NUR250 Medical Surgical Nursing 1

1.

Mr Bob Jackson is a 55 year old man, who is a sheep farmer by profession. He resides in a rural community, namely Patersons Plains, situated 100 km North-West of Melbourne. He has been admitted to the emergency department with complaints of nausea, malaise, diarrhoea and increasing Left Lower Quadrant (LLQ) abdominal pain. The most likely disease that fits Mr Jackson’s vital symptoms is Gastroenteritis or stomach flu.

Aetiology:

Gastroenteritis is described as a pathogen induced inflammation of the intestinal lining. It is mainly caused by bacteria, virus or parasites and spreads through contaminated food, water or contact with infected person (Quigley & Jiang, 2014). The various causes of gastroenteritis are as follows:

Viral: norovirus, rotavirus, calcivirus, astrovirus, enteric adenovirus

Bacterial: Campylobacter sp., Salmonella sp., Shigella sp., Clostridium sp.

Parasite: Giardia, Cryptosporidium

Non-infectious: Food allergy, intolerance or malabsorption.

In recent years, food-borne diseases have become a global concern. Previously, Australian government recorded 1 to 4 million occurrences of food-borne diseases per year. Gastroenteritis is highly infectious. The pathogens can easily transmit through ingested food or water or environmental particles to a normal, healthy individual. Most of these pathogens have multiple modes of transmission. Some transmit through food such as Bacillus sp. while others transmit through non-foodborne routes such as rotavirus which transmits through faecal matters (Ahmed et al., 2014). In Australia, there are recorded 17.2 million incidences of gastroenteritis per year, out of which estimated 32% are food-borne. The most commonly responsible pathogens for this disease include norovirus (in adults), rotavirus (in children), Escherichia coli, Salmonella sp. And Campylobacter sp. (Shirasu et al., 2015). It has also been stated that food-borne gastroenteritis causes almost 15,000 cases of hospitalization and 80 deaths per year. Therefore, food-borne diseases pose a major threat on the communities.

The major issues Mr Jackson is suffering from include diarrhoea and nausea, which are the main symptoms for gastroenteritis. Sheep typically become infected with gastrointestinal parasites. The lifecycle of these parasites include a host (sheep) stage and an external environmental stage. Since Mr Jackson is a sheep farmer, it is quite evident that he may have got the infection from the cattle’s GI parasites. Also, He has medical history of suffering from depression. But he is currently not on any anti-depressant medication. That is probably one of the reason behind his current malaise.

Pathophysiology:

Acute watery diarrhoea results from an imbalance between the absorption and secretion of water by the intestinal villi. The important pathophysiological mechanisms are osmotic, secretory, motility, invasive and mixed. Damage to the villous brush border membrane of the intestine, causing malabsorption of intestinal contents, leads to osmotic diarrhoea. Release of toxins that bind to specific enterocyte receptors and cause release of chloride ions into the intestinal lumen, leads to secretory diarrhoea (Jalanka-Tuovinen et al., 2013). Changes are majorly non-inflammatory in the small intestine, but inflammatory in large intestine. That is the reason why Mr Jackson is feeling severe pain and discomfort at lower abdominal region, specifically at LLQ abdomen.

The patient has medical history of piles.  About three months per year, he suffers from loose stool and has frequent bloody stool too. He also often suffers from watery diarrhoea from time to time and takes Gastro-stop medicine to treat it. The bloody stool results from inflammation of the GI tract, which usually results from food intolerance, indigestion, intestinal parasite, or irritable bowel syndrome. Therefore our hypothesis is evident in this matter since after examining the patient, it has been found that he has distended, tender abdomen which is the result of any of the previously mentioned causes. He is experiencing pain in his left lower quadrant of abdominal region. Which is simultaneous with the symptoms of gastroenteritis (Kirk et al., 2014).

