CNA250 Nursing Practice 2

2.Gastrointestinal Disease

Using the files in this session and the resources in the course introduction below, prepare a care plan for a client who is in an acute stage of a gastrointestinal disease. You may pick any disease you wish to prepare this case study.

The case study must include information on the following:

1. Demographic and biographical details of the client.
2. Signs and symptoms of the disease
3. Information on drugs commonly prescribed to alleviate symptoms or cure the illness.
4. Other forms of treatment for the illness.
5. A full care plan, addressing the nursing needs during the acute illness.
6. A teaching and learning plan for the client and his/her family/significant others when preparing for discharge.

1.Case Study: HIV/AIDS

1.

The positive test results of EIA (enzyme immune essay) means that Sheila might have HIV. Although the EIA test is highly accurate and provide the best results, the test outcomes may be false. This is called false positive. This means that the result shows the patient has HIV but they actually do not. Therefore in the case of Sheila, it cannot be said that she definitely has HIV. To confirm the results physician may conduct more sophisticated test such as western blot (Centers for Disease Control and Prevention, 2015).

2.

As discussed above the positive results of EIA sometimes not true.  The person diagnosed with HIV may not have this disease (CDC, 2018). Therefore the physician must conduct other tests to be sure about the positive tests before informing the patient about the disease. Other situation such as the patient might refuse to give samples, can be raised if informed prior to other diagnoses (Centre to Advance Palliative Care ,2018).

3.

There are various local HIV/AIDS support groups in Canada such as Canadian AIDS society, positive youth Canada, Sexuality and you, world vision Canada, ACCM and Canadian strategy on HIV/AIDS. These local organizations provide a complete support to the patient with Acquired immune deficiency syndrome. They help the person with practical assistance and treatment information programs which aim to improve the quality of life. They also encourage the patient’s personal development. AIDS is the life-threatening disease that cannot be treated. Therefore the person should be provided with the emotional support which essential after the diagnosis of the disease (CATIE ,2018)  . These communities or organization or support groups provide sex education and advocating for important HIV associated issues like discrimination. These support groups also help the person to arrange financial support for their better care and high-quality health services and motivate the person to happily live longer with HIV/AIDS disorder (Canadian HIV/AIDS legal network, 2012).

4.

The patient has been diagnosed with HIV/AIDS, which might develop the emotional breakdown and she might think of every negative aspect of her previous life. The statement mentioned by Sheila is based on three assumptions these are:

• The first assumptions are that her boyfriend is responsible for this situation as she discussed that he had sexual relations with many girls before proposing her for marriage.
• The second assumption is that her boyfriend lied to her that he is not HIV/AIDS positive she might be assuming that he had this disease all the time but he never discloses that to her.
• The last assumption on which Sheila made the statement is that her boyfriend still engaged in sexual relations with other girls even after proposing her, that is why her boyfriend developed the symptoms of this disorder and transferred to her.

5.

The statement made by Sheila indicated that she has developed the ‘why me’ thoughts after diagnosed with the disease.  The patient with HIV infection or disease may suffer a great psychological and stressors through the fear of social stigma, rejection, disease progression, and some uncertainties that are associated with the future management of AIDS (Bor, Miller and Goldman, 2013). At this time psychological support is essential. Sexual transmission is not the only risk factors that can cause HIV infection there are other factors associated with this disorder such as HIV positive blood transfusion, by sharing needles, during pregnancy and using intravenous drugs. The statement made by Sheila was on assumption and completely blaming her boyfriend about the situation, she can be approached by educating her about other risk factors. There might be a possibility that she is having this disorder before meeting her boyfriend as the symptoms of HIV/AIDS may arise after years. She can be counselled about the life with HIV. The patient should be educated about what the HIV can be managed and the person with AIDS/HIV can be lived longer with the help of good health services.

6.

