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You are the nurse looking after Mr Keith Manor, an 86 year old male admitted to the Medical ward with gastroenteritis and dehydration.  Keith has had a two day history of abdominal cramping and diarrhoea.  He also has a one day history of vomiting. He currently has symptoms of watery diarrhoea, a mild temperature of 37.7 degrees Celsius, abdominal pain, headache and mild dehydration.  Mr Manor is also complaining of lethargy.

Choose 3 of the four AoL’s and discuss how they have been altered for Mr Manor.  Your answer must include the following:

  • An overview of how the three AoL’s may be affected
  • How you would assess Mr Manor’s in relation to the three identified AoL’s. Include in your answer what care you would provide Mr Manor

Gastroenteritis and Dehydration

Gastroenteritis is an infection that targets the lower part of the digestive system (Payne et.al, 2013). It keeps the intestines from absorbing food and water properly. It results from poorly sanitized source and spread to the host after eating an apparently unsafe food. This infection in adults is caused by Norovirus (Payne et.al, 2013) which is characterized by its habitat, that is, fecal contaminated water and food. It spread by contact and therefore, it can easily be transmitted from one person to another. Once the virus is contracted, it targets the small intestines. When particle is at the small intestines, it behaves like a normal virus and latches itself into a cell nearby immediately. From there, the virus goes through cell wall and insert itself into the cells enzyme, in essence hijacking them. The virus then put in the genetic information that it contains into the enzyme making it to produce another virulent particle (Koo, Ajami, Atmar, & DuPont, 2010). Vomiting, diarrhea and stomach pains take over the intestinal cells. Due to vomiting and diarrhea, the amount of fluid that is lost become more than the one taken in. This leads to dehydration which is a life threatening condition to the patient. (Blinderman, & Billings, 2015). Older people are at high risk of getting dehydrated. The reduction in total body water leads to decrease in both extracellular and intracellular fluid volume as dehydration ensues. Hypovolemic shock ultimately develops causing organ failure and finally death (Chaithongdi, Subauste, Koch, & Geraci, 2011). Neurologic complications may develop in hyponatremic and hypernatremia states. Symptoms include low urine output, dry or sticky mouth eating and drinking

Eating and drinking

How it has been altered for Manor

Gastroenteritis causes vomiting, diarrhea and abdominal cramping (Humphries, & Linscott, 2015). Vomiting come as a result of rapid release of serotonin by the virus. When copious amount of serotonin rush into bloodstream, the body tries to eliminate serotonin through vomiting which lead to loss of more water and electrolytes in the body leading to fluid and electrolyte disequilibrium. Abdominal cramping is as a result of the body immune system. Immune system makes white blood cells to attack the virus and in turn the body undergoes inflammation which is an attempt by the body to destroy the virus by filling the part infected area blood. Flooding the blood around the virus makes the infected cells washed away through the bloodstream and eliminated from the body. The lower abdomen becomes very sensitive to touch and this cuases cramps and pain causing discomfort and nausea this reduces the amount of food intake by the patient leading to malnutrition (Surena, 2010). Diarrhea causes loss of water electrolytes and nutrients in the body (Field, 2016). It come as result of small intestines unable to absorb water and essential nutrients from the food, they do not take in much water from the food that is passing, so the passing food is almost fully liquid and excreted as watery stool. Vomiting and diarrhea affects drinking in that the patient will need more of fluids and become thirsty frequently, while abdominal cramping affects eating because the patient will not have the desire to eat food.

Activities of Life Affected

This can be assessed by checking the signs of both dehydration and malnutrition. For dehydration, the clinical signs that are assessed include weight loss, thirst, dry mucous membrane, sunken-appearing eyes and decreased skin turgor. Monitoring the vital signs four hourly to check signs of hypotension, monitoring his fluid input and output each shift and balancing daily. Ask patient if he is frequently feeling headaches.

