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NSG2201 Clinical Care B Assignment 2018

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  • Course Code: NSG2201
  • University: Baptist Health College Little Rock
  • Country: United States

Question:

Using the Clinical Reasoning Cycle:

  • Consider the patient situation
  • Collect the cues/information
  • Process the information
  • Formulate a care plan as instructed for 2 priority nursing diagnoses with 5 interventions with rationales & the expected outcomes.

His vital signs are stable & he is afebrile. He is due to be reviewed by the Neurology team today. He cannot walk to the shower or toilet. His mouth has mouth ulcers & is not eating his food. He is nauseated & has been vomiting.

  • Formulate a care plan as instructed for 2 priority nursing diagnoses with 5 interventions with rationales & the expected outcomes. 2 days later, the Neurology team think Mr. Green can go home. He is aware of where he is but has lapses in concentration & cannot finish his sentences. His fiancée is concerned as she works full time & he can’t even walk to the toilet.
  • Formulate a priority nursing diagnosis with 5 interventions with rationales & the expected outcome relating to discharge management.
 

Answer:

Mr Brown is a 32-year-old male who has been having Ulcerative Colitis for a period of 10 years. Following persistent bleeding of the large bowel, Mr Brown has been transfused with 4 units of whole blood. He has been having a lot of pain which necessitated for a high doses of Codeine Phosphate 30 mg. Mr Brown is on 80 mg of Prednisolone daily and 1000-2000 mg of Sulfasalazine 4 times in a day and no improvement is noted. Over the past few weeks, he has lost 20k.

History of Presenting Illness

Mr. Brown presents to the health care facility with complaints of severe abdominal pain, a score of 9/10 and, vomiting ++ and bloody diarrhoea ++. His vital signs are Temperature-38, Pulse-128beats/min and regular, Blood pressure-100/60mmHg, Respiration, Rate-32 breaths/minute, Oxygen saturation- 96% on room condition. 

Physical Examination and Investigations

Left Lower Quadrant sited ileostomy, pink mucous membrane with a long bag attached. He has a bloody drainage with IV insitu: 6/24 Hartman’s NGT insitu on free drainage and an in-dwelling Catheter insitu. His vital signs include:  Temperature-380C, Pulse-120 beats/minute and regular, Respiration rate-26 breaths/minute, Blood Pressure-100/60 mmHg and Oxygen Saturation - 98% on 8L O2 via face mask. The central abdominal suture line is intact with dressing. Full blood count was done and his Hemoglobin is 9.0g/dl and Erythrocyte Sedimentation Rate is 40. Currently the patient is on Hydrocortisone 100mg IV 4/24, Maxalon 10mg IV 6/24, Morphine 10mg IM 4/24 and Vancomycin 500mg 6/24.

 

Pathophysiology of Ulcerative Colitis

Ulcerative colitis (UC) refers to an inflammatory disease of the bowel whose cause is not well known. UC is a relapsing and chronic inflammatoryy disorder of the colorectum. Patients with this disease may exhibit inflammation starting from the cecum to the rectum. Diagnosis of UC is often reached after investigation of lower portion of the gastrointestinal tract and confirmation of continuous, superficial and diffuse inflammation of the large bowel (Sandborn et al, 2014).

Usually, UC starts at the rectum may remain there or extend proximally and may involve the whole colon. Inflammation due to UC affects the submucosa and mucosa hence creating a sharp border between normal and affected body region/tissue. In severe cases of ulcerative colitis, the muscularis is often involved (Sandborn et al, 2014).

  The mucous membrane is erythematous, friable and with fine granular which has lost its normal vascular pattern. As a result of this, there are scattered areas of haemorrhage involved (Sandborn et al, 2014). Large mucosal ulcers in UC with copious purulent exudate is a characteristic of severe disease. In UC, islands with relatively hyperplastic or normal inflammatory mucosa (pseudopolyps) often project above areas of ulcerated mucosa. There are no abscesses and fistulas involved in the disease.

Individuals having UC are at high risk of having adenocarcinoma of the colon and dysplasia which require lifelong and regular endoscopic surveillance. Colectomy is the commonly recommended intervention when medical treatment becomes unsuccessful. Colectomy is the most curative approach of managing of UC (Rogler, 2014).

