NSB334 : Integrated Nursing Practice 4

Complete the following workbook questions from your simulation including the clinical reasoning cycle:

Back pain: Mr Dwight might have been experiencing pain in the abdomen as indicated in the history. At times the symptoms of cancer might fail to show until it gets to spread to all the other parts of the body including the bones of the spine. Mr Dwight is experiencing pain in the abdomen a clear indication of discomfort at that part of the body. The pain is normally a discomfort or bloating that is experienced after taking a meal. This may lead to a reduction in the food consumed by the patient and even culminate in loss of body weight (Olsson, 2017).

Loss of weight: As a result of the pain felt in the abdomen, Mr Dwight might have found minimal comfort in eating due to fear of bloating. Still, Mr Dwight might be taking a very low quantity of meals. Either of these results in limited nutrients into the body and hence loss of body weight. At other times, Mr Dwight might not just be feeling hungry hence decided to forego his meals. This would still lead to a significant drop in the weight of the body.

This is a condition in which the end of the ileum is dislodged out o the abdomen and stitched onto the outer surface of the skin to form a stoma. Colostomy is another type of stoma which could be formed after a colectomy. It is achieved when there is any section of the large colon attaching to the small colon. An open hemicolectomy is a surgical process that involves the removal of the caecum, the hepatic flexure, the ascending colon, the first third of the transverse colon as well as a section of the terminal ileum together with fats and lymph nodes (McLatchie, 2013). It is a treatment that is used for surgical treatment of malignant neoplasms of the right colon.

The surgical procedure for hemicolectomy with the formation of a colostomy involves colostomy formation which is to form an opening or a stoma stitched to the outer surface of the skin. The procedure of the operation is as follow;

A hole is made through the wall of the abdomen

Stitching the upper end of the colostomy (when making an end colostomy)

Removal of the other end/ closing it by the use of a tape

The surgeon may as well decide to form a loop colostomy. Under such a circumstance, the skin surface will have both the downstream and upstream ends stitched to it.

Old age: People aged above 50 years are found to be at higher risks of contracting bowel cancer compared to those younger than 50. With an increase in the age of an individual, the cell DNA damage tends to increase. The damage can result from some biological processes that are occurring the body of the individual or due to exposure to the risk factors (Yeo, 2012).

A family history of bowel cancer: Up to a third of bowel cancers can result from a variation or fault in one or more genes. The mutant genes can easily be passed from one generation of the family to another. In cases where one has the changed gene, risks of contracting bowel cancer become high at a point in the life of the individual. However, it is not clear which genes take part in the transmission of bowel cancer. Research has established that up to 5% of the cases of bowel cancer are directly associated with the genetic mutation. Some of the genetic conditions include MUTYH Associated Polyposis, Lynch syndrome and Familial Adenomatous Polyposis. The risk of developing bowel cancer among individuals with any of these conditions is high and may be diagnosed with the disease at tender ages.

The normal blood sugar level is not static but fluctuates throughout the day in individuals. While fasting, the normal blood sugar level should for the case of non-diabetic individuals range between 3.9 and 5.5 mmol/L which is 70 to 100mg/dL. The mean normal level of blood glucose in the human body is approximately 5.5 mmol/L.

Mr Dwight’s blood sugar level reading is 22mmol/L. This is higher than the above normal sugar level in adults which is 20mmol/L. in this regard, Mr Dwight could be suffering from moderate to severe high blood pressure symptoms (Ruhl, 2017). Such symptoms may include extreme thirst, flush, dry skin, blurred vision, restlessness, or difficulty to wake up. In case Mr Dwight’s body is producing little or no insulin at all, he could be suffering from either diabetes 1 or diabetes 2. Should that be the case, he could be having such symptoms as vomiting, rapid, depth breathing, pains in the belly, vomiting, weak pulse, false heart rate or even loss of appetite as well as a strong fruity breath smell. Some of these symptoms were noticed in Mr Dwight.