Patient is cared by encouraging   him to drink clear liquids such water or diluted juice at regular interval and small amounts each time. Patient to avoid undiluted juice and soft drinks because it will worsen diarrhea (Yunus, 2011). Patient to take fruit juice during the day about 8-12 cups to avoid vomiting and diarrhea. Encourage sips of water in between the meals. Use sports drink to replace potassium and sodium, salt and other electrolytes the body lost during diarrhea and if nausea is present encourage the patient to take sips of water and to eat slowly, drink ice –cold drinks, avoid activity after eating and to avoid fried and greasy food. Administer normal saline intravenous 500mls. It comprises of sodium and chlorine (Floss, & Borthwick, 2018) so that it replaces lost fluid and prevent or corrects some type of electrolyte imbalance alternating with ringer’s lactate six hourly, ringers lactate contains mixture of sodium chloride, sodium lactate and calcium chloride. It also contains microbial agents also antimicrobial agents for prevention of infection. you check signs of fluid overload and give the patient soft foods, BRAT diet which are high in potassium and help replace nutrients lost including bananas, rice, applesauce, dry toast and soda crackers this reduces vomiting and diarrhea. Another alternative food are potatoes, peanut butter, skinless chicken and yoghurt, this food help recover from upset of diarrhea. Administer bismuth salicylate 525mg 2 tablets every 30minutes as needed 16tablets 24 hours which treat discomforts of stomach and diarrhea. Administer paracetamol 100mg if the patient is in more discomfort of abdominal cramps. Administer loperamide which slows movement of food through the intestines and allows the body absorbs more liquid (Brunner, 2010), 4mg orally after first stool then 2mg after each unformed stool. It should be 16mg per day.

This affected by vomiting, diarrhea and lethargy. Vomiting and episodes of watery diarrhea is unpredictable and it can cause soiling of oneself and also the clothing’s and beddings. It also causes transfer of the disease if there is improper hand washing and hygiene also especially after using the toilet or being in contact with vomitus, equipment and environmental surfaces can be contaminated and lead to further spread. It can further cause urinary tract infection if poor cleaning technique of genitals after diarrhea is done. Lethargy makes the patient unable to change the soiled clothes and maintain personal hygiene

It can be assessed by examining patient's clothing if it is wet soiled, smelling or are wet, skin if it oily, greasy has acne or rashes especially the genital regions, assess the mouth if it has smell due to vomitus, has gingivitis, cavities if the lips are dry and cracked, check the nails if they are well kept and not dirty, check the hair if they are unkempt, smelly and oily.

How to assess

Ensure the clothing are changed whenever soiled if diaper is soiled   and washed separately with hot water and detergent and allow to dry thoroughly. Ensure the patient wash his hands properly and frequently with soap and water, wash hands before contact meals and other people and after using the toilet. Do sponge bath daily or bathe the patient normally to prevent smell and spread of the infection, ensure enhanced cleaning of environment and equipment, control the source of the disease if water or food and also isolate the patient to prevent spread of the infection to other people, this precaution should continue for 48hours. Use the adult diapers in case of increased frequency of diarrhea and change it when it is soiled and ensure it is disposed well. Administer fluids like 0.9% dextrose 500mls over 6 hours as you monitor blood glucose thus supplies energy to the patient so that he can get energy to do even daily dressing or even to be able to eat and walk by himself. Encourage the patient to take energy drinks like Ribena and lucozade to energize the patient also.

Elimination is affected by diarrhea and vomiting. Diarrhea is characterized by loose watery stools due to Inflammation of stomach and intestines. This affects the normal elimination due to secretion of water into intestines exceeds absorption. Gastroenteritis causes intestinal inflammation which impair intestinal urate excretion of ABCG2 enzyme which in turn causes hyperuricemia which contributes to nausea and vomiting and this can cause renal failure, it leads to fall in osmolality which is corrected by excretion of water, dehydration makes urine more dilute and urine volume will increase, dehydration can cause kidney and urinary problems which will later tamper with urine elimination.

