Medical/ Surgical Case Study



Medical/ Surgical Case StudyLacey HastingsStenberg CollegeMedical/ Surgical Nursing Practice TheoryNURS 201-3Medical/ Surgical Case StudyThis case study was written to provide an in depth analysis of one of the writer’s patients on the medical unit of Nanaimo Regional General Hospital.Identifying Data and General DescriptionFor confidentiality purposes the client will be referred to as only L.W. L.W. is a 31 year old Caucasian European Canadian female, married with 1 child. She is an accountant, a non-smoker, and non-drinker, and lives a healthy lifestyle. L.W. is fit, and takes care of her body. She is a tall woman, with a fair complexion, and appears well put together prior to admission.Chief Complaint/ History of Present IllnessThe primary complaint that brought L.W. to the hospital was viral diarrhea, and what appeared to be a reaction to a medication (Keflex). L.W had oral ulcers, a rash on her face, chest and stomach, as well as an abscess on her thigh and stomach, and a fever (38). L.W. was admitted with the diagnosis of diarrhea/SIRS (systemic inflammatory response syndrome) (Nanaimo Regional General Hospital, 2013). L.W had nausea and vomiting upon admission to the medical unit, and shortly began passing blood from her bowels (1-2 cups) and vomiting blood/sputum. L.W. was in ‘agonizing’ pain, with the oral ulcers, and ‘gut wrenching’ pain in her stomach. At the beginning of L.W. stay, the hospitalists were unsure what was exactly going on, was this in fact a drug reaction from the Keflex that was prescribed just before the diarrhea started, or was it a coxsackievirus (hand foot- and- mouth disease)-which was the initial diagnosis. However towards the end of L.W. stay she was noted to be diagnosed and treated for inflammatory colitis or ‘inflammatory bowel disease’ (NRGH, 2013).Past Medical/ Surgical History and AllergiesL.W. has a history of anxiety and depression, this was noted to be ‘significant’ in her chart (NRGH, 2013). L.W. also has asthma, however does not currently take medication or use an inhaler, and she has no acute signs or symptoms. She has eczema, and suggests she has ‘very sensitive skin’. L.W.’s father also has a history of depression, and irritable bowel disease; which she claimed not to be aware of prior to her diagnosis of inflammatory bowel disease.L.W. does not have a surgical history, however underwent procedures while on the medical floor that I will include. She had a CT scan of her chest, abdomen, and pelvis, which showed diffuse thickening of the colon and rectum consistent with infectious or inflammatory colitis (NRGH, 2013). She also had a sigmoidoscopy done; a sigmoidoscopy is a procedure in which the inner lining of the lower large intestine is examined. Flexible sigmoidoscopy is commonly used to evaluate gastrointestinal symptoms, such as abdominal pain, rectal bleeding, or changes in bowel habits (WebMD, 2013). During the procedure, a doctor uses a sigmoidoscope, a long, flexible, tubular instrument about 1/2 inch in diameter, to view the lining of the rectum and the lower third of the colon (the sigmoid colon) (WebMD, 2013). The photos and biopsy showed query severe inflammatory bowel disease (NRGH, 2013).L.W. allergies to medications include: Erythromycin, Cephalexin, and although not added or clarified, potentially Keflex. There is no food allergies known at this time.Disease ProcessPlease see the attached Appendix A , Table 1 and 2 for Disease Processes.MedicationsThe medications that L.W. is currently taking at home include Valcyclovir an antiviral for the sores in her mouth; Valcyclovir decreases the severity and length of these outbreaks. It helps the sores heal faster, keeps new sores from forming, and decreases pain (WebMD, 2013). Tramadol, which is an opioid analgesic used to treat moderate-severe pain, and previously Keflex which is an antibiotic used to fight bacteria and treat infection (WebMD, 2013).The medications that L.W. received in the hospital included in the table belowDrug: Generic/ TradeClassificationRouteDose & FrequencyTimeMajor side effectsReason for medicationCeftriaxone/rocephinCephalosporin-antibioticIV1g- Q24 