Management of Safe and Effective Care Environment - Assignment Example

Patient care plan Introduction Percutaneous endoscopic gastrostomy (PEG) tube is used to feed artificially and nutritionally support patients who require long-term enteral nutrition. These patients usually have none functional GI tracts. Therefore, nutritional needs cannot be met solely through the GI tract. Hydrations as well as medications are conveyed directly into the patient’s stomach. However, this form of delivery increases the likelihood of contamination and infections. Poor management of PEG tube may also cause injuries to the abdominal walls. One of the risk factors of PEG tube is a condition called buried bumper syndrome. Bumper migration to subcutaneous tissue was found to be one of the most common complications reported after PEG placement (Marks & Dunkin, 2013). Approximately 70% of 97 patients who have percutaneous endoscopic gastronomy (PEG) placement have hospital revisits with complications (Naik, Joshipura, Patel, Haribhakti, 2008). Purpose of paper The purpose of this study is to explore the nursing treatment and management of a patient who has been diagnosed with the buried bumper syndrome in a clinical setting (Ramdass & Mann, 2013). It discusses the role of RN in managing the different needs of human beings as a consumer of health care in a patient-centered environment. The paper will base its in-depth exploration on previous healthcare literature and evidence from previous related cases. Patient’s condition Currently, the patient has obesity, hypoventilation syndrome as well as obstructive sleep apnea. The woman has obstructive sleep apnea which is characterized by obesity. On 14th October 2014, the patient’s condition was critical because she had a respiratory failure that was requiring endotracheal intubation. Patient’s history revealed that the PEG tube was inserted. The placement of endotracheal tube was delayed leading to a bradycardia asystolic arrest. The respiratory failure that the patient experienced on 14th October 2014 required intubation. However, the CT scan shows signs indicating that the endotracheal tube was not correctly placed. This placement may be one of the causes of hospital revisits. The CT scan revealed a bumper migration to subcutaneous tissue. CT scan also showed purulent discharge at the site of PEG. No edema was found; the patient was alert and oriented. 2. Safe and Effective Care Environment a. Management of care Although hospital policies and current nursing texts do not offer adequate recommendations for care of the patient with PEG tube (Simons & Remington, 2013), it is important not to neglect this area. It is important that care providers are aware of the complications that may arise from PEG insertion in order to identify and manage them well. Nurses should clearly know the indications and contraindications for PEG tube placement to minimize related complications (Rahnemai-Azar, Rahnemaiazar, Naghshizadian, Kurtz & Farkas, 2014). Awareness of the current patient’s complications is of paramount importance for comprehensive management. Recovery from PEG complications treatment procedures should meet the minimum standards of patient care and safety requirements. Sound clinical judgments, identification of “red flag” indications and timely intervention allows for the optimal patient management (Marks & Dunkin, 2013). In the present case, the doctor has recommended PEG-J. Therefore, verification of tube placement is regularly needed to prevent the tube migrating into the stomach. b. Safety and infection control One study conducted in Germany over a period of six years indicated that 13.5% of complications result from poor PEG insertion, whereas 11.1% of complications result from infections (Marks & Dunkin, 2013). The case patient was showing signs of infection which include fever and tachycardia. This is commonly referred to as post-operative infection, and it may have occurred due to multiple attempts for endotracheal tube placement. Another likely cause of fever and tachycardia may be as a result of abdominal wall perforation. Wound infection is one of the common complications of PEG placement. The patient-related factor that has been found in the case patient case and likely to result to wound infection is obesity. However, it may also have resulted from technique-related factor considering that push or pull technique can also lead to wound infection. In this patients case, it is important to consider a multiplicity of causes so as to provide all-encompassing care. Treatment of wound infection includes adherence to antibiotic administration and wound care. Most wounds infections respond to first-generation cephalosporin or quinolone. In case of failure to respond to antibiotics, the nurse should recommend surgical intervention. The skin around the PEG should be cleaned daily, and the tape around the tube replaced whenever loosened or soiled. However, one should avoid taping the tube to the patient’s abdomen and wait until the site is completely healed (Simons & Remington, 2013). c. Potential priority nursing diagnosis The diagnosis in the 64-years old woman is buried bumper syndrome, and it has been diagnosed through CT scan. The PEG tube was placed through a push (Sacks-vine) method. One of the risk factors of buried bumper is poor healing of the wound. The case patient has revisited the hospital several times with PEG complications. CT scan was used to determine the position of the bumper in the abdominal wall. Probably, the tape was not securely placed which may have resulted in accidental dislodgement into the subcutaneous tissues. The current literature regarding PEG dislodgement does not provide enough evidence of any workable preventive practice to prevent dislodgement or displacement (Rahnemai-Azar, Rahnemaiazar, Naghshizadian, Kurtz & Farkas, 2014). However, care providers can allow for an additional 1.5 or 2 cm between the skin and the external bumper to prevent pressure necrosis. The care provider can also gently rotate and manipulate the tube in and out on a daily basis. The tube can be pushed 1cm inwards and rotated a few times every time the tube is being cleaned to prevent intramucosal migration. Taking a measurement of the length of the external portion of the tube is also important to establish whether any migration is occurring. Measurement will also help the nurse to manage the tube well to prevent unnecessary tube traction. Regular checking of the PEG tube position is recommended. A small distance between the external bumper and the patient’s skin should be maintained. The PEG tube should be checked every 4 hours and every time after feeding to prevent the cases of dislodgement. A daily rotation of 180-360 degrees is recommended (Rahnemai-Azar, Rahnemaiazar, Naghshizadian, Kurtz & Farkas, 2014). 