It can be assessed by monitoring amount of urine, color and concentration and ensuring that daily input and output is carried out, balancing it daily and documented, check the amount of diet the patient is taking and comparing it with the excreted faces, checking the  stool if its watery or there is any change, if it watery administer loperamide ,asses the concentration of uric acid by doing blood test, auscultate the abdomen to check bowl  sounds and to determine if there is and gurgling sound, check for kidney function by carrying out glomerular filtration rate to check if there is any problem for early interventions and treatment

Monitoring fluid intake and output to evaluate patient’s fluid and electrolyte imbalance and also to allow for prompt intervention to correct the imbalance this is done at regular interval of 4 hours and recording it in fluid chart (Metheny, N., & Metheny, N. M. 2011). The normal urine output range for 24 hours is of 800-2000 liters with normal fluid intake of 2litres per day. Monitor temperature, inflammation of intestinal lining causes increase in temperature due to infection and administer antipyretic such as paracetamol, hyperuricemia can be treated by giving non- steroidal anti-inflammatory such as ibuprofen and diclofenac which can prevent its severity, osmolality can be corrected by giving electrolyte balance drugs or fluids such as ringers lactate, polyuria is corrected by desmopressin which increase permeability of renal tubules which increases water reabsorption (Rahnama’i, Vrijens, & Marcelissen, 2018).

Assess

Plan

Implement

Evaluate

Vomiting

Diarrhea

Lethargy

Soiled clothing and beddings and are smelly

Acne or rashes in genital area

Smelly mouth with gingivitis and cavities

Passage of loose watery stool

Dehydration

Decreased urine output

fever

To administer normal saline 500mls to run alternatively with Ringer's lactate 500mls

To administer lower amide 4mg orally

To ensure patient drinks clear fluid sip by sip slowly

To administer bismuth subsalicylate 525mg

To administer 0.9%dextrose 500mls

To take blood sample for urea, electrolytes and creatinine

Monitor vitals 4 hourly

Ensure clothing and bedding changed whenever soiled

Ensure patient washes hands thoroughly to avoid spread

Use diapers for frequent diarrhea

Promote skin integrity to reduce irritation of buttocks and genital area, apply soothing protective ointment

Increase fluid intake such as water or administer through intravenous route to prevent dehydration and maintain hydration status (Neville et.al, 2010)

Provide oral care to prevent dryness

Monitor temperature every 2 hours,

Administer paracetamol to reduce fever

Measure fluid input and output and balance it daily to ensure fluids are delivered accurately and at desired rate

Reduce solid food intake to allow bowel rest and to reduce intestinal workload (Mahan & Raymond, 2016)

give the patient water slowl,y sip by sip

Patient also was given sports drink at 3pm to replace potassium

Nurse to also administer loperamide 4mg at 9 am orally Administered bismuth subsalicylate 525mg 2 tablets every 30 minutes, administered 0.9% dextrose 500mls at 7am to run for 6hours

Administer normal saline 500mls intravenously at 2pm

Ensure personal cleaning of the patient, change clothing and ensure oral care. Apply ointment on genital area and buttocks

provide oral care service at 6pm

Measure temperature at 2pm

Administer Panadol orally

After 24 hours;

Patient skin turgor improved

patient became active and was able to do daily activities

On assessing patient stool, it was hard and normal

On repeat of urea electrolyte and creatinine test it was at normal range

After 24hours of nursing intervention person cleaning and dressing was achieved, the mouth of patient is clean and not smelly

After 24hours of nursing intervention the patient showed improved hydration and nutritional intake

