response (IR). The IR is a systemic response that produces extensive inflammation by attracting nutrients, fluids, clotting factors and large numbers of macrophages and neutrophils to a damaged site, which causes increase in capillary permeability that leads to oedema, swelling, pain, and vasodilation causing redness and heat to the site of inflammation (Tornetta, Puskas & Wang 2016). Similarly, compartments have relatively fixed volumes so introducing fluid or constricting them increases pressure and decreases tissue perfusion which will result in hypertension, or an increase in hydrostatic pressure, at the venous end of the capillary bed (Thabet et al. 2018). Jane also states her blood pressure is normally “quite low” however, in this instance her blood pressure has gone up which could be the activation of the compensatory mechanism that is meant to protect the affected muscle from ischemia. However, hypertension will cause more bleeding, and the increased compartment pressure in turn will require a higher systemic blood pressure to sustain adequate perfusion (Barshes, Pisimisis & Kougias 2016). Thus, a dangerous cycle could initiate.
Predict (100 words): Make it 150 words (excluding intext citation)
ACS of the lower leg is a time sensitive limb threatening surgical emergency. If not treated expeditiously, compartment syndrome could cause irreversible damage in the form of significant nerve and muscle damage. As ACS progresses, the extremity becomes oedematous and tense. The increased interstitial pressure overcomes the intravascular pressure of the microcirculation causing the walls of the vessels to collapse and thus obstructing blood flow (Du et al. 2019). As swelling increases and muscles loses its blood supply, cells eventually die, and muscle necrosis occurs. If the situation further worsens, ACS can
lead to permanent disability, contractures, paralysis, multi-organ failure, limb amputation or even death (Du et al. 2019).

Develop, Articulate and Prioritise Nursing Diagnoses – at least 3 (not included in word count)
 Severe Pain
 Hypertension
 Wound Care
Goals, Actions and Evaluation 2 highest priority diagnoses only (450 words)- Make it 550 words (excluding intext citation)
Diagnosis 1 Goal/s Related actions Rationale Evaluate outcomes
Severe pain Patient to experience decreased level of pain. Initiate an urgent clinical review.

Remove backslab and bandage and keep the extremity to the level of the heart. Jane’s pain score on movement is 9/10 and on rest is 8/10 which is quite severe and falls under a clinical review category (Clinical Excellence Commission 2014).

Red flags for ACS are pain out of proportion and pain on passive stretch which is both found in Jane. Therefore, any patient with complaints of numbness of motor dysfunction like Jane must have their cast and any dressing removed as the plaster may be putting pressure on an underlying nerve (Mar, Barrington & McGuirk 2009). Clinical care review is the process of retrospectively assessing potential mistakes or gaps in medical care, aimed towards future practice refinement. It is made up of multidisciplinary team that conveys many benefits to the patients, improves health outcomes and patient satisfaction (Walker et al. 2018).

Removing any restrictive casts, dressings, or bandages, in this case backslab in Jane will help relieve pressure, and likewise keeping the affected limb at the level of the heart will help prevent hypoperfusion (Mar, Barrington & McGuirk 2009).

Request an urgent compartment pressure monitoring. To establish the severity of the problem and a diagnosis, it is recommended that a compartmental pressure measurement be performed in high-risk patients such as Jane (Mar, Barrington & McGuirk 2009). Normal pressure in the muscle compartment is below 10-12mmHG and upon assessment should the pressure be greater than 30mmHG, it would indicate the presence of a compartment syndrome, thus, manifesting a need for an urgent fasciotomy to relieve compartmental tension and maintain circulation for adequate tissue perfusion (Torlincasi
& Waseem 2018).
Diagnosis 2 Goal/s Related actions Rationale Evaluate outcomes
Hypertension Patient’s blood pressure to return within the normal range. Consult team for an anti- hypertensive treatment. Jane’s BP has increased and even though it may be a compensatory mechanism where the body is trying hard to irrigate the fracture site with sufficient oxygen and nutrients to prevent muscle necrosis, continuous hypertension could cause various other unwanted complications such as damaged and narrowed arteries, aneurysm, clot formation, left ventricular hypertrophy leading to significantly increased risk of heart attack, heart failure and sudden cardiac death (Wong et al. 2018). Once BP starts to normalise her heart rate would reduce. Anti-hypertensive medications lead to vasodilation caused by relaxation of smooth muscle cells in arteries and as a result lesser strain is put into blood vessels (Wong et al.
2018). However, Jane may show signs of side effects and therefore, it is important for me to remain vigilant.

Using therapeutic communication frequently and offering reassurance. Jane is the sole carer and is worried about her mother who is in the early stages of dementia. She has also suffered from a traumatic injury which has increased her level of anxiety. In anxiety our body pumps fight/flight hormones like adrenaline and cortisol that help prepare our body to fight against the stressor by increasing the heart rate and blood pressure and dilating the airways (Porth 2014).
Therefore, gaining her much needed trust is important at this stage that could reduce the activation of stress response that takes a toll on
the body (Mollon 2014). Offering reassurance and communicating effectively with the patient will promote confidence and faith and reduction of anxiety and unwanted hormonal changes which could be beneficial in reduction of blood pressure (American Psychological Association 2019). I would reassess her vital signs particularly the heart rate and blood pressure to confirm any therapeutic changes.