Some of the potential complications of UC are; severe hemorrhage, severe dehydration, perforation of the colon, osteoporosis (bone loss), inflammation of joints, skin, eyes, high risk of development of toxic megacolon (Ananthakrishnan, 2014).

Development of mucosal ulcers and ulcerations in the colon and any other area of the GIT affected by UC lead to severe abdominal pain (patient’s scale of pain was 9/10), bloody diarrhea, nausea and vomiting which the patient presented with according to the case study. Due to the inflammatory process involved in UC, the patient presented with fever (Temperature-380C). Due to fluid loss through diarrhea and vomiting, the patient was put on NGT tube and IV Hartman’s solution for free drainage and fluid and electrolyte replacement.  Nausea in UC leads to nutritional intolerance. The patient did not retain any food eaten leading to drastic weight loss (20k in 2 weeks). The patient was put on IV Maxalon to prevent nausea and increase the rate of food passage in the stomach while hydrocortisone was given to suppress the inflammation of the colon. Morphine was used to relieve pain. 

Signs and Symptoms of Ulcerative Colitis

Manifestation of UC do vary based on the severity and intensity of inflammation and its anatomical location.  Signs and symptoms are bloody diarrhoea, abdominal cramping and pain, rectal hemorrhage, tenesmus, drastic loss of weight, fever and fatigue (Dignass et al, 2012).

Bloody diarrhea of varied duration and intensity is commonly interspersed with asymptomatic intervals. Usually, an attack begins insidiously and its commonly associated with increased urgency to defecate, blood and mucus in stools and lower abdominal crampsing and pain.  Some cases of the ulcerative colitis develop after an infection such as, bacillary dysentery or amebiasis (Conrad, Roggenbuck & Laass, 2014).

 Proximal extension of ulceration is emaciated with looser stool.  Loose stool due to proximal extension of the ulceration is associate with increased bowel movements in a patient for more than 10 in a day. This is often accompanied with severe cramping and distressing rectal tenesmus with no respite at night (Rogler, 2014).

Initially, fulminant or toxic colitis manifests with sudden and violent diarrhea, abdominal pain, fever upto 40° C (104° F), signs of peritonitis such as rebound tenderness and profound toxemia (Sasaki & Klapproth, 2012). In extensive ulcerative colitis, systemic manifestations are very common. Thye include; fever, malaise, anorexia, anemia and loss of weight. In presence of systemic manifestations,  extraintestinal manifestations of Inflammatroy Bowel Disease (IBD) particularly skin and joint complications are very common (Burisch, 2014)

Possible Risk factors of Ulcerative Colitis

Environmental factors such as urban settings, industrialization and northern geographical latitudes are associated with the different incidences, prevalence and rate of Ulcerative Colitis. Family history is also a risk factor for UC whereby an individual with UC have their immediate relatives this UC disease. Ethnicity is another key risk factor, whereby the whites have a high rate of developing UC than the non-whites but it can occur in any race. Additionally, the Jews of the Eastern European descent have a greater risk of developing UC. Age is associated with UC whereby people before the age of 30 have a high risk of having UC than those aged more than 30 years (Jess, Rungoe & Peyrin–Biroulet, 2012).  

 

NSG2201 Nursing Care Plan 2018

Scenario 1

Nursing Diagnosis

Goal

Intervention

Rationale

Expected Outcome

 

Acute pain related to prolonged diarrhea, hyperperistalsis, prolonged diarrhea, perirectal excoriation, tissue irritation, fistulas and fissures as evidenced by reports of cramping/ colicky referred pain/abdominal pain, self-focusing, restlessness, guarding and facial mask of pain.

Short Term Patient should report controlled or relieved pain.

Long Term

Should appear relaxed, comfortable and able to rest and sleep appropriately

Assess and note nonverbal cues such as abdominal guarding, restlessness and reluctance to movement.

Investigate for presence of discrepancies between non-verbal and verbal cues.

Cleansing rectal region with soap and plenty of water or proper wiping after passing stool and providing skin care such as skin jel or ointment.

Assess patient and take history of abdominal pain and cramps and note the site, duration and the severity of pain in a scale of (0–10).