hr.0900c-diff(diarrhea), allergic reaction, seizures, chest pain, trouble breathingSuspected infection- this was d/c shortly after startingFluconazole/diflucinAzole AntifungalPO200mg0900Severe stomach/abdominal pain, nausea/vomiting, fast/irregular heart- beat, faintingTreat fungal and yeast infections. Sores in mouthBenzydamine/difflam-hydrochlorideLocally acting non-steroidal anti-inflammatorywith local anesthetic and analgesic propertiesPO RinsePRNPRNNausea or vomiting, burning, or numbness in mouth, throat irritation.relieves pain and inflammation associated with a sore throat or mouth soresNystatin/nilstatantifungalPOliquid100,000 units090013001800Diarrhea, nausea or vomitingUsed to treat fungus infection of the mouthMorphineOpioid/narcoticPOPRNPRN- q 4 hoursAllergic reaction, slowed heartbeat, shortness of breath, severe vomiting, decreased awareness or responsiveness, feverTo treat Moderate-severe PainStomach and mouth soresAcetaminophen/TylenolAntipyretic/ analgesicPOPRNPRNToo much acetaminophen may cause serious (possibly fatal) liver disease and liver problems. Persistent nausea/ vomiting.feverDalteparin/fragmin type of heparinAnticoagulant ‘blood thinner’injection5000 IUOnce daily 1600Unusual or prolonged bleeding, unusual or easy bruising, unusual pain or swelling, allergic reaction, fainting, seizures.Treat/prevent blood clotsDimenhydrinate/gravolantiemeticIVPRNPRNConstipation, dizziness, allergic reaction, confusion, blurred vision, difficulty passing urineNausea and vomitingzopliconeSedative hypnoticPO5mg HS2100Behavior changes, confusion, anxiety, wheezing, tightness in chestshort-term and symptomatic relief of sleep disturbances(Vallerand & Sanoski, 2013)Nursing Physical AssessmentWhile competing a head-to-toe assessment, L.W. temperature was 38, radial pulse was 80, strong and regular, Respirations were easy at 16 per minute. BP was 108/71. Neck veins flat at 45 degree angle. Apical pulse S1, S2 clear without rubs or murmurs. Radial and pedial pulses strong and regular. L.W. was alert and oriented x4, she was pleasant and calm. Her hand and leg strength was strong bilaterally. Capillary refill to hands and toes returns 2 sec. bilaterally. Skin turgor returns less than 1 second, skin is warm, but very pale, rash on face, abscess on buttocks and thigh. Lung sounds clear bilaterally, good air entry, oxygenation- 97 on room air. Pt. c/o not being able to void this a.m. Bowel sounds present and active x 4 quadrant; pt. having diarrhea, with blood approx. 1-2 cups, frank red. Nausea and vomiting present. No peripheral edema. L.W. c/o pain in mouth (sores), 8/10, throbbing pain, worse when eating and drinking; also c/o pain in stomach, 7/10, ‘gut wrenching’ pain, worse with diarrhea and vomiting.Lab ResultsThe out of range significant lab results from L.W stay at the hospital are provided in the table belowLab TestNormal RangeClients’ resultsPurpose of the testIndications about the clientHemoglobin120 to 155 grams per liter)105To assess overall health. Usually done as part of complete blood count (MayoClinic, 2013)Could indicate anemia. L.W.Was losing blood due to Inflammatory bowel disease.RBC’s3.90-5.03 trillion cells/L3.34Typically ordered as part of a complete blood count (CBC) and may be used as part of a health checkup to screen for a variety of conditions (Mayoclinic, 2013)Anemia- Blood lossWBC’s3.5-10.5 billion cells/L11.5Complete Blood CountInflammation- Inflammatory Bowel disease(MayoClinic, 2013).Treatment While L.W. was in the hospital she was receiving antifungals, antibiotics, antiemetics, pain control and towards the end when finding out she had inflammatory bowel disease she was started on a steroid for inflammation (NRGH, 2013). She was on continuous IV D5NS w 40 meq KCL @ 125 ml which is used for fluid and electrolyte replenishment and caloric supply (RxList, 2013). She was given a regular diet and then switched to a small pureed diet which was easier on her mouth and her stomach, and she was seeing a dietician while on the floor (NRGH, 2013). We were taking L.W. vitals BID and temp QID, and continuously monitoring her nausea, vomiting, diarrhea, and pain. We were monitoring her hemoglobin