Diarrhoea causes severe water loss and thereby dehydration in the body. It is known that properly functioning kidneys show SG levels between 1.002 and 1.030. If the person is dehydrated, the SG level goes above 1.010. The higher the value, the more dehydrated the person is.  Mr Jackson’s urinalysis shows specific gravity of 1.05. Therefore it can be concluded that Mr Jackson is quite dehydrated, due to constant loss of water through diarrhea and vomiting. Dehydration results in mild to severe headache, muscle cramps and dizziness (Gibney et al., 2014). Although Mr Jackson did not experience any dizziness or muscle cramps yet, but he is having mild headache from the last few days. Therefore, special care must be taken to ensure that he stays hydrated.

The risk factors for the disease include excessive alcohol consumption, smoking, increased stress and poor bowel habits (Belliot et al., 2014). The patient Mr Jackson consumes 6 stubbies of heavy beer every week. For the last 35 years he has been smoking 1 pack of cigarrette each day. Also he has history of hypertension along with quite poor bowel habits. All these factors strengthens the hypothesis of gastroenteritis.

2.

The other chronic disease that explains Mr Jackson’s symptoms is Bronchitis. Bronchitis is the most prevalent cause of blood-cough (Kim & Criner, 2013). His physiological system review showed that he is facing haemoptysis and persistent cough, with mild pleuritic pain for over a month. Over the last year he has been suffering from recurrent bronchitis and colds.

Patients with mild respiratory diseases possess a blood oxygen saturation or SpO2 level of 90% or above. Mr Jackson’s SpO2 level is 98% on RA. Respiratory rate denotes the number of breaths taken per minute, which should be 12 to 20 for a healthy adult. When it goes below 12 or exceeds 25, then it is considered abnormal. Mr Jackson’s RR is 20, which falls in the normal range.

Infection in the upper respiratory tract involves symptoms which are quite common such as runny nose, nasal congestion, sneezing, sore throat, cough and fever, along with a few less common symptoms including headache, nausea, vomiting and diarrhea. Bronchitis develops when any foreign infection causes irritation and inflammation in the bronchi (Blush III, 2013). This results in the generation of more mucus, which is rejected by the body through the way of cough. Common cold and flu often develops into acute bronchitis, mostly in case of children. This is a temporary condition and lasts up to 3 weeks. But chronic bronchitis is a more severe condition, lasting up to years. Chronic bronchitis is a part of the chronic obstructive pulmonary disease (COPD), affecting mostly elderly people.

Bronchitis can be caused by a virus or a bacteria, although prevalence of viral bronchitis is more commonly found. Smoking is a major risk factor for the disease. The harmful chemical and smoke in the cigarette makes the condition of bronchitis even worse, it even increases the chances of developing emphysema. Although there is no proven medical cure for bronchitis till date, some major lifestyle changes can be followed to improve the situation (Kim & Criner, 2015). Such as maintaining a healthy food habit, regular moderate exercise and most importantly avoiding smoking all together.

Diagnosis:

Although it is quite difficult to differentiate between the signs of common cold and bronchitis at the start, therefore doctors suggest some tests to diagnose the actual reason depicted behind, so that they can start treating the patients (Zhukova et al., 2016). The followings are a few very common diagnostic tests:

• Chest X-ray: Mostly done to determine the reason and nature of cough, mostly in people who smoke cigarettes. It helps distinguish between health conditions of pneumonia and bronchitis.
• Sputum test: Sputum or the coughed up mucous can be tested for probable diseases or allergies. This can be a quite definitive diagnosis. Some of the diseases can be treated with antibiotics.
• Pulmonary function test: This is done with the help of a spirometer to measure the capacity of lungs. The volume of air in lungs associated with different phases of the respiratory cycle differs among healthy individuals and diseased persons. This test mainly checks for symptoms of asthma or emphysema.  

Although there is no specific medical diagnostic test for gastroenteritis, there are tests performed to negate the chances of other diseases. The symptoms of inflammatory bowel diseases such as Crohn’s disease, and the symptoms of gastroenteritis are quite similar, therefore the doctors may ask for a sigmoidoscopy which is an invasive examination of the sigmoid colon that mostly checks for colon cancer, to evaluate the symptoms. After excluding the possibilities of other diseases, a stool culture is performed to determine the type of microorganism that is causing the infection.