Provide patient with relaxation and comfort measures such as back rub, diversional activities and reposition.

Encourage the patient to assume a comfortable position with flexed knees.

Nonverbal cues and body language may be used together to identify the severity and extent of patient’s condition (Van Assche et al, 2013).

Cleaning protects the skin from impacts of bowel acids hence it prevents excoriation (Sasaki & Klapproth, 2012).

Colicky intermittent pain results from Crohn’s disease/fulminating ulcerative colitis (Sasaki & Klapproth, 2012).

Promotes patient comfort and relaxation, enhances patient’s coping abilities and refocuses patient’s attention from pain (Van Assche et al, 2013).

Reduces and relieves abdominal pain

Patient reports relived and controlled pain.

 

Patient reports no abdominal cramping and pain.

Patient is comfortable and relaxed. He is able to rest and sleep comfortably.

Patient reports relived pain.

 Risk of deficient fluivolume related to excessive loss due to severe diarrhea, vomiting, hypermetabolic conditions such as  and inflammation,  low intake due to nausea and anorexia, and hemoconcentration secondary to altered serum sodium

 

Long Term

To ensure adequate fluid volume and good skin turgor, moist mucous membranes.

Short Term

To ensure the vital signs are stable and normal.

 

Noting possible processes or conditions that may cause deficits through fluid loss, fluid shifts and limited fluid intake.

Monitor intake and output noting the frequency, amount of stools and to identify insensible fluid losses such as diaphoresis.  Observe for oliguria.

 

Measure and identify the specific gravity of urine.

Assess and monitor patient’s vital signs such as pulse, BP and temperature.

Observe the patient for excessively dry mucous membranes and skin and decreased skin turgor.

Monitor patient’s laboratory investigations especially  electrolytes and ABGs.

To assess and identify any contributing and precipitating factors. Excessive loss of body fluid loss may be a result of vomiting and diarrhea (Seidelin, Coskun & Nielsen, 2013).

 

Provides more information and ideas about overall fluid balance, bowel disease control, renal functioning and appropriate guidelines and criteria for fluid replacement (Burisch, 2014)

Tachycardia, Hypotension  and fever are indicators of response of fluid loss in the body (Bressler et al, 2015).

Dry mucous membranes and skin are indicators of resultant dehydration or excessive fluid loss (Feuerstein & Cheifetz, 2014).

Helps in determination of patient’s effectiveness of therapy and replacement needs (Bressler et al, 2015)

Patient demonstrates fluid tolerance, good skin turgor and moist mucous membranes.

 

 

 

 

 

 

 

Patient’s vital signs stabilizes and normalizes.

The patient has moist mucous membranes and skin.

 
 

NSG2201 Nursing Care Plan 2018

Scenario 2

Nursing Diagnosis

Goal

Intervention

Rationale

Expected Outcome

Anxiety related to physiological changes and sympathetic stimulation such as inflammation and change in patient’s sate of health social status and interaction patterns as evidenced by increased apprehension, tension, distress, apprehension and expression of concerns on changes in life.

 

 

 

 

Short Term

To alley patient’s level of anxiety and ensure that he appears relaxed and reports reduction of anxiety a manageable level.

Long Term

To ensure that the patient verbalizes awareness of anxiety feelings and healthy tactics of dealing with them.

To identify and develop healthy strategies of dealing with and expressing anxiety.

 

Reviewing physiological factors like active medical conditions or any ongoing stressors.

Provide a calm and restful environment.

 

 

 

 

 

Encourage health care staff and the significant other to project a caring and concerned attitude.

Provide detailed, accurate and concrete information on everything procedure or intervention done on him.

Encourage the patient to verbalize his feelings.

 

Observe and note patient’s behavioural clues such as irritability, restlessness or withdrawal.

These factors exacerbate anxiety and its disorders (Burisch, 2014).

The Calm environment promotes patient relaxation hence helping in reduction of anxiety (Sasaki & Klapproth, 2012).

A supportive manner of health care makes the patient feel relieved of stress hence giving him more energy directed towards recovery (Sasaki & Klapproth, 2012). (Bressler et al, 2015).

Engaging the patient in plan of care gives a sense of control hence decreasing his level of anxiety (Burisch, 2014).

