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Peri-op: Case Study

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                                                       Assessment Task 2: Case Study

The following case study documented is patient-centred care of a patient I was privileged enough to care for during my time placed at Auburn Hospital on the surgical ward. This case study will follow in the format of clinical reasoning cycle as described in clinical reasoning: Learning to think and act like a nurse (Levett-Jones, 2013). The case study will compact of research and reflections of my care of this particular patient whilst caring for the patient and at the conclusion of care.

Consider the patient situation 

The particular patient in whom I was allocated to care for over a five day period was a 28 year old Middle Eastern male whom was admitted complaining of severe abdominal pain as well as nausea and vomiting with query appendicitis/alcoholic gastritis. On first observation I could clearly see the patient was shaken up and in a state of distress. He was sweating profusely, pale, shaking and avoiding eye contact whenever possible. My first impression of this young male was he was anxious, and in a state of distress.

Collect cues and information

Upon patients arrival to the ward I monitored his vital signs. He was hypertensive, febrile, tachycardic, and had a high respiratory rate of 24. I received handover from the nurse from Emergency and she told me he had symptoms of ataxia, disorientation and had been admitted three months prior for alcoholic Gastritis to the medical ward. Handover notes showed a history of alcohol/substance abuse, depression, fatty liver, and memory loss. Handover also suggested on arrival his vitals were unstable and the doctor was aware and believed he was going through a withdrawal of alcohol/substance abuse and had been charted up for 15-20mg Benzodiazepine PRN to prevent seizures and reduce severity of withdrawals. He was placed on an Alcohol withdrawal scale and was to be monitored closely. I went over to present myself and told him I was a student nurse and that I’m just here to talk to him and if there is anything I could get him? He felt a little more at ease talking to another male of a similar age and told me he had recently broken up with his long time girlfriend and went on a drinking binge, as well as taking methamphetamines. He also begged me not to contact his family as he was from Afghanistan and his family don’t know he drinks. I assured him we are here in his best interests alone and tried to empathise with him and told him I’m not here to judge him  and that I just want to see you come out of this for the better, short-term as well as long-term. Natan, (2011) suggests that even if you don’t agree with the patient’s lifestyle decisions, the most important thing is to be empathetic without getting personally involved. The nurses’ objective is to properly serve our patients in complete professionalism (Natan, 2011).

Process information/interpret

Over the course of the following hours with close monitoring I became aware that the patient seemed to be deteriorating, with increased confusion and restlessness. I continued regular intervals of vital sign checks and they had slightly risen from previously observations but still between the flags. I referred back to the Alcohol withdrawal scale chart and the mental health and suicide risk assessment as per NSW Health protocol. The patient wasn’t posing any suicide risk but was scoring an 11 out of a potential 28 on the AWS chart (New South Wales drug and alcohol withdrawal clinical practice guidelines, 2008).  I notified the nurse in charge about my findings. According to Maldonado, & Sher (2014), alcohol withdrawal can lead to potential seizures, hallucinations, aggression, fever, coma and occasional death. Patients drinking large quantities of alcohol are also at risk of Wernicke’s encephalopathy, a neurological condition in which nerves and cells are affected due to exhaustion of vitamin b cells, an essential vitamin for the brain to function (Maldonado, & Sher, 2014).

Identify Problems/Issues

The most concerning condition the health care professional should be looking for when they have a patient with alcohol withdrawals is delirium tremens. Delirium tremens is the rapid onset of confusion caused by alcohol withdrawal. People who drink large amounts of alcohol are vulnerable to the condition in which death can occur. Death occurs in approximately 1-4% of people who are left untreated (Schuckit, 2016). Even though the patient was admitted for abdominal pain, untreated alcohol withdrawal was a priority with signs and symptoms of delirium tremens showing, so the nurse in charge called a clinical review.

Establish Goals

Upon the doctors’ arrival, he took notes and asked the patient a number of questions including how much alcohol has he consumed recently and how often as well as patterns of misuse. The doctor relayed back to the nurse in charge as well as me that there was no signs of urgent intensive care strategies but to continue close monitoring and page him if things get worse. The nurse and I decided it would be most appropriate moving the patient to a single room to prevent any added anxiety to the patient. According to Kattimani, & Balaji (2013), when someone consumes alcohol a central nervous system depressant that acts on the excitatory neurotransmitters over a long period of time and then ceases suddenly the excitatory neurotransmitters continue to transmit at an alarming rate in which the person experiences withdrawal. The amount consumed plays a major role in the severity of the withdrawal (Kattimani, & Balaji, 2013). The timeframe of withdrawal will vary from person to person but usually start with mild to moderate symptoms 6-48 hours since cessation. 48 hours to 72 hrs is the critical stage in which seizures and delirium tremens usually occur (Schuckit, 2016).

Take Action

Problem/issue:  Abdominal Pain– Nursing Intervention (and evidence).  It is important to keep the patient nil by mouth (NBM) if suspected of having Appendicitis or Pancreatitis until results from ultrasound, blood tests, CT scan or MRI return (Banks, 2011).

Problem/issue: Pain– Nursing Intervention (and evidence). For patients with conditions such as Appendicitis or Pancreatitis, pain is a major contribution for the patients’ admission. It is therefore an issue that should be addressed as soon as possible. Common medications used for pain relief, moderate to severe are Oxycodone hydrochloride (endone, oxycontin, oxynorm), Tramadol (Tramedo), and Paracetamol (Mckenna, & Mirkov, 2012). The use of the pain measurement tools are useful in indicating the severity of the pain with the use of verbal, numeric and visual analogue scales (Banks, 2011).