A nurse can play an important role in managing the symptoms of HIV/AIDS. The medicine prescribed the patient may not be managed by the person properly; a nurse can help the patient to monitor the medicines such as antibiotics and narcotics. The patient can be educated about health promotion to reduce HIV related condition and disease transfer. Psychological or mood disorders commonly occur in a patient with HIV/AIDS; nurses can assess the mental health issues and provide interventions. A patient in this situation seeks advocacy and support from other person and in the absence of the support, they may isolate themselves from social life. In this situation, a nurse can advise the patient and provide an encouragement for living healthy (Family Health International, 2007).

7.

There are various issues can be raised during the care of Sheila such as lack of confidentiality, lack of knowledge of HIV/ AIDS, patients behaviour. The patient with this disorder may not believe on the care provider that they keep it secret or not, therefore the patient might co-operate with the nursing care. Lack of knowledge about the disorder is another issue. The patient with this disorder should have known about the symptoms and how the disease transfers to others. Lack of knowledge may lead to the issues related to the nursing care. Patient after knowing that they have this disorder may suffer from behavioural change and negative thoughts about themselves and the quality of life may be reduced (Mametja, 2013). As discussed in the case study the patient already developed “why me” thoughts, which can also create problems for the nurse to provide care to her.

8.

Most of the people with the human immune virus do not even know they became infected. As discussed mentioned the patient has no sign and symptoms of AIDS. HIV symptoms can differ person to person; some people do not show any symptoms for many years and AIDS caused due to worsening of HIV infection. At the first stage of HIV, the patient shows symptoms like fever, body rash, sore throat, swollen glands, and headache. In the second stage of HIV, the patients start feeling better and HIV virus does not reveal the symptoms for up to 10 years, this stage is also called asymptomatic stage (Murrel, 2018).

9.

Acute sign & symptoms of HIV infection: the acute sign & symptoms that can occur in HIV infected patient include fever, body rashes, sore throat, swollen glands, headaches, upset stomach, joint aches & pains, and muscle pain (Cohen et al. 2010). These symptoms may appear due to the reaction of the body against the HIV virus. The immune system tries to kill the virus by producing HIV antibodies (McMichael, 2010).

Blood and body fluid precautions: a health professional or nurse might be affected when providing a nursing care to the person with HIV. This can happen if the nurse exposed to the body fluids of the affected person. The universal precaution set for the body fluids such as blood, Semen and vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, amniotic fluid, and pericardial fluid (Li et al. 2011. Although blood is the most common and important source of HIV in the occupational setting, exposure to other fluids that are mentioned above should also be avoided (Centers for Disease Control and prevention, 2016).

10.

The patient diagnosed with HIV often seeks for confidentiality or wants other like nurses and friends to keep it secret. They have the fear that they might be discriminated by the surrounding people if they know. Therefore to keep the information confidential or secrete, recommending someone Sheila can trust escort her home is a good idea.  After the diagnosis, psychological and emotional support should be provided to the patient, and a friend or trustworthy person can provide that support to Sheila more than anyone else (Cook et al. 2018).

11.

According to the Canadian right to privacy Law, a person with HIV has the right to decide when, to what extent, how and to whom they should disclose their personal information. They have the right to know how the information about their health issues going to be used and safeguard (Canadian HIV/AIDS network, 2004). And without their permission, their information should not be disclosed to others. However, there are some limitations on the right to privacy policy such as the health professional or nurses can breach the right to privacy to prevent the spread of disease infection to someone who is close to them. They have the power and the right to contact the past sexual partner to take medical advice. But they should not use the patient’s name.  The Canadian Court has decided to provide the health professional to disclose the information to protect someone in some circumstances like:

• The known person or group of person have the clear risk of harm
• The person or group may suffer serious health issue or death
• The harm is about to happen to person or group (Canada’s source for HIV and hepatic C information, n.a).

12.

