Introduction: This week during clinical rotation at Kaiser Permanente I encountered a 21 year old female patient. (Follow sample paper for more on what’s included in the introduction.)
Background: This was my first encounter with this patient, therefore, I hadn’t had any previous contact. This patient has a history of cellulitis in the upper left leg as well as recurring infections after engaging in sexual intercourse. Since 2018, the patient has experienced 5 episodes which consisted of groin pain, redness and inflammation of the left upper thigh, and severe infection which has resulted in sepsis. Given that this patient has a history of becoming septic, I immediately assessed vital signs to determine if the patient was at risk and evaluated the patients current level of pain. Further elaborate on the role of the nurse in this situation and any emotions that may arise in this given situation.
Noticing: Upon entering the room, I noticed the patient seemed to be uncomfortable. I inquired about her pain level, and she stated that her pain was a 6/10. Knowing this patient has a history of sepsis, I immediately started on morning vitals which are as follows: Temperature was 102.8, BP was 84/32, Respirations were 20, and Pulse was 87. After spending more time with the patient, I was informed that this was an ongoing battle to which there has been no diagnosis. Physicians have been unable to confirm the root cause of why this infection continues to occur, which has left the patient frustrated and in need of answers.
Interpreting: Describe any potential resolutions and any other pertinent data, assessments, or evaluations that you would think are necessary given the above information. Describe a situation in practice that could relate to this and how it is similar or different from this patients situation.
Responding: After documenting this patient’s vitals, I immediately notified the primary RN of my findings. The primary RN promptly administered Acetaminophen in an attempt to control this patients elevated temperature. I began removing blankets from the patient and applying cooling packs as an effort to bring down her body temperature. The primary RN instructed me to monitor the patients vitals over the next hour to ensure that the fever was decreasing and that her BP was increasing closer to normal range.
Reflection-in-action: The patient responded well to the Acetaminophen. When I assessed her next vitals, her temperature had decreased to 97.8 and her blood pressure had risen to 94/48. The pain also stated that her pain level had dropped from a 6 to a 4 and she was feeling more comfortable.
Reflection-on-action and clinical learning: Follow rubric attached and answer all questions under this section.