To prevent the symptoms of the disease several medications can be helpful. These are as follows:

• Beta-blockers: Beta-blockers can be quite significant in order to prevent symptoms of asthma or respiratory difficulties, although in some cases these may trigger asthma symptoms. These medicines block the binding of adrenaline with beta receptors on nerves and help achieving a normal heart rate. The potential beneficial effects of beta-blockers outweigh its risks in COPD.
• NSAIDs: Aspirin, ibuprofen or other non-steroidal anti-inflammatory drugs may cause asthma symptoms to increase. Although in most patients these drugs are found to relieve pain, decrease inflammation and reduce fever.
• Narcotic analgesics: The narcotic and analgesic drugs are mostly used to relieve pain, dim the sensations and increase drowsiness. Long-term usage may lead to addiction towards such medications.
• Antibiotics: Antibiotics are not usually not recommended for treatment of bronchitis, but can be preferred for treating the infections. Sometimes patients with COPD are treated with prescribed doses of amoxicillin, doxycycline or trimethoprim-sulfamethoxazole, which are suggested as inexpensive medications (Gonzales et al., 2013).

References:

Ahmed, S. M., Hall, A. J., Robinson, A. E., Verhoef, L., Premkumar, P., Parashar, U. D., … & Lopman, B. A. (2014). Global prevalence of norovirus in cases of gastroenteritis: a systematic review and meta-analysis. The Lancet infectious diseases, 14(8), 725-730.

Belliot, G., Lopman, B. A., Ambert?Balay, K., & Pothier, P. (2014). The burden of norovirus gastroenteritis: an important foodborne and healthcare?related infection. Clinical microbiology and infection, 20(8), 724-730.

Blush III, R. R. (2013). Acute bronchitis: Evaluation and management. The Nurse Practitioner, 38(10), 14-20.

Gibney, K. B., O’Toole, J., Sinclair, M., & Leder, K. (2014). Disease burden of selected gastrointestinal pathogens in Australia, 2010. International Journal of Infectious Diseases, 28, 176-185.

Gonzales, R., Anderer, T., McCulloch, C. E., Maselli, J. H., Bloom, F. J., Graf, T. R., … & Metlay, J. P. (2013). A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. JAMA internal medicine, 173(4), 267-273.

Jalanka-Tuovinen, J., Salojärvi, J., Salonen, A., Immonen, O., Garsed, K., Kelly, F. M., … & de Vos, W. M. (2013). Faecal microbiota composition and host–microbe cross-talk following gastroenteritis and in postinfectious irritable bowel syndrome. Gut, gutjnl-2013.

Kim, V., & Criner, G. J. (2013). Chronic bronchitis and chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine, 187(3), 228-237.

Kim, V., & Criner, G. J. (2015). The Chronic Bronchitis Phenotype in COPD: Features and Implications. Current opinion in pulmonary medicine, 21(2), 133.

Kirk, M., Ford, L., Glass, K., & Hall, G. (2014). Foodborne illness, Australia, circa 2000 and circa 2010. Emerging Infectious Diseases, 20(11), 1857.

Quigley, C., & Jiang, X. (2014). Gastroenteritis. In Metabolism of Human Diseases (pp. 137-142). Springer, Vienna.

Shirasu, A., Ashida, A., Matsumura, H., Nakakura, H., & Tamai, H. (2015). Clinical characteristics of rotavirus gastroenteritis with urinary crystals. Pediatrics International, 57(5), 917-921.

Zhukova, O. V., Brusnigina, N. F., Kononova, S. V., Speranskaya, E. V., & Efimov, E. I. (2016). Persistent pathogens as risk factors of community-acquired pneumonia and acute bronchitis in children. Žurnal Infektologii, 8(2), 56-64.