Gastroenteritis - Patient Involvement in the Planning and Resolution Process - Assignment Example

Gastroenterology Clinical Case NSG6001 Advanced Practice Nursing Week 3 Sept. I. Patient involvement in the recognition, planning and resolution of the problem Gastroenteritis is a common problem that exists in our society today and it is one disease that is both stressful and painful. The patient involved in this case is an Italian male school teacher who was ushered in with severe pain in the umbilical area. The nurse kept the patient at ease by casually speaking to him and collecting informative data about his background, his occupation, food habits and about the other members of his family with similar symptoms. All through the clinical process, the caregiver guided and encouraged the patient to involve himself in the planning and resolution process to bring about awareness of his present condition and how to go about making lifestyle changes to resolve the painful issues and restore good health. By involving the patient in the clinical process, the care rendered would be less stressful because the patient would make better adjustments where food, hygiene and other activities were concerned. The symptoms experienced by the patient were severe spasms of pain in the umbilical area accompanied by nausea, and feelings of warmth, sweat and vomiting. From these symptoms, the diagnosis drawn was that the patient suffered from gastroenteritis. II. Plan of Care The delivery of care was customized according to the needs of the patient in order to ensure better adjustment and better health outcomes. The format used for this clinical case was SOAP (Subjective, Objective, Assessment and Plan) format in order to arrive at the right diagnosis. Subjective data such as the health issues of the patient, the background he came from, occupational and financial status, substance abuse, emotional stability and information of other social activities was collected through dialogue with the patient and other friends and members of his family. Subjective data included that the patient was a male 60 years of age and was a retired school teacher with a Master’s degree in education. He and his wife live off a state teacher’s pension, though his wife continues to work at a grocery store. They have two children, a son and daughter who do not live with them. He is also covered by health insurance. He is a sociable individual because he showed inclination of wanting to involve himself in community work. He denies substance abuse but admits to drinking wine and eating fast foods on a regular basis. His primary complaint was that he had acute pain around the umbilical region accompanied by nausea, queasiness, sweating and a feeling of vomiting and these symptoms prevailed for the past 24 hours before his visit to the doctor. He also had heartburn which accelerated after meals. He regularly visited his primary care provider and was being treated for hypercholesterolemia, hypertension and gout. Though concerned about his condition, he is wary of taking medication considering that he may experience side effects. Objective data collected included diagnostic tests, height and weight of the patient, lab reports, vital signs, family medical history and the medication presently taken. His vital signs showed a BP of 175/70; T: 99, po; P: 64 regular, R: 18 non- labored. Examination of the abdomen showed + BS in all quadrants with radiating pain accompanied by palpation in the epigastric area. Stools were heme negative and light brown in color. The Lab results showed the CBC’s and LFTs to be within the normal limits. The Amylase and Lipase were also normal with H. Pylori showing positive. Radiological results after an abdominal ultrasound was done showed the Gall bladder and liver to be normal with EKG normal sinus rhythm. Assessment: Based on the diagnostic tests that included both subjective and objective data findings, a clear diagnosis was arrived at. The diagnostic tests of the abdominal area showed persistent pain in the umbilical area accompanied by radiating pain with nausea and sweating proving that the patient had gastroenteritis. Plan of Care Based on the diagnosis of gastroenteritis, the patient was given a customized care plan that was both viable and suitable according to his present condition of health. The following was the Plan of Care that was adopted. a. Diagnostic work-up Based on all the symptoms the patient experienced such as severe and persistent abdominal pain that was radiating and accompanied by nausea, sweating and a feeling of vomiting, a diagnosis was arrived at. Results of the diagnostic tests showed that the patient suffered from gastroenteritis. (0091) b. Medication Considering that the patient was already taking medication for hypercholesterolemia, hypertension, gout and depression, the medication suggested for treatment of gastroenteritis (0091) was Indocin 50 mg., Zocor 20 mg QD and Propranolol 50 mg BID c. Conservative management The patient was asked to stop eating fast foods and instead eat a healthy diet of lots of fruits and vegetables. He was advised to do walking and few simple exercises on a daily basis and was advised to take his weight regularly. d. Education Educating the patient is one of the primary goals to ensure better health outcomes. The caregiver explains the salient features of gastroenteritis for the patient to have a better understanding on how to cope with this condition. The patient is advised to eat healthy foods with a lot of fruits and vegetables in his diet instead of the unhealthy fast food he used to consume. The patient is educated on the availability and usefulness of joining support groups from the community to alleviate symptoms of depression and develop a feeling of holistic well being. Walking exercises and taking the given medication regularly formed a part of the educating process. e. Collaboration and/or referral The Care Plan is a two way process where the patient and care giver work in collaboration to bring about holistic health to the patient while getting rid of his disease. The patient is advised to respond immediately if abdominal pain occurs. He is also advised to come for regular check ups to check out the progress made. f. Follow-up plan The care giver has a Follow up Plan in place and this is closely followed to keep track of the patient’s progress. Rationale Gastroenteritis is a very painful but treatable disease. According to (Chung M. Chow, et al. 2010) this disease is responsible for the significant mortality in developing countries and significant economic burden to developed countries.” There are many factors that contribute to gastroenteritis and two of the most important are food and water. In the case of the patient in question, the food seemed to be a major contributing factor of the disease because he regularly consumed fast foods which are unhealthy and could have been contaminated with harmful Salmonella thereby giving the patient Salmonella gastroenteritis (0030) According to M. S. Murphy, 2010. p. 279 – 284) Dehydration is also a major contributing factor and the “severity of dehydration is usefully expressed in terms of weight loss as a percentage of total body weight.” This is one of the reasons that our patient was asked to keep a close check on his weight regularly to track the progress made in the delivery of care. Since the patient was suffering from acute gastroenteritis medication could include Loperamide which is anti-diarrhoeal and helps to increase water absorption and prevent dehydration. Nursing interventions were set in place and they include building a good rapport with the patient and assessing the vital signs from time to time. Dietary changes were made and the patient was asked to restrict the intake of solid foods especially fatty foods and take foods rich in fiber. The patient was advised to make use of relaxation techniques and to take a lot of fluids to hydrate the body. (7 Gastroenteritis Nursing Care Plans, 2011) He was also advised to take foods like yoghurt and cultured milk. The importance of proper washing of hands especially before meals was emphasized. References Chung M. Chow, Alexander K C. Leung, Kim L. Hon (2010) Acute Gastroenteritis: from guidelines to real life. A review. Volume 3, pgs. 97 – 112 www.dovepress.com/acute-gastroenteritis-from-guidelines-to-real-life-pe... M. S. Murphy, (1998) Guidelines for Managing Acute Gastroenteritis based on a systematic review of published research. A review. Volume 79, Iss. 3, p. 279 – 284) www.adc.bmj.com 7 Gastroenteritis Nursing Care Plans. (2011) Web. Accessed on 2nd Sept. 2014 from www.nurseslabs.com/gastroenteritis-nursing-care-plans Read More