Among the interventions that can be used to address Mr Dwight’s diabetes include eating food containing less calories, engaging in regular physical exercise in order to improve the sensitivity of the cells to insulin, seeking medical intervention and avoiding both physical and mental stress as these release stress hormones which lead to a rise in the level of blood sugar (Ruhl, 2017).

A nasogastric tube is a tube used in conducting food and medicine from the source to the stomach via the nose. Dwight uses the tube for feeding. Upon arrival at the hospital, Dwight confesses that he has not eaten for quite some time and this could be attributed to the discomfort he feels when he eats due to bowel cancer.

The routine checks when a patient has nasogastric tube in the body are among them;

Taking note of the measurement-This involves ensuring the tape is the correct length of the tape as required. This is done to ensure the tube has neither slid nor moved farther to an extent is not supposed to. It is possible that the tube might not have been correctly placed or the patient changed his position thereby displacing the initial position of the tube. The check is done through auscultation (Cresci, 2016).

Checking the pH-The pH of the contents of the tube also require continuous monitoring to ensure its at the recommended values. A pull back on the syringe gives the gastric contents which can be used to do a pH test in case testing strips are available.

Performing a chest x-ray-This is known to be the standard used in the establishment of the positioning of the tube.
Answer:

pH checks are done to establish the level of acidity in the stomach of te patient. The normal pH value should not be more that four but this may change depending on the types of drugs the patient is on. The pH value may range between 4 and 6 in case the patient is one drug that are inhibiting acids. Litmus paper is not used in conducting this test since it cannot establish the actual levels of the activity in the body. In case the pH values have not given the expected or normal results for example values higher than 5.5 or in cases, the patient is found to have become unconscious, the initial position of the nasogastric tube is established (Cresci, 2016). This is done through an x-ray.

Regular checking of the position of the nasogastric tube is important as it would help in establishing if it is possible to pull out the tube partially when the patient moves or when the tube is tugged by a confused patient. Upward dislocation upon vomiting or coughing can change the position of the tube. Still, a faulty initial placement may lead to incorrect positioning or placement of the tube. Correct or proper placement of the tube would ensure effective feeding by the patient.

There exist emotional, spiritual, social and psychological needs that patients with palliative care need. The social needs are informative to the caregiver and provide him with an understanding of the social and cultural perspective of the patient. By assessing the social needs, it is possible to understand the patient in the cultural and social context thereby helps in guiding care plans for the patient. Social assessments are done by nurses who would like after that make the necessary arrangements for referral in the cases where there may be nee for comprehensive assessment and special support. By assessing the social needs of the patient, it would be possible to provide enough support should issues arise including anxiety, concerns or distress. These needs can then be assessed by the recommended healthcare professionals or a general healthcare provider as dictated by circumstances.

An understanding of the social needs of Mr Dwright would also help the care providers in understanding the family background and what he believes in. This would provide an easy time to the caregivers while attending to him. Patient-physician conflicts that may arise due to lack of an understanding of the patient would be eliminated (Dodds, 2013).

Assessment item on pain and an item on high-risk medication. An assessment of pain would be conducted to ascertain the quality of pain the patient is feeling. Mr Dwrght has reported abdominal pain that causes him discomfort that even prevents him from taking his meals regularly. This assessment would be able to help the caregivers rate the pain experienced based on the intensity and the interference. Depending on the outcome of the intervention, the level of interference with the body by the pain would be established of which is already clear that it causes him his life enjoyment (Giddens, 2016).

High-risk medication assessment would monitor and assess the most probable risks that Mr Dwright would be exposed to in case he is put on high-risk medication. Through this assessment, the hospital will be able to establish the impact that high-risk medication would have on the patient and hence make an informed decision whether to administer such medication or not.high-risk medication drugs are those drugs that may subject the patient to high risks thereby able to result into significant harm to be the patient should they not be used correctly. The consequences of any errors made in the use of such drugs are devastating to the patient.