and RBC’s, as she was losing blood through her bowels and vomiting. L.W. was mainly on bed rest , with activity as tolerated (AAT). We assisted her with ADL’s, however she is a young woman and independent so we set up her hygiene supplies and she did this on her own. L.W. would get very anxious about being in the hospital and not knowing what was wrong, and her heart would start “racing”, so we spent some time teaching her about deep breathing, and relaxation techniques. L.W. was involved in her care; she wanted to know what she was taking, and why she was taking it. She would involve in her care and treatment, she wanted to know everything that was going on, what her tests results were, what her vitals were, etc. She would notify us of any changes that she noticed or felt, and would let us know what PRN’s were working for her and which weren’t, what we could do to make her comfortable, etc. There was good communication with L.W. and a definite ‘team’ approach.Teaching, and Discharge PlanningUpon finding out that L.W. in fact has inflammatory bowel disease, which was inflamed, L.W. was discharged to Victoria General and referred for tertiary care to see a gastroenterologist (NRGH, 2013). Thus the discharge instructions will come from the specialist at Victoria General, she would follow up with her GP. Just prior to her discharge from NRGH L.W. was started on hydrocortisone IV, a steroid for inflammation (NRGH, 2013).Writer’s ReflectionThis was a very interesting case, and I learnt a lot while caring for this patient, and while reflecting and analyzing through this case study. This case was so interesting because it was a mystery at the beginning, what was happening to this poor lady? When she came to the hospital she was sure it was a reaction to an antibiotic, she had a rash, fever, nausea, vomiting, diarrhea, and thus this seemed to be the first consensus. However after being on the floor, the consensus changed to the thought of her having hand-foot-and-mouth disease or ‘coxsackie’ virus. It seemed as though this ladies whole body was under attack, she was placed on contact precaution, as they weren’t sure whether this was a contagious virus. When L.W. started passing a lot of blood through her bowels, and then vomiting with blood, the consensus again shifted. I quickly noticed it is like putting pieces together in a puzzle. You have to look at the whole picture, piece by piece to get a good idea of what is going on. With vitals, assessments, lab values, tests, and procedures (Ct scan, sigmoidoscopy), the pieces start to come together. Thus L.W. was diagnosed with inflammatory bowel disease. What I did learn was that with inflammatory bowel disease, the digestive system becomes scarred due to excessive inflammation, and ulcers can develop (NHS, 2013). Over time these ulcers develop into tunnels, or passageways, that run from one part of your digestive system to another or, in some cases, to the bladder, vagina, anus or skin- these passageways are known as fistulas (NHS, 2013). Larger fistulas can become infected and cause symptoms such as: a constant, throbbing pain , a high temperature (fever) of 38°C (100°F) or above , and blood or pus in your faeces (stools) (NHS, 2013). Fistula can also develop on your skin, as well as skin lumps or sores- which could be the explanation for the abscesses present on her buttocks and thigh. (NHS, 2013). With this inflammation or obstruction from inflammatory bowel disease, one can also feel nausea/vomiting, and have abdominal pain and cramping (NHS, 2013). Although the exact cause of her mouth ulcers were not determined I did find some resources that note mouth ulcers can be symptoms associated with inflammatory bowel disease (Medline Plus, 2013; Mayo Clinic, 2013).Thus I was able to see the connections of some of the complications of inflammatory bowel disease, and some of L.W. signs and symptoms. Finally the puzzle came together, and she was able to get the treatment she needed. Priority Nursing Diagnosis and GoalsPlease see attached the attached Appendix B for a short term nursing diagnosis and goal, Appendix C for a long-term nursing goal, and Appendix D for a community focused nursing goal. ReferencesLewis, S. L., Heitkemper, M. M., Dirkson, S. R., Butcher, L., & O’Brian, P. G. (2010). Medical-surgical nursing in Canada assessment and management of clinical problems (2nd ed.).Toronto, Canada: Mosby Elsevier.MayoClinic. (2013). Inflammatory bowel disease (IBD). Health Information. Retrieved from: .