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401010 Health Variations

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Questions 

Eleanor Brown has been admitted to hospital with complications of ulcerative colitis. Eleanor, now 48 years old, was diagnosed with ulcerative colitis when she was 31 years old. Over the years, she has had numerous admissions to hospital for acute episodes of ulcerative colitis. Eleanor’s ulcerative colitis has been managed with a combination of diet, medication (infliximab) and medical monitoring.

Eleanor has been experiencing an acute exacerbation of ulcerative colitis over the last two weeks. She has had up to fourteen episodes of diarrhoea with blood and pus per day and severe pain in her lower abdomen. She has been experiencing a sensation of abdominal bloating and cramping pain. Eleanor states she has been feeling too ill to eat and drink much and that she has lost nine kilograms in the last two weeks. She also states that she is feeling fatigued and has been unable to complete daily activities.

A colonoscopy performed four years ago revealed that Eleanor had developed a large number of pseudopolyps in her descending and sigmoid colon. Due to her current exacerbation of ulcerative colitis, Eleanor’s gastroenterologist ordered an MRI scan of Eleanor’s abdomen as a colonoscopy posed a risk of perforation and haemorrhage. The MRI
scan revealed that Eleanor had now developed pancolitis. The gastroenterological surgeon has recommended that Eleanor has a total colectomy and construction of an ileostomy.
 
On examination, Eleanor has a tender distended abdomen. Her skin is dry, pale and cool to touch with poor turgor. Eleanor’s capillary refill is slow and she has flat neck veins. She states she has had reduced urine output over recent weeks.

Observations on admission

Blood pressure: 90/50 mm/Hg
Pulse rate: 112 beats/minute
Weak peripheral pulses
Respiratory rate: 23 breaths/minute
Temperature: 38.4C
Sa02: 97% in room air
Weight: 54 kilograms
Height: 165 cm
 
Urinalysis:
  • specific gravity: 1039
  • dark coloured urine
  • no other abnormalities noted
Initial pathology results
  • Haemoglobin: 86 g/L (117 – 157 g/L)
  • Haematocrit: 52% (35 – 47%)
  • WBC 16780/mm3 (3500 – 11000/mm3 )
  • Erythrocyte sedimentation rate (ESR): 31.3mm/hour (0 – 20 mm/hour)
  • C-reactive protein (CRP): 33.6mg/dl (20 mg/dl)
  • Albumin: 22.8g/L (35 – 50 g/L)
The MO orders the following
  • Morphine 15mg IMI QID PRN
  • metoclopramide (Maxolon) 10mg IMI TDS
  • 1000mL Hartman’s solution over 6 hours
  • methylprednisolone 20mg IVI TDS
  • nil by mouth
1. Prioritise the nursing responsibilities and associated rationales related to the administration of morphine to Eleanor.
(Learning outcome 7; NMBA Registered nurse standards for practice 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 2.3, 2.5, 4.1, 4.2, 4.3, 5.1, 5.2, 5.3, 5.4, 6.1, 6.2, 6.5, 7.1, 7.2, 7.3)
 
2. Describe the structural and functional changes that occur in the pathogenesis of ulcerative colitis that led to Eleanor’s episodes of diarrhoea with blood and pus.
(Learning outcome 5; NMBA Registered nurse standards for practice 1.1, 2.7, 3.3)

3. Explain the characteristics of the intravenous fluid that was ordered for Eleanor, and the rationale, related to Eleanor’s specific fluid balance status, for the administration of this intravenous fluid to Eleanor.
(Learning outcome 1, 2; NMBA Registered nurse standards for practice 1.1, 2.7, 3.3, 4.1, 4.2, 4.3)
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