Helps in establishment of therapeutic relationship and assists the patient in identification of sources of stress (Bressler et al, 2015).

They are key indicators of patient’s degree of stress or anxiety (Burisch, 2014).

The patient verbalizes relieved anxiety to a manageable level.

Patient demonstrates relaxed mood and verbalizes awareness of feelings of anxiety.

Imbalanced Nutrition less than body requirements related to altered absorption, hypermetabolism and medical restriction on intake fearing that eating may cause vomiting and diarrhea as evidenced by weight loss of 20k, steatorrhea and eating aversion.

 

Short Term

To ensure that the

patient feeds regularly and tolerates all meals given.

 

Long Term

To ensure that patient demonstrates stable weight and progressive gain

Encouraging patient to measure and monitor his weight daily.

Encourage patient’s bedrest and limited physical activity.

Recommend rest before meals.

Encourage patient to limit foods that exacerbate abdominal pain and cramping such as milk high-fibre diet, alcohol, tomatoes, chocolate.

Provide and encourage oral hygiene

Observe and record dietary intake and symptomatology changes.

 

Provides feedback and information on patient’s dietary requirements and effectiveness of treatment (Rogler, 2014).

Bed-rest decreases metabolic requirements hence preventing depletion of body calories thus conserving energy (Burisch, 2014).

Quiets the peristaltic process and increases energy available for consumption ((Bressler et al, 2015).

Individual dietary tolerance changes based on the phase of disease process and affected areas of the bowel (Bressler et al, 2015).

Oral hygiene enhances one’s  taste of food and generally his appetite (Burisch, 2014).

Useful in identification of specific dietary deficiencies hence enhancing determination of response of GI to foods (Bressler et al, 2015).

The patient is progressively gaining weight.

NSG2201 Nursing Care Plan 2018

Scenario 3

Nursing Diagnosis

Goal

Intervention

Rationale

Expected Outcome

 

Knowledge deficit related to misinterpretation of information, failure to recall and unfamiliarity with health care resources as evidenced by questions, misconception statements, requesting for information and inaccurate adherence to instructions.

 

 

 

 

 

Short Term

To ensure that the patient verbalizes proper understanding of disease pathophysiology, its effects and complications.

To identify patient’s stressful situations and particular actions that need to be taken.

To ensure that the patient verbalizes proper understanding of therapeutic medication.

Long Term

To Initiate appropriate lifestyle changes to the patient.

 

Determine perception of patient of the disease process.

Remind patient on observation side effects associated with medication regimen.

Put more emphasis on patient’s periodic and long-term re-evaluation and long-term.

Recommend for cessation of smoking.

Stress on good and regular skin care.

Review patient’s medications, frequency, purpose, dosage, and their side effects.

 

 

 

 

 

 

Helps in establishment of baseline knowledge hence providing some insight on the learning needs of an individual (Bressler et al, 2015).

It promotes early recognition of any medication-induced health issues for timely intervention (Rogler, 2014).

Patients suffering from IBD have a high risk for rectal or colon cancer hence they require regular diagnostic evaluations (Rogler, 2014).

Smoking increases intestinal motility and aggravates the symptoms (Bressler et al, 2015).

Reduces bacterial spread of bacteria and risk of skin breakdown, irritation or infection (Rogler, 2014).

Promotes proper understanding and enhances cooperation with the treatment regimen (Burisch, 2014).

The patient verbalizes understanding of disease pathophysiology and therapeutic medication.

 

 

 

 

 

Patient demonstrates appropriate and improved lifestyle modifications

 

Ineffective coping related to unpredictable nature of disease as evidenced by patient verbalizing, inability to cope, anxiety, emotional worries and tension and low self-esteem

Short Term

To accurately assess patient’s current situation.

Long Term

To identify behaviour and consequences of ineffective coping.

To acknowledge own abilities of coping and demonstrate necessary lifestyle modifications to prevent/limit recurrent episodes.

 

Determine external stressors such as relationships, family, work or social environment.

Allow the patient to discuss the impact of the illness on his family or relationship, including sexual concerns.

Encourage the patient to skills of stress management such as visualization, relaxation techniques, guided imagery and deep-breathing exercises.