The person with HIV has the right not to disclose their HIV information. However, in some case, they have the legal duty to inform the other person. According to the Canadian court, the person with this disorder has a legal duty to disclose their HIV status before having vaginal sex without the condom. Therefore Sheila does not have to disclose the HIV information to her boyfriend but before having sex with him without any protection, she should inform him about the situation.

Understanding the relationship side of HIV/AIDS

1.

After knowing that her boyfriend is also HIV positive and they are going to be married in the future, the emotional support will be there and they can better understand each other’s situation. Nursing care is necessary for both the persons. But nursing care is still necessary for both of them to understand how to manage the symptoms associated with HIV. HIV infection can be worse if not managed properly. Its symptoms start appearing after a long period of time. The patients with this disorder can live longer lives by using some healthy HIV management plans and nurses might play a critical role to assist them for the better life (Dr.  Peter Aids Foundation, 2016).

2.

AIDS is Stands for Acquired immune deficiency syndrome and it can be developed after the HIV has damaged the infected person’s immune system to a state where it cannot fight to the infection effectively. Although both the partner requiring Nursing care to manage their health condition, if one develops AIDS in future then she might need more focused nursing interventions. Nursing professional can help the person by providing guidance about how to take medicines like ARV’s to slow down the progression of the disorder and to improve the quality of life. The precaution associated with the HIV infection now more focused so that to slow the disease development. At this stage, the patient might be needed psychological support and the positive behaviour related to their health. A skilled nurse can help the person to understand that the symptoms can be prevented by following the precaution and medication.  In the late stage of HIV infection, a nurse can assist the patient with ART (antiretroviral therapies) which enable the majority of the people to live longer and healthier lives (Halman, et al. 2014)

2. Gastrointestinal diseases

Peritonitis

Demographic and biographical information of the client

A 67 year old lady was presented at the emergency ward after a fall at her house. It was reported that she was suffering from abdominal pain and fever from several days. Upon physical examination, she was feverish to 103.7^oF. The rate of the pulse was 110 beats a minute and blood pressure was 74/40 mm Hg with a mean arterial pressure (MAP) of 51bmm Hg.

She was lethargic and diaphoretic, so was unable to explain her history to the doctors. Upon the examination of the abdomen, it was found that there was abdominal tenderness and a palpable fullness in the lower left quadrant. So, it was diagnosed that she was suffering from peritonitis (Paul and Ridolfi, 2012).

Peritonitis is an inflammation of the peritoneum which is the thin layer of tissues that cover the abdomen from inside and the majority of its organs. The inflammation is the result of microbial (bacteria and fungi) infection. This can be caused due to the abdominal injury, a medical condition, or any treatment device like a catheter or a feeding tube. The patient with this disorder may have worsening abdominal pain, nausea, and vomiting (Samuel, 2013).

Sign & Symptoms

The symptoms of this disorder vary depending on the cause of the infection. Some common symptoms associated with this medical condition are:

• Pain in abdomen
• Abdominal bloating
• Vomiting
• Nausea
• Diarrhea
• Tenderness in abdomen
• Constipation
• A minimal output of urine
• Anorexia
• Thirst
• Fatigue
• Fever and chills (Nolph, 2013).

Drugs commonly used to treat peritonitis

There are various drugs has developed to treat this medical condition like Clindamycin, Garamycin, laforan, Fortaz, Zinacef, amikacin, ampicillin, Mefoxin and unasyn, vancomycin. Clindamycin is the most popular medicine used widely. Vancomycin is the newest drug used for the treatment of peritonitis (Ma et al. 2016). Other drugs that are used for peritonitis includes metronidazole, ciprofloxacin, Cipro, vancomycin, ancef, Flagyl, cefotaxime, ceftazidime, ceftriaxone, cefazolin (Nova Scotia health authority, 2017), Cleocin, albumin human, zosyn, Azactam, Vancocin, cilastatin, piperacillin, cefuroxime, amikin and gentamycin (Daley, 2017). 