The medication prescribed for Mr Dwright in the palliative care unit for pain is 50g of Pethidine that is to administer four times a day. Pethidine is a narcotic analgesic that is associated with multiple actions which have the same properties as morphine medication route for the drug is through injection. Pethidine relaxes the muscles and is sedative at the first stage of pain or labour. The drug works by inhibiting the receptor of pain from reaching the brain, and the effect is felt for about 15 minutes after the time of having a jab. After 30 minutes of administration, the full effect of the drug is felt which lasts for up to 4 hours. The medication is the right one for Mr Dwright. It helps in the relaxation and coping with a strong contraction of the muscles but does not come with a numbing effect (Calvey, 2012). This allows the patient to move around even after administration. Among the side, effects/ complications of the medication include vomiting, dehydration, sepsisscikle cell crisis and dyspnea. Serious adverse effects may include depression of the circulatory system, shock, respiratory depression, cardiac arrest and apnea besides a lesser degree.

Answer:

High blood sugar level: Mr Dwright is found to be having a blood sugar level is above the normal range. His blood sugar level is found to be 22 mmol/L. Such a high blood sugar level has devastating health effects on the patient and may lead to such conditions as loss of consciousness or impaired mentality. The condition is attributed to the failure of insulin hormone to break down the excess sugars in the body thereby leading extra accumulation of the substance (Aghababian, 2011).

Abdominal pain: This is a symptom of bowel cancer. Abdominal pains have significantly contributed to poor health in Mr Dwright. Ranging from the discomfort to preventing him from taking his meals usually, abdominal pains form an integral part of the findings of the clinical assessment. Mr Dwright is unable to move freely, has to strain to get the nutrients into his stomach due to this condition.

High blood sugar level: Mr Dwright is found to be having a blood sugar level is above the normal range. His blood sugar level is found to be 22 mmol/L. Such a high blood sugar level has devastating health effects on the patient and may lead to such conditions as loss of consciousness or impaired mentality. The condition is attributed to the failure of insulin hormone to break down the excess sugars in the body thereby leading extra accumulation of the substance.

Abdominal pain: This is a symptom of bowel cancer. Abdominal pains have significantly contributed to poor health in Mr Dwright. Ranging from the discomfort to preventing him from taking his meals usually, abdominal pains form an integral part of the findings of the clinical assessment. Mr Dwright is unable to move freely, has to strain to get the nutrients into his stomach due to this condition (Smith, 2013).

Among the nursing diagnoses that can be used in the diagnosis of Mr Dwright include interviews, questionnaire and physical examination. The nurse, using his skills and expertise in nursing would observe the notable symptoms in Mr Dwright that would indicate deterioration of his health status. Mr Dwright can talk despite his medical condition. The nurse may, therefore, engage him in discussions that would enable access to his clinical history. Through an interview, the nurse would be able to access first-hand information from the patient at the same time building on the patient-doctor relationship. The discussion should only be about information that the nurse finds relevant in the understanding and after that establishing a care and treatment plan for him. Questionnaires may be used to get information on what the nurse may feel the patient may not be free to share and is more comfortable writing it. The level of confidentiality of any of the information sought must be highly maintained and should there need of sharing it should be at the discretion of the patient (International, 2012).

The main goals of the Emergency Department are stabilization and rapid evaluation. The evaluation is done to establish the clinical history of the patient by performing physical examinations. It aims to identify the cause of precipitation, especially under conditions when the cause of the condition or illness is reversible (Kayden, 2014). Stabilizations aims at ensuring Mr Dwights is brought back to his normal body operations. Such would include measures geared toward stopping or significantly reducing the levels of abdominal pain, stopping vomiting and the foul breath.

Among the signs and symptoms that would be limelight that the condition of Mr Dwright is improving are those that demonstrate stabilization. Restoration of the blood sugar level to the normal range and reduction in the levels of abdominal pain would be some of the indicators that the goals are being achieved. While in the hospital, Mr Dwright is put under nasogastric tube from which he feeds. The nutrients provided should be such that they match the health requirements of them being a diabetic patient. Restoring his blood sugar level to normal would be an indicator that he health is improving while in the Emergency Department.