Provide periods of uninterrupted rest and sleep.

Refer the patient to resources as indicated (social worker, local support, spiritual advisor or psychiatric clinical nurse specialist).

Offer emotional support through active listening and maintenance of non-judgmental language when providing care to the patient.

Stress alters autonomic nervous response which affects the immune system hence exacerbating the disease (Feuerstein & Cheifetz, 2014).

Stressors associated with the illness impact on all aspects of one’s life making him have difficulties coping his feelings (Feuerstein & Cheifetz, 2014).

Refocuses patient’s attention, enhances coping abilities and promotes patient relaxation (Feuerstein & Cheifetz, 2014).

Exhaustion due to the disease magnifies problems hence interfering with patient’s coping ability (Feuerstein & Cheifetz, 2014).

Counselling and additional support can help the patient deal with specific stressors (Rogler, 2014).

Helps in communication and understanding viewpoint of the patient and gives him feelings of self-worth (Bressler et al, 2015).

The patient demonstrates coping abilities and lifestyle modification behaviours.

Patient uses stress management techniques like deep breathing exercises.

 
 

Reflection

Ulcerative colitis is an idiopathic Inflammatory Bowel Disease. Personally, I had a perception that UC does not have serious manifestations and complications. When I did a research about it, I discovered that its signs and symptoms are life-threatening especially bloody diarrhea. I also discovered that UC has fatal complications such as colon or rectal cancer if it goes untreated.

 

References

Ananthakrishnan, A. N., Khalili, H., Konijeti, G. G., Higuchi, L. M., de Silva, P., Fuchs, C. S., ... & Chan, A. T. (2014). Long-term intake of dietary fat and risk of ulcerative colitis and Crohn's disease. Gut, 63(5), 776-784.

Bressler, B., Marshall, J. K., Bernstein, C. N., Bitton, A., Jones, J., Leontiadis, G. I., ... & Afif, W. (2015). Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus. Gastroenterology, 148(5), 1035-1058.

Burisch, J. (2014). Crohn's disease and ulcerative colitis. Occurrence, course and prognosis during the first year of disease in a European population-based inception cohort. Dan Med J, 61(1), B4778-B4778.

Conrad, K., Roggenbuck, D., & Laass, M. W. (2014). Diagnosis and classification of ulcerative colitis. Autoimmunity reviews, 13(4-5), 463-466.

Dignass, A., Eliakim, R., Magro, F., Maaser, C., Chowers, Y., Geboes, K., ... & Travis, S. (2012). Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 1: definitions and diagnosis. Journal of Crohn's and Colitis, 6(10), 965-990.

 Feuerstein, J. D., & Cheifetz, A. S. (2014, November). Ulcerative colitis: epidemiology, diagnosis, and management. In Mayo Clinic Proceedings (Vol. 89, No. 11, pp. 1553-1563). Elsevier.

Jess, T., Rungoe, C., & Peyrin–Biroulet, L. (2012). Risk of colorectal cancer in patients with ulcerative colitis: a meta-analysis of population-based cohort studies. Clinical Gastroenterology and Hepatology, 10(6), 639-645.

Rogler, G. (2014). Chronic ulcerative colitis and colorectal cancer. Cancer letters, 345(2), 235-241.

Sandborn, W. J., Feagan, B. G., Marano, C., Zhang, H., Strauss, R., Johanns, J., ... & Gibson, P. R. (2014). Subcutaneous golimumab maintains clinical response in patients with moderate-to-severe ulcerative colitis. Gastroenterology, 146(1), 96-109.

Sasaki, M., & Klapproth, J. M. A. (2012). The role of bacteria in the pathogenesis of ulcerative colitis. Journal of signal transduction, 2012.

Seidelin, J. B., Coskun, M., & Nielsen, O. H. (2013). Mucosal healing in ulcerative colitis: pathophysiology and pharmacology. In Advances in clinical chemistry (Vol. 59, pp. 101-123). Elsevier.

Van Assche, G., Dignass, A., Bokemeyer, B., Danese, S., Gionchetti, P., Moser, G., ... & Oldenburg, B. (2013). Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 3: special situations. Journal of Crohn's and Colitis, 7(1), 1-33.

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