Temperature became within normal range

Fluid input and output balanced

The oral mucosa become moist due to oral care

Weakness of the body

Monitor the level of activity of the patient

Administer dextrose 500mls over 6 hours

Ensure the patient take food of high energy levels

Ensure patient exercise by walking short distances to strengthen the muscles

Check the patient level of activity

Administer 0.9% dextrose 500mls at 2pm

Support the patient to work in and out of the ward

Patient was active and could walk without support

He verbalized that he is much stronger and can do other activities

Mild fever temperature of 37.7c

Expose the patient and reduce the beddings

Open the windows to allow in more air

Administer aspirin after meals to reduce fever

Administer gentamycin IV to reduce infections

Open the windows and exposed the patient and reduced the beddings

Administer aspirin tablets orally 100mg at 3pm

Give 40mg of gentamycin at 3pm

Temperature reduced to 36.5c

How to care


Conclusion

Viral gastroenteritis is the most common illness since affects many people. The paths that it follows is simple. It starts from fecal contaminated substance where the body contracts the virus, enabling it to travel to small intestines (Cutler, 2013). After causing touble on the lower digestive system, the virus gets attacked by the white blood cells of the immune system which is powerful. Understanding the life cycle of can help in diagnoses, elimination and prevention of the disease (Tille, 2015). It can be prevented by washing hands, cooking meat thoroughly and drinking plenty of water daily. Dehydration occurs when the fluid amount leaving the body is higher than the amount going back to the body (Roberts, 2016). In case of dehydration and signs like extreme thirst, confusion, little or no urine output, notify the doctor because it’s an emergency. Certain individuals with heart or kidney disease many need less fluid to correct dehydration ( Ter Maaten, 2015)

References

Blinderman, C. D., & Billings, J. A. (2015). Comfort care for patients dying in the hospital. New England Journal of Medicine, 373(26), 2549-2561.

Brunner, L. S. (2010). Brunner & Suddarth's textbook of medical-surgical nursing (Vol. 1). Lippincott Williams & Wilkins.

Chaithongdi, N., Subauste, J. S., Koch, C. A., & Geraci, S. A. (2011). Diagnosis and management of hyperglycemic emergencies. Hormones (Athens), 10(4), 250-60.

Cutler, E. (2013). Clearing the Way to Health and Wellness: Reversing Chronic Conditions by Freeing the Body of Food, Environmental, and Other Sensitivities. iUniverse.

Field, L. (2016). Nursing & Health Survival Guide: Nutrition and Hydration. Routledge.

Floss, K., & Borthwick, M. (2018). Intravenous fluid therapy—background and principles. Lung cancer, 15, 05.

Humphries, R. M., & Linscott, A. J. (2015). Laboratory diagnosis of bacterial gastroenteritis. Clinical microbiology reviews, 28(1), 3-31.

Koo, H. L., Ajami, N., Atmar, R. L., & DuPont, H. L. (2010). Noroviruses: The leading cause of gastroenteritis worldwide. Discovery medicine, 10(50), 61-70.

Mahan, L. K., & Raymond, J. L. (2016). Krause's food & the nutrition care process-e-book. Elsevier Health Sciences.

Metheny, N., & Metheny, N. M. (2011). Fluid and electrolyte balance. Jones & Bartlett Publishers.

Neville, K. A., Sandeman, D. J., Rubinstein, A., Henry, G. M., McGlynn, M., & Walker, J. L. (2010). Prevention of hyponatremia during maintenance intravenous fluid administration: a prospective randomized study of fluid type versus fluid rate. The Journal of pediatrics, 156(2), 313-319.

Payne, D. C., Vinjé, J., Szilagyi, P. G., Edwards, K. M., Staat, M. A., Weinberg, G. A., ... & Wikswo, M. (2013). Norovirus and medically attended gastroenteritis in US children. New England journal of medicine, 368(12), 1121-1130.

Rahnama’i, M. S., Vrijens, D., & Marcelissen, T. (2018). The management of nocturia and nocturnal polyuria in the daily practice: Results of a Dutch survey. European Urology Supplements, 17(2), e1545-e1546.

Ter Maaten, J. M., Valente, M. A., Damman, K., Hillege, H. L., Navis, G., & Voors, A. A. (2015). Diuretic response in acute heart failure—pathophysiology, evaluation, and therapy. Nature Reviews Cardiology, 12(3), 184.

Tille, P. (2015). Bailey & Scott's Diagnostic Microbiology-E-Book. Elsevier Health Sciences.

Surrena, H. (Ed.). (2010). Handbook for Brunner and Suddarth's textbook of medical-surgical nursing. Lippincott Williams & Wilkins.

Yunus, S. (2011). Diarrhea and undernutrition. In Public Health Nutrition in Developing Countries (pp. 274-291).

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