The three goals of palliative care include;

Identification of the goals of care: Care may aim at reducing the impact of the symptoms of a disease or completely eradicating the disease depending on the nature and complexity of the infection.

Caring for the patient(treatment): The primary goal of palliative care is to see a patient restored back to the original health condition before he was attacked by a disease.

Controlling signs and symptoms: Palliative care aims at providing the best quality of care to a patient. This it achieves by ensuring the patient receives the best quality of life (Matzo, 2014). At times the treatment of some diseases for example cancer could come with symptoms that are so burdening that the healthcare providers may decide to neglect. Through palliative care, patients get treated for such symptoms as depression, fatigue, constipation and pain among other symptoms.

Mr Dwight would find it more confident and comfortable when the family members form part of her caregiver team. While the family members have an important role to play in ensuring the continuity of life of Mr Dwight, there is need to have precautionary measures that would ensure the family is safe and does not contract healthcare associated infections even as they take care of one of their own. A strategy that would ensure care for the family members is avoiding coming into contact with the body fluids of Mr Dwight. These body fluids among them semen, tears, saliva and others are found to be likely contaminants and therefore a source of microorganisms that would cause infection to the family members. From these body fluids, medication from the body of the patient gets their way out to the environment. This would mean the need for caution when one has to handle such body fluids (Glick, 2015).

Among the multi-disciplinary clinicians that Mr Dwright mat be referred to include practice nurse, general practitioner, diabetes specialist nurse.

The diabetes specialist nurse is a nurse with special and detailed knowledge of diabetes. Such a nurse is integral in assisting and supporting diabetes patients on how to manage their conditions. These nurses form the backbone of treatment of diabetes. Using their vast knowledge of diabetes, they help the patient ensuring that their medical conditions are correctly managed. Diabetes specialist nurse ould this guide Mr Dwright on how to manage his high blood sugar level conditions. The nurse would come up with a care plan that would tell the patient what to do and what diet to use to improve his medical condition.

It is required of such nurses to be equipped with vast knowledge and understanding of diabetes as well as ensuring that they are personally qualified and have met the requirements to carry out a duty for which they might be entrusted (Masters, 2013).

The main goals of the Emergency Department are stabilisation and rapid evaluation. The evaluation is done to establish the clinical history of the patient by performing physical examinations. It aims at identifying the cause of precipitation, especially under conditions when the cause of the condition or illness is reversible. Among the signs and symptoms that would be limelight that the condition of Mr Dwright is improving are those that demonstrate stabilization. Restoration of the blood sugar level to the normal range and reduction in the levels of abdominal pain would be some of the indicators that the goals are being achieved. While in the hospital, Mr Dwright is put under nasogastric tube from which he feeds. The nutrients provided should be such that they match the health requirements of them being a diabetic patient. Restoring his blood sugar level to normal would be an indicator that he health is improving while in the Emergency Department. The discomfort he was feeling made him avoid his meals for some time. Upon monitoring him while on the NG tube, it would be possible to establish the point at which the discomfort sets in and the appropriate medical measures observed thereby improving on his conditions (Mallory, 2013).

Blood and blood product may be important for cancer patients because of cancer itself. Such instances are among them;

Cancer which begins from the bone marrow or spread from that point to the other body parts. Such cancers are capable of reducing the normal making of blood cells since they would crowd the surfaces.

Cancer may lead to the development of chronic anaemia disease which has a negative impact on the production and lifespan of the red blood cells of the body due to the longterm medicals associated with the condition.

Organs such as the spleen and the kidney are affected by cancer thereby leading to reduced blood count. Such organs are important in ensuring there are enough blood cells in the body of an individual (Carroll, 2010).

Some cancer for example cancers that affect the digestive system cause bleeding of the internal body organs. Such bleeding may lead to anaemia thereby resulting in very few red blood cells left in the body.

The treatment of cancer is also a cause of alarm and rhus leads to the need for blood and blood products in such ways as;

Cancer treatment surgery may lead to loss of blood

Low blood cell counts are a result of the effects of chemotherapy drugs used in the treatment of cancer

Low blood cell counts as a result of radiations in cases where it is used in the treatment of large bone areas.