Other forms of treatment for peritonitis

Treatments involve antibiotic therapy, surgery, and dialysis.

Antibiotics: the patient with peritonitis is likely to give an antibiotic medicine course to treat the infection and to prevent its progression. The course type and duration totally depends on the severity of the condition and type of peritonitis a patient has.  The risk of developing early peritonitis can be reduced by using perioperative IV antibiotics. In severe intra-abdominal infection, piperacillin/ tazobactam,  imipenem, and the combination of metronidazole and aminoglycoside are often effective.

Surgery

Surgical treatment is often used to remove the infected tissues, cure the underlying cause of infection, and to prevent the microbial or other forms of infection from spreading, specifically id the infection is caused by rupturing appendix, colon, or stomach (Rular and Boermeester, 2016).

Dialysis

Depending on the sign and symptoms of the condition the treatment may include dialysis. The dialyses have been recommended for several days until the body clear or heal the infection (Ballinger et al. 2014).

Other forms of treatment include intravenous fluids, blood transfusion in some cases, and supplemental oxygen while the patient is in the hospital (Furgeson, and Teitelbaum, 2009).

Nursing care plan

Peritonitis is the Inflammation of the peritoneal cavity which can occur due to bacteria or chemical, and even by the medical equipment’s applied to the patient for treatment. Surgical intervene can be curative in localized peritonitis. If the condition is diffuse, a medical management is important before the surgical treatment.

Care setting for the patient: inpatient acute medical or surgical unit.

A first part of nursing care plan for the patient peritonitis is to assess the patient for health condition related concerns such as pain, sepsis, any inflammatory bowel disease, weakness, difficulty ambulating, abdominal distension, Hiccups, decreased urine output, anorexia, nausea, vomiting, dry mucus, swollen tongue, and poor skin turgor. The pain can be assessed by using DSM 5. The patient should also be assessed for any respiratory complication such as shallow respiration and tachypnoea.

The nursing goal for the patient with acute peritonitis includes

• Reducing the pain level
• To restore the balance of fluid and electrolyte
• To prevent the complication
• To restore the normal functioning of the gastrointestinal tract (leMone et al. 2014).

Nursing interventions

Risk of infections

• Risk of being infected by pathogenic microorganisms that can occur due to the inadequate primary defences such as traumatized tissue, broken skin and altered peristalsis. It can also cause due to the invasive procedures and inadequate secondary defences.
• Nursing intervention should be provided in this situation includes
• Noticing the individual risk factors like trauma, peritoneal dialysis and acute appendicitis influence the choice of interventions.
• The change in mental statuses like confusion and stupor should be noted. A nurse should also record any change in skin colour, moisture and temperature to analyse the symptoms like the dry skin of septicaemia (Belleza, 2016)
• A nurse should maintain the strict aseptic techniques to provide better care in abdominal drains, open wounds, incisions, dressings and invasive sites to prevent the access of spread of microorganisms.
• A nurse should monitor or restrict the staff and visitors when appropriate or necessary. This may help to reduce the risk of exposure.
• Obtain the specimens and analysing and monitoring the results in serial blood, wound cultures and urine to identify the causative agents.

For deficient fluid volume:

• It is the condition which is defined as the reduced intravenous, interstitial and intracellular fluids. For this nursing intervention that can be helpful are:
• Monitor the vital sign, measure CVP (central venous pressure), and recording presence of tachycardia, hypertension, tachypnoea, and fever. To reduce the hyperactivity of the bowel and diarrhoea losses NPO can be maintained with nasogastric or intestinal aspiration.
• Blood, fluids, electrolytes, and diuretics can be administered to maintain electrolyte balance to move back the water into intravascular compartments.
• Eliminating the noxious sights and any smell from the surroundings the gastric stimulations and nausea or vomiting response can be reduced.

