Mr Kevin Daniels: Post-operative Inguinal Hernia Repair – Clinical Reasoning Cycle – Nursing Case Study Assessment Answer

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Nursing Case Study Assessment Answer
Task:
Mr Kevin Daniels: Post-operative inguinal hernia repair
Mr Kevin Daniels a 67-year-old man who is admitted to the Surgical ward, following an open mesh inguinal hernia repair. He had presented to ED with a 6-hour history of a R non-reducible tender, inguinal mass, post commencing a new gym/weight lifting regime.
Past Medical History: Mr Daniels is retired, lives with his wife, ex-smoker and is obese, with a body mass index (BMI) of 30. Incidentally, he is an ex weight lifter. He is on medication for hypertension and hyperlipidaemia, which are both well controlled, and he also has mild congestive heart failure (CHF).
Mr. Daniels was recovering well, but on Day 2 post op, he has become a little agitated and confused, complaining of significant left calf pain.
On your assessment:
· Vital signs: Temp: 39.3oC, RR: 25, HR:106 regular, SpO2 95% on room air (R/A), BP: 165/90, Pain score 7-8/10 (wound site and left calf), GCS 14/15
· Physical assessment: Mr. Daniels is restless and confused to.. His chest is clear, skin is dry, post-op surgical wound dressing is oozing green purulent discharge and tender to touch. His left calf appears larger than the right and it is red, and warm to touch.
Investigations:

Haemoglobin 16.5 gm/dl,

WCC, neutrophils and CRP – all elevated

Nursing notes:

Mr. Daniels has an 18g Cannula in his Right arm

He has tolerated diet and is voiding well

Bowels opened yesterday

Agitated and confused to time and place on assessment this am.

You are the registered nurse looking after Mr. Daniels.
The assessment will take the form of a 1700 words case study, in the field of medical-surgical nursing, which discusses the provision of ethical, legal, evidence-based, holistic person-centred care including the establishment of realisticand relevant goals through the theoretical examination of a particular nursing specialty case study using the Clinical Reasoning Cycle (Levett-Jones, 2018).
Case study instructions:
Utilise the Clinical Reasoning Cycle (Levett-Jones, 2018) (a clinical decision making
framework) to plan and evaluate person-centred care:

Considering the person’s situation, collect, process and present related health information;

Identify and prioritise at least three (3) nursing problems/issues based on the health assessment data that you have identified for the person at the centre of care;

Establish goals for priority of nursing care as related to the nursing problem/issues identified;

Discuss the nursing care of the person, link it to assessment data and history;

Evaluate your nursing care strategies to justify the nursing care provided;

Reflect on the person’s outcomes

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