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Clinical Reasoning Assessment Part A

Patient Enquiry

Salbutamol (100 mcg prn) and Ipratropium (42 mcg QID) puffers. Jaime has no allergies, has never smoked and only drinks during special occasions. Jaime Watson is a 52 year old woman weighing 59kg and has a height of 155cm. The patient’s past history indicates a use of α1-antitrypsin deficiency related COPD which was diagnosed when she was 32 years. She is currently taking

She sits in a tripod position using the over bed table to support her arms.Later on the patient displays a number of signs and symptoms which include a grimacing facial expression, restlessness, nausea and vomiting, shortness of breath and use of accessory muscles for breathing. On arrival back to the day procedure unit Jaime’s vital signs have been within acceptable parameters. Vital signs — HR 64 bpm, BP 125/70 mmHg, RR 12, SpO2 96% Jaime has oxygen 4 litres via a Hudson mask and an IV cannula in her left arm. Postoperatively Jaime recovered well in Post anesthetic care unit. Jaime had pain 6/10 in recovery and has had 50 mg IM Pethidine 40 minutes ago. Pain score is now 2/10. Jaime has been admitted to the day procedure unit. She is having 4 wisdom teeth removed under general anaesthetic.

Hypothesis Identified That Shows Relevance to the Date and Scenario

From the observations made and based on Jamie Watson’s past social and medical history, a number of hypotheses can be made on this case. The relevant hypotheses include patient possibly suffering from pain, Post Operative Nausea and Vomiting (PONV), the patients Alpha-1 antitrypsin deficiency COPD, Atelectasis, respiratory problem and the effects of the pethidine.

  1. Acute pain is a likely reason for the Jamie Watson’s current condition. The occurrence of acute pain after surgery is an indication of tissue alteration or damage. Acute pain could be a reason for the patient’s grimaced facial expression, restlessness and anxiety. The intensity, duration and occurrence of pain after surgery is influenced by factors such as the incision location and time, retraction degree and duration and the level to which a patient can tolerate pain (Hogas & Yoon, 2008). Jamie’s pain could have been caused by a number of reasons. One possible cause of pain could be postoperative dental pain (Farsi et al., 2009). Such is found to have been present in six out of every ten patients who had similar surgeries as found by Guillon-Attali et al. (2008). Wisdom teeth have been found to be more painful after extraction as the nerves are more deeply rooted hence deeper incision is needed during surgery/ extraction (Adeyemo et al., 2008). Another possible cause of pain would be the intravenous (IV) cannula in her left arm. IV cannula is a cause of discomfort and even pain to (some) patients especially in situations where the cannula is either not sited correctly (Ahmed, n.d.) or the veins are particularly fragile and have ruptured (Chiarella et al., 2008).

  2. As a result of the general anesthesia used on the patient during surgery. Jamie Watson could be suffering from PONV (Postoperative Nausea and Vomiting). Scorza et al., (2007) states that nearly 25% to 40% of patients who have had surgery under general-anesthesia are affected by PONV. This occurs mainly due to the effect or stimulation of anesthesia on the Chemoreceptor Trigger Zone in the medulla which in turn activates the vomiting center of the brain. The presence of nausea and vomiting may have been increased by the patient’s age of 52 years. Women who have already reached menopause but who are below 60 years are at a higher risk of suffering from PONV (Steel &Carlson, 2007).

  3. The anxiety and restlessness by Jaime Watson, as well as her difficulty in breathing could also be a possible recurrence of the patient’s Alpha-1 antitrypsin deficiency COPD. She was diagnosed to have this sickness two decades prior to her operation now. A number of COPD patients have been found to be oxygen sensitive and Jamie could be one of such patients (Wood et al., 2011).

  4. According to the patient’s medical history, she is currently taking Salbutamol (100 mcg prn) and Ipratropium (42 mcg QID) an indication that she is having respiratory problems like asthma. The patient’s shortness of breath, anxiety and difficulty in breathing could therefore be from a possible attack on the respiratory system.

  5. As a result of the anesthesia, Jamie Watson could have suffered from atelectasis. This condition occurs when the lungs become airless and in turn collapse. Anesthesia suppresses the urge to breathe deeply and cough preventing the bronchial tubes from opening hence atelectasis (Hedenstierna, 2005; Lennart et al., 2007). This condition could be the reason for the patient’s difficulty in breathing and use of accessory muscles for breathing.