Problem/issue: Anxiety, insomnia, hyperflexia, diaphoresis, & tachycardiaNursing Intervention (and evidence). The use of antianxiety drugs such as Diazepam (valium), and Miazolam hydrochloride can be used to relieve the severity of all the conditions mentioned above. As these drugs work on the central nervous system. Monitoring patients’ respiratory rate and heart rate is a necessity (Mckenna, & Mirkov, 2012).

Problem/issue: Nausea & vomiting- Nursing Intervention (and evidence). The use of antiemetics such Metoclopramide hydrochloride (Maxalon) are often used to combat nausea and vomiting. Considerations to take into are account with patients who have nausea and vomiting are, the position of the patient (high fowlers) to prevent aspiration and to have a vomit bag nearby at all times. Monitoring fluid intake and outtake is essential also to prevent dehydration (Mckenna, & Mirkov, 2012).

Problem/issue: Uncontrolled behaviour- Nursing Intervention (and evidence). Environment for patients with alcohol withdrawal syndrome is important as they unintentionally pose a threat to themselves and others (Natan, 2011).

Problem/issue: family intervention- Nursing Intervention (and evidence). Family intervention can play a pivotal role in recovery for the patient, sometimes working in favour or against the patient. Considerations to apply in these circumstances are gaining consent from the patient before contact is made with family. Educate the family not to internalize abusive statements and to be empathetic as well as non-judgemental. Also allow time to comfort family, as seeing their loved one in such conditions can be confronting and disturbing for them. Reassure the family staff understand AWS, and will provide compassionate and objective care (Strobbe, 2012).

Problem/issue: Fluid, & nutritional deficiency- Nursing Intervention (and evidence). Heavy etoh use can leave patients severely depleted of essential vitamins and minerals the body craves. It is therefore they are given adequate amounts of folate, thiamine, vitamin B12, and multi vitamins for a more successful recovery. Considerations to take in to account are baseline albumin levels to identify just how depleted the patient is of essential vitamins (Jarvis, 2010). Adequate fluid intake is also essential to make up for loss fluids through vomiting, diaphoresis, and as the patient is NBM. Intravenous Dextrose to maintain stable glucose levels and potassium intake for possible irregular heartbeat and atrial fibrillation (Rossi, & Massironi, 2015).

Problem/issue: Nursing Interaction- Nursing Intervention (and evidence). The most important factors for the nurse when interacting with the AWS patient is the use of a soothing and  calm voice, basic questions, simple explanations and minimal interaction ( Rossi, & Massironi, 2015).

Evaluate Outcomes

Through the actions provided above, all the nursing considerations have been taken in to consideration in regards to the particular patient of discussion. Blood results returned positive for acute pancreatitis. Patient was kept NBM for 4 days and monitored continuously for pain, withdrawals and mental stability as well as adequate fluid intake. After 5 days of therapeutic interaction with the patient I build a trust from him in which time I gave him advice on the services available on discharge and that he was still young and had plenty to live for and still had his health if he changed his ways. He was very appreciative of our services towards him and he felt a sense of a positive outlook towards life in the future.

Reflect on process and new learning

Throughout the caring of the patient and at the conclusion of care I learnt that there is no age immune to the destroying effects alcohol has on someone. As Australia is known for its large drinking culture I’m sure I will face many patients in a similar scenario to that of the patient I cared for and I hope that my new learning skills will make a difference.

 

                                                    References

Banks, P. (2011).The management of acute and chronic pancreatitis.

Gastroenterology & Hepatology. 45-51. Retrieved from:

https://ncbi.nlm.nih.gov

Jarvis, S., & Blad, K. (2010). Nursing care of patients with alcohol withdrawal

syndrome. Society of Central Care Medicine. Retrieved from:

https://www.sccm.org

Levett-Jones, T. (Ed) (2013). Clinical Reasoning: Learning to think like a nurse.

Melbourne. Pearson

 

Maldonado, J., & Sher, Y. (2014). The “Prediction of Alcohol Withdrawal

Severity Scale” (PAWSS): Systematic literature review and pilot study

of a new scale for the prediction of complicated alcohol withdrawal

syndrome. Retrieved: Doi:

https://dx.doi.org/10.1016/j.alcohol.2014.01.008

 

Mckenna, L., & Mirkov, S. (2012). Nursing & Midwifery Drug Handbook (6th ed).

Lippincott Williams & Wilkens Pty Ltd. Sydney NSW 2000

 

Natan, B. (2011). Nurses’ perception of the quality of care they provide to

hospitalized drug addicts: Testing the reason of action. International

                Journal of Nursing Practice. 15, (6), 566-573. Doi: 10.1111/j.1440-

172X.2011.01799.x

 

NSW Government Health. (2008). Drug and Alcohol Withdrawal Clinical

Practice Guidelines-NSW. Retrieved from

http//www0.health.nsw.gov.au/polices

 

Rossi, R., & Massironi, S. (2015). Diagnostic and treatment deficiencies in

alcoholic liver disease: Overview of available evidence and open

issues: Science Direct. 47, (10), 819-825. doi:

https://dx.doi.org/10.1016/j.dld.2015.05.021

 

Schuckit, M. (2016). Recognition and Management of Withdrawal. Delirium

(Delirium Tremens). The New England Journal of Medicine. 2109-

  1. Massachusetts Medical Society.

 

Shivanand, K., & Balaji, P. (2013). Clinical management of alcohol withdrawal: A

systematic review. Industrial Psychiatry Journal. 34-39. Retrieved

from: http//ncbi.nlm.nih.gov

 

Strobbe, S. (2012). Applying the nursing theory of human relatedness to

alcoholism and recovery in alcoholics anonymous. J Addict Nursing.

                 23, (4), 241-247. doi: 10.1097/JAN.0b013e31826f67e8.

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