(2013). Crohn's disease. National Insititute of Health. Retrieved from: Health Service. (2013). Crohn's disease – Complications. Retrieved from: , G. (2009). Principles and Practice of Psychiatric Nursing. (9th ed). St.Louis, Missouri: Mosby Elesvier.Vallerand, A.H., Sanoski, C.A. (2013). Davis’s Drug Guide for Nurses. (13th ed). Philadelphia, PA: F.A. Davis CompanyWebMD. (2013). Inflammatory Bowel Disease Health Center. Retrieved from: DESCRIPTION OF DISEASE PROCESSCLIENTS PRESENTATION OF DISEASE PROCESSDiagnosis- Inflammatory Bowel DiseaseDiagnosis- Inflammatory bowel diseaseEtiology/ Pathophysiology-Disorder of the gastrointestinal tract, characterized by idiopathic inflammation and ulceration (Lewis et al, 2010).Causes remain unknown, potential causes are infectious agents, autoimmune responses, environmental influences, or genetics (Lewis et al, 2010)Etiology- Dad has irritable bowel syndromeClinical Signs and symptoms- Bloody, diarrhea and abdominal pain are the major symptoms; other symptoms include fever, fatigue, weight loss, anemia, and dehydration.Clinical Signs and symptoms- Bloody diarrhea, abdominal pain, fever, vomiting, mouth ulcers, abscesses, fatigue, dehydrationAppendix ATable 1- Disease ProcessesDepressionEtiology/ PathophysiologyPsychiatric and medical illness. Significant abnormalities can be seen in many body systems, including electrolyte imbalances, neuropsychological alterations, dysfunction or faulty regulation of ANS activity, adrenocortical, and thyroid changes, and neurochemical alterations in neurotransmitters (Stuart, 2009). Causes are unknown, can be life events, genetics,, medical comorbidity etc.Etiology-Again, father had depression. Possible life events- this was not clarified Clinical signs and symptoms- Feelings of sadness or unhappiness, feelings of helplessness or worthlessness. Irritability, anxiety, agitation, trouble thinking or slowed thinking, indecisiveness, change in appetite, etc. (Stuart, 2009).Clinical signs and symptoms- Anxiety, fatigue and change in appetite- although this was due to her medical condition. Unhappiness and sadness, was partly due to hospitalization and being sick, however could be partly due to depression.TEXTBOOK DESCRIPTION OF DISEASE PROCESSCLIENTS PRESENTATION OF DISEASE PROCESSDiagnosis- Anxiety (Generalized)Diagnosis- AnxietyEtiology/ Pathophysiology- Psychiatric disorder involves excessive, unrealistic worry and tension (Stuart, 2009). May be caused by environmental factors, medical factors, genetics, brain chemistry, substance abuse or a combination of these (Web MD, 2013).Etiology- Unknown.Could be from depression, could be genetics. Seems to be worse while in hospital, could be related to medical factors.Clinical Signs and symptoms- Restlessness, on edge, fatigue, difficulty concentrating-mind going blank, ongoing worry, muscle tension, irritability (Stuart, 2009).Clinical Signs and symptoms- Worry, restlessness, heart racing, trouble breathing.Table 2- Disease Processes continuedNursing DiagnosisRelated To:Etiology/Risk FactorsDefining (S/S) CharacteristicsDesired Outcomes (Goals)InterventionsRationale for InterventionsDiarrheaInflammation, irritation- Inflammatory Bowel Disease.Frequent and persistent watery stools.Blood mixed with diarrhea.Abdominal pain-urgency and crampingL.W. will report reduction in frequency of stools, return to more normal stool consistency.Identify/avoid contributing factors.1.Observe and record stool frequency, characteristics, amount, and precipitating factors2.Promote bed rest, provide bedside commode.3.Identify foods and fluids that precipitate diarrhea, e.g., raw vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products4.Restart oral fluid intake gradually. Offer clear liquids hourly; avoid cold fluids.5.Observe for fever, tachycardia, lethargy, leukocytosis, decreased