Drugs used for chemotherapy are very powerful and thus likely to have adverse health effects on the family members and the caregivers of the patient. It is for this reason that there is need to take the necessary precautionary measures that would ensure the household members and the caregiver of the chemotherapy patient be taken into consideration. The precaution should be done in such a way that prevention is prevented even as the drugs leave the body of Mr Dwright. Chemotherapy drugs can be found in the body fluids among them urine, semen, vomit, tears, blood or even stool. Being that Mr Dwright is suffering from bowel cancer whose one of the risk factors is a family history of bowel cancer, chances of transmitting the disease to the family members would be increased in case of any carelessness or negligence while on the chemotherapy (Bartz, 2017). There could be younger members of his family who could be possessing a dormant gene of the disease and should there be leakages or exposure to the chemotherapy, any of the family members might fall a victim of the infection at early stages.

Source of Microorganisms: Patients may be exposed to a variety of microorganisms either from the healthcare provider to the visitors. Other sources of these microorganisms could be from the flora of the patients. Such microorganisms may be difficult to control and suppress thereby leading to the deterioration of the health of the patient.

Means of transmission: Various mechanisms of transmission of diseases occur among the patients and the healthcare providers. The disease-causing microorganisms can be transmitted through either direct contact or indirectly which occurs through such channels as air, respiratory droplets and common vehicle (Safdar, 2011). Others include vector-borne transmissions. As the medication leaves the body of the patient, it calls for utmost caution to ensure that it does not come into contact with the body fluids which would otherwise serve as an indirect transmission means of the infections and related conditions to the caregiver and the healthcare professionals.

Susceptibility of the host: such factors as age, the severity of the illness, underlying diseases and the medical treatment are also factors that increase the risks of infections that are associated with healthcare among patients undergoing chemotherapy. Invasive devices have been found to have to a great extent impact on the contraction of healthcare associated infections.

References

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Bartz, B. (2017). Prioritization, Delegation, and Assignment – E-Book: Practice Excercises for the NCLEX Exam. Tokyo: Elsevier Health Sciences.

Calvey, N. (2012). Principles and Practice of Pharmacology for Anaesthetists. Beijing: John Wiley & Sons.

Carroll, W. L. (2010). Cancer in Children and Adolescents. New York: Jones & Bartlett Publishers.

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Cresci, G. A. (2016). Nutrition Support for the Critically Ill Patient: A Guide to Practice. Washington DC: CRC Press.

Dodds, C. (2013). Oxford Textbook of Anaesthesia for the Elderly Patient. Oxford: OUP Oxford.

Dunning, T. (2013). Care of People with Diabetes: A Manual of Nursing Practice. Manchester: John Wiley & Sons.

Giddens, J. F. (2016). Health Assessment for Nursing Practice – E-Book. Oxford: Elsevier Health Sciences.

Glick, M. (2015). The ADA Practical Guide to Patients with Medical Conditions. New York: John Wiley & Sons.

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Kayden, S. (2014). Emergency Department Leadership and Management. New York: Cambridge University Press.

Mallory, M. N. (2013). Behavioral Emergencies for the Emergency Physician. New York: Cambridge University Press.

Masters, G. A. (2013). Multidisciplinary Care of the Cancer Patient , An Issue of Surgical Oncology Clinics, E-Book. London: Elsevier Health Sciences.

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McLatchie, G. (2013). Oxford Handbook of Clinical Surgery. Oxford: OUP Oxford.

Olsson, L. (2017). Timely Diagnosis of Colorectal Cance. Berlin: Springer.

Ruhl, J. (2017). Blood Sugar 101: What They Don’t Tell You About Diabetes. Pennyslvia: Pronoun.

Safdar, A. (2011). Principles and Practice of Cancer Infectious Diseases. Texas: Springer Science & Business Media.

Smith, M. (2013). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Chicago: National Academies Press.

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