3. Health Promotion and Maintenance a. Age and developmental considerations The care nurse should consider the age of the patient to provide the best care because different age groups have different needs. b. Health and wellness Obesity is considered to be the most common risk factor for BBS. Obesity causes unnecessarily increased tension on the tube leading to BBS over a period. Weight management is of paramount importance in this client’s case. The obese state of the case-patient may be the major cause of hypertension. Marks & Dunkin (2013) state that weight reduction has a direct correlation with improved hypertension. Therefore, to effectively reduce hypertension, care providers will have to manage the patient’s weight. There is a risk of impaired skin integrity. The patient already has one site of impaired skin integrity. Further disturbance of the tube through Peg infiltration and surgery causes additional concerns of new infections. Skin is the first line of defense against infections. By incising through this first line of defense, there is potential for new bacteria to enter the body and cause new infections. c. Health promotion/illness prevention Food is one of the factors that promote or deteriorate someone’s health. Some research studies have demonstrated the efficacy of therapies about a particular physiologic problem. The primary indication for parenteral feeding is the provision of nutrients to meet the metabolic requirements for the patient. In consideration of the case patient’s age, the goal is not only to improve the nutritional status and survival, but also to improve her quality of life which does not necessarily correlate with nutritional improvement (Rahnemai-Azar, Rahnemaiazar, Naghshizadian, Kurtz & Farkas, 2014). d. Other considerations Based on NCLEX test plan, it is important to consider managing pneumonia. Oral care reduces pneumonia in the elderly in nursing homes. The aspiration of salivary secretions containing oral bacteria into the lower respiratory tract may be the main cause of pneumonia in the present case. The aspiration of a pathogen from a proximal site establishes the connection between oral health and pneumonia. There is an increased risk of developing pneumonia in the elderly individuals not receiving oral care. Therefore, to reduce detected pneumonia in the case patient, oral health interventions are necessary. The patient may also be experiencing bouts of dehydration. The hematocrit level of the case patient is very low. Hematocrit indicates the level of RBC in the total blood volume. Serum and RBC are contained in the total blood volume. According to Schuster (2011), the normal level of hermatocrit is higher in male patients (42% to 52%) than in female patients (37% to 47%). The level of hematocrit should be approximately three times that of hemoglobin concentration. In the patient under consideration, this is not the case. The hematocrit level of the case patient (26.5%) has dropped along with the hemoglobin level (8.8 g/dl). That is, both levels are low at the same time. This is indicative of bleeding because a drop in hematocrit level and hemoglobin level indicates that the patient is bleeding (Schuster, 2011). The patient may also be experiencing dehydration because in the instances when the hemoglobin level is normal, the hematocrit level remains low. e. Potential priority nursing diagnosis The potential priority nursing diagnosis that has been identified is morbid obesity. According to Naik, Joshipura, Patel & Haribhakti (2009), PEG complications are likely to occur in elderly patients with co-morbid illnesses. The authors have stated that the risk increases in patients with previous infections and a history of aspiration. In the case patient, the Systolic Blood Pressure of 97/54 was too low and hypotensious. The systolic pressure of 148 on 19th April at 1957hrs was in the hypertension stage 1 range whereas the diastolic reading of 73 was within the normal range. Therefore, the reading of 148/73 was in high BP Stage 1. High blood pressure in the patient is as a result of Obesity Hypoventilation Syndrome. Probable excess weight against her chest walls may have been making it harder for her muscles to draw in a deep breath or have a quick breathe. 4. Psychosocial integrity To achieve utmost PEG complications healing outcomes in the case patient, it is important to provide compassionate care to the patient especially considering her age, condition and history of treatment. Age is one of the most important factors to consider. The care provider should be conscious of the stages of human growth and development across the life span. This will enable him/her to assess the condition of the patient and her ability to accomplish her aspirations and goals. a. Cultural considerations The patient under care is a married woman who has a husband and a son. This family unit may play a very important function in the patient’s healing process. The nurse must include the patient’s spouse and son in the care plan because they commonly participate caring for the patient at home. Determining the family background is important for the assessment of the patient’s social support system (Schuster, 2011). The family will also help the patient to improve her self-esteem. There is a likely risk for low situational self-esteem. The responsible nurse should formulate a plan that includes the management of this problem. b. Coping mechanisms The nurse should seek to promote the patient’s coping ability. The psychosocial goal of nursing care in the current case is to support and encourage the elderly patient to accept physical changes. Encouraging acceptance of oneself is the first step towards healing. The second step is to convey hope to the patient that progressive improvement is possible. Also, the nurse follows an optimistic