serum protein, anxiety, and prostration.1.Helps differentiate individual disease and assesses severity of episode.2.Rest decreasesintestinal motility and reduces the metabolic rate when infection or hemorrhage is a complication. Urge to defecate may occur without warning and be uncontrollable, increasing risk of incontinence/falls if facilities are not close at hand.3.Avoiding intestinal irritants promotes intestinal rest.4. Provides colon rest by omitting or decreasing the stimulus of foods/fluids. Gradual resumption of liquids may prevent cramping and recurrence of diarrhea; however, cold fluids can increase intestinal motility.5. identify toxic Megacolon or Perforation/peritonitisAppendix BTable 3- Short term care plan for L.W.Appendix CTable 4-Long term care plan for L.WNursing DiagnosisRelated To:Etiology/Risk FactorsDefining (S/S) CharacteristicsDesired Outcomes (Goals)InterventionsRationale for InterventionsPain- AcuteHyperperistalsisprolonged diarrheaskin/tissue irritation, perirectal excoriation, fissures and fistulasMouth sores(Inflammatory Bowel disease)Colicky/cramping- abdominal painPt. states ‘gut-wrenching pain’8/10Stinging, burning pain in mouth (sores), unable to eat. 8/10RestlessnessFacial grimacing- non- verbal expressions of painL.W. will report pain is relieved and controlled.She will appear relaxed and able to sleep/rest appropriately1-Encourage L.W. to report pain.2. Utilize PRN’s- morphine, Tylenol, and antifungal mouth rinses3. Review factors that aggravate or alleviate pain.4. Note nonverbal cues, e.g., restlessness, reluctance to move, abdominal guarding, withdrawal, and depression. Investigate discrepancies between verbal and nonverbal cues5. Provide comfort measures (e.g., back rub, reposition) and diversional activities6. Implement prescribed dietary modifications, e.g., commence with liquids and increase to solid foods as tolerated.1 she may try to tolerate Pain, rather than requestAnalgesics.2.Control, relieve pain3. May pinpoint precipitating or aggravating factors (such as stressful events,food intolerance) or identify developing complications.4. Body language &nonverbal cues may be both physiological and psychological and may be used in conjunction with verbal cues to determine extent/severity of the problem5. Promotes relaxation, refocuses attention, and may enhance coping abilities.6. Complete bowel rest can reduce pain and cramping.Appendix DTable 5- Community care plan for L.W. Nursing DiagnosisRelated To:Etiology/Risk FactorsDefining (S/S) CharacteristicsDesired Outcomes (Goals)InterventionsRationale for InterventionsAnxietyThreat to self-concept (perceived or actual)Threat to/change in health status, socioeconomic status, role functioning, interaction patterns (new diagnosis)Pain- abdominalHistory of anxiety and depressionExacerbation of acute stage of diseaseIncreased tension and distressHeart racing- expressed concerns about her health and being in the hospital/ changes (new diagnosis)Increased pulse rateObsessing over signs and symptomsL.W. will appear relaxed and report anxiety reduced to a manageable level.L.W. will verbalize awareness of feelings of anxiety and healthy ways to deal with them.1.Note behavioral clues, e.g., restlessness, irritability, withdrawal, lack of eye contact, demanding behavior.2.Encourage verbalization of feelings. Provide feedback.3.Acknowledge that the anxiety and problems are similar to those expressed by others. Actively-Listen to L.W. concerns.4. Help L.W. identify/initiate positive coping behaviors used in the past5. Assist L.W. to learn new coping mechanisms, e.g., stress management techniques (deep breathing, imagery, etc.).1.Indicators of degree of anxiety/stress2.Establishes a therapeutic relationship. Assists L.W. in identifying problems causing stress.3. Validation that feelings are normal can help reduce stress/isolation4. Successful behaviors can be fostered in dealing with current problems/stress, enhancing L.W.’ssense of self-control.5.Learning new ways To cope can be helpful in reducing stress and anxiety- andenhancing disease control; whenin the community ................
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