Acute pain

• A nurse should investigate the pain reports, noting the pain location, duration, intensity on 0 to 10 scales, and the characteristics to analyse if the change in location or intensity may developing the complications. Moving the patient deliberately and slowly, splinting the pain area helps to reduce the muscle tension and minimize the pain of movement.
• Comfort measures like massage, deep breathing, and back rub promote relaxation and can enhance the person’s coping abilities.

Risk of imbalanced nutrition

• Nursing intervention, in this case, includes auscultating bowel sounds, noting the hyper-acting or absence of sounds monitoring NG tube output and noting the presence of diarrhoea and vomiting. This helps to get the idea about the bowel obstruction which indicated that further evaluation is required.
• A nurse should monitor BUN, albumin, pre-albumin, nitrogen, and glucose balance as indicated. This helps to analyse the functioning of organs and national status and requirements.
• An advanced diet that can be tolerated by the person can be used which helps to reduce the risk of gastric irritation.
• Checking the person’s weight regularly helps to determine any initial losses or gains that reflect the changes in hydration and nutritional deficits( Ministry of Health Services ,2009).

Anxiety or fear

• Anxiety and fear might be there in patient’s behaviour due to the situational crisis or threat of death and physiological factors. In this case, the nursing interventions can be provided are:
• Evaluating the anxiety level, recording the patients verbal and nonverbal messages and encourages the patient for expressing his/her emotions freely. A nurse should provide information to the patient about the disease process and the related treatment. Anxiety is reduced after knowing what to expect.

Other interventions

• Medicine can be administered to the patient are analgesics and anti-emetics as prescribed by the physician
• To reduce the pain associated with the medical condition analgesics and positioning can be used
• I & O monitoring should be done which include recording the entire intake and output to assess the fluid replacement
• A nurse should administer and monitor the IV fluids.
• A nursing intervention should also include the blood pressure monitoring

Evaluation

A nurse should evaluate the reduced level of pain, restored fluid and electrolyte balance, stoped complications, and restored gastrointestinal functions.

Teaching

Nurse’s duties during the discharge and for care at home include:

• The patient had his/her family should be taught about the proper hand washing techniques before discharging the patient to reduce the cross-contamination and spread of the microbial infection.
• The nurse should teach the patient and the family about how to care the incisions and drains after sending the patient home
• A nurse should discuss with the patient and their families about the medication regimen, timings, and the associated side effects. This might help the person and their family carers to maintain the medication after discharge as antibiotics are continued.
• The patient should be instructed not to lift heavy weight. They should be recommended to take adequate rest and some tolerated usual activities, this helps to prevent weakness, fatigue and enhance the feeling of wellbeing.
• The nurse should ask them to visit the hospital whenever necessary and emphasize the importance of medical follow up. This is necessary to monitor the infection resolution and recheck that the medication is properly following at home or not.

References

Ballinger, A. E., Palmer, S. C., Wiggins, K. J., Craig, J. C., Johnson, D. W., Cross, N. B., and Strippoli, G. F. (2014) Treatment for peritoneal dialysis- Associated peritonitis. Cochrane Database Systematic Reviews, 26(4).

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Bor, R., Miller, R., and Goldman, E., (2013 )Theory and practice of HIV counseling: a systemic approach. New York, Routledge, pp. 4-10.

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Ma, T.K.W., Leung, C.B., Chow, K.M., Kwan, B.C.H., Li, P.K.T. and Szeto, C.C. (2016) Newer antibiotics for the treatment of peritoneal dialysis-related peritonitis. Clinical kidney journal, 9(4), pp.616-623.

Mametja, V. L. (2013)  Problems experienced by professional nurses caring for HIV/AIDS patients in public hospitals of Polokwane municipality, Limpopo province. Available from: https://ulspace.ul.ac.za/bitstream/handle/10386/973/mametja_vl_2013.pdf?sequence=1&isAllowed=y [Accessed 18 August 2018].

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