  6. Jamie’s condition could also be as a result of the Pethidine given to the client to reduce her pain. The medication could be a possible cause of the patient’s nausea and vomiting which is one of its adverse effects. (Oztekin et al., 2006).

Physical Assessment and Rationales for the Identified Assessment

To assess for acute pain, possible questions will be where the patient is feeling the pain, how strong is the pain and how often she is experiencing it. Observing the patient is also another criterion. Patients are more likely to hold points where they are feeling the pain. This will help in understanding the intensity and duration of the pain as well as identify what type of pain it is (Horgas& Yoon, 2008). Asking the patient where she is feeling the pain will be important in identifying the root cause of the pain. Pain in the gum will for example indicate pain from the teeth extraction (at the wound).

Assessment for PONV would entail correlating the occurrence of the condition with other factors such as medications, gender, diet, pain, possible illness and the surgery procedure (ASPAN, 2006; Bischoff, 2006). This will be important in identifying the main cause of the condition.

Salbutamol and Ipratropium and on the frequency of her respiratory attacks if any in the past will help in understanding if this could be a possible cause of her breathing problems.Enquiring on why the patient is currently on

Asking the patient if she gets affected by pethidine will be effective in identifying if it is the cause for her nausea and vomiting.

Effective assessment will also entail assessing the occurrence of other symptoms related to a particular condition.


Adevemo, W.L. et al. (2008). Indications for extraction of third molars: a review of 1763 cases. The Nigerian Postgraduate Medical Journal, 15 (1), 42-46.

Ahmed, N. (n.d.). Revisiting peripheral intravenous cannula insertion. Retrieved on 10 August, 2011, from

American Society of PeriAnesthesia Nurses (ASPAN). (2006). ASPAN’s evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV. Journal of Perianesthesia Nursing, 1(4): 230-250.

Bischoff, S. (2006). Nausea and nutrition. Autonomic Neuroscience, 129(1-2): 22-27.

Chiarella, A.B., Jolly, D.T., Huston, C.M. and Clanachan, A.S. (2008). Comparison of four strategies to reduce the pain associated with intravenous administration of rocuronium. British Journal of Anaesthesia, 90 (3), 377-379.

Farsi, N., Ba’akdah, R., Boker, A. and Almushayt, A. (2009). Postoperative complications of pediatric dental general anesthesia procedure provided in Jeddah hospitals, Saudi Arabia. BioMed Central, 9:6, doi: 10.1186/1472-6831-9-6

Guidon-Attali, C., Mouillac, F., Quilichini, D., Paut, O. and Francois, G. (2008). Propofol as the main anaesthetic agent in dental surgery. Acta Anaesthesiologica Scandinavica, 34 (5) doi: 10.1111/j.1399-6576.1990.tb03110.x

Hedenstierna, G. (2005). Effects of anaesthesia on respiratory function. Bailliere’s Clinical Anaesthesiology, 10 (1), doi: 10.1016/S0950-3501(96)80003-1.

Horgas, L., & Yoon, S. (2008). Pain management. New York, NY: Springer Publishing Company.

Hudcova, J., McNicol, E.D., Quah, C.S., Lau, J., and Carr, D.B. (2006). Patient controlled opiod analgesia versus conventional opiod analgesia for postoperative pain. Cochrane Database of Systematic Reviews, 4, doi: 10.1002/14651858.CD003348.pub2

Lennart, E., Kostova-Aherdan, K., Mats, E. and Hedenstierna, G. (2007). Optimal oxygen concentration during induction of general anesthesia. Anesthesiology, 98 (1), 28-33.

Oztekiin, D.S. et al. (2006). Postoperative effects of opiod analgesics via continuous perfusion and patient controlled analgesia after open heart surgery. Yakugaku Zasshi, 126 (7), 499-504.

Scorza, K., Williams, A., Phillips, J. D. & Shaw, J. (2007). Evaluation of nausea and vomiting. American Family Physician, 76(1): 76-84.

Steele, A., & Carlson, K. (2007). Nausea and vomiting. AACN Advanced Critical Care, 18(1): 61-75.

Wood, A.M., de Pablo, P., Buckley, C.D., Ahmad, A. and Stockley, R.A. (2011). Smoke exposure as determinant of autoantibody titre in Alpha-1 antitrypsin deficiency and COPD. European Respiratory Journal, 37 (1), 32-38.