approach. He/she identifies indicators of progress such as electrolyte balance and daily weight trends (Schuster, 2011). c. Support systems Support services are necessary, and they include all the disciplines involved caring for the patient. The case-patient may require the services of dietician since she is obese. Other support services that should be planned prior to the discharge from the hospital include respiratory therapy, social worker support, and physical therapy. Each of these disciplines is important because it will have a role to play in patient’s care. The nurses main role is to do an assessment of patient’s health status so as to establish whether the support is needed or not or whether the patient can manage to tolerate such support. The nurse then communicates with the support service providers and the physician attending the case so as to give recommendations for therapy. d. Potential priority nursing diagnosis identified The potential priority nursing diagnosis in this area is the failure of the patient to adjust to changes in body image. The condition is commonly referred to as dumping syndrome. The signs of dumping syndrome include shortness of breath. 5. Physiological integrity a. Basic care and comfort The treatment and management plan must include psychological care of the patient who is not able to eat and drink. There are other changes that occur with normal aging and the distinction of physiological alterations from the disease. The primary care provider of the case patient should be sensitive to the basic physiological and morphological changes in the patient. It is the role of the primary care provider to go beyond relying on scientific information and attune himself/herself to patient needs, experiences, and emotions to facilitate her healing and coping. The comfort measure in the present case should include: i. The assistance with oral care to the patient in a duration of 4 to 8 hours. ii. The feeding through PEG tube should be administered at room temperature because cold tube feeding causes abdominal pains and cramps. b. Pharmacological and parenteral therapies Parenteral nutrition is an important therapy used in people of all ages including the elderly, other adults, and children (Ayers, Adams, Boullata, Gervasio, Holcombe, Kraft, Marshall, Neal, Sacks, Seres & Worthington, 2013). PN is a complex therapy that maximizes treatment and management outcomes while minimizing the potential risks for adverse effects. The pharmacological and parenteral therapies should be based on appropriate guidelines and evidence for use. Before prescribing therapy, the care team should confirm that the medications prescribed are appropriate (Ayers, Adams, Boullata, Gervasio, Holcombe, Kraft, Marshall, Neal, Sacks, Seres & Worthington (2013). In collaboration with the nutrition specialists, the care team shall specify and document their therapeutic goals of both pharmacological and parenteral therapy. Therapeutic goals for the case patient shall include determination of energy and protein goals; parameters and monitoring frequency for patient’s condition which shall include fluid requirement and glucose concentration. These goals should also include endpoints, treatment response, and treatment failure. The care nurse should have adequate understanding of the principles of pharmacology. Pharmacology entails the study of medication, the body’s effect on the medication, and the medication’s effect on the body. Patients respond differently to drug therapies; therefore, drug dosage, in this case, must be individualized to the case patient. c. Reduction of risk potential According to Ayers, Adams, Boullata, Gervasio, Holcombe, Kraft, Marshall, Neal, Sacks, Seres & Worthington (2013), a standardized process that has been recommended by the American Society for Parenteral and Enteral Nutrition (ASPEN) includes incorporating clinicians with expertise in nutritional support. In the 63-year old patient’s case, who is obese, through knowledge of protein and energy requirement, acid-base balance, micro, and macronutrients are required. Wrong prescriptions can even result in death; therefore, the prescriber should be highly knowledgeable because the case under consideration is sensitive. A clear communication channel must also be established between all the care providers. The first step towards ensuring that the risk potential is reduced is to evaluate, clearly define, and accurately document the medical condition of the patient. The case patient shows the signs of PEG complications. d. Physiological Adaptation Older adults experience physiological changes that lead to nutritional problems (Ayers, Adams, Boullata, Gervasio, Holcombe, Kraft, Marshall, Neal, Sacks, Seres & Worthington (2013). Also, with age, organs decline to function and, as a result, there are alterations in digestion, nutrients absorption, metabolism, and elimination of waste products via the kidneys. In the case under consideration, the patient’s obesity status has affected the gastroesophageal sphincter function (Meiner, 2014). e. Potential priority nursing diagnosis The potential priority nursing diagnosis identified in this area is a failure of the patient and the family to accept the extended life span through tube feeding and ventilators. Nursing Plan of Care a. Comprehensive Care Plan based on priority diagnoses The major goals for the case patient include an optimal level of nutrition, prevention of further infections, knowledge of and skill in self-care, and the absence of complications. One of the diagnosed priorities is the mechanical complication (tube placement complications). Mechanical complications are mainly associated with tube feeding. To reduce the risk of mechanical complications, the intervention includes: i. Checking the length of the feeding tube every 4 hours. ii. Checking the length of the tube every time it is used to ensure that the external length of the tube is retained. Another top priority is impaired swallowing. Therefore, the patient is at high risk for aspiration. Aspiration pneumonia is one of the late complications that have been revealed in patient’s history. To prevent aspiration, the intervention includes: i. Placing a Nil per os (NPO) sign above the patient’s bed. NPO instructions are essential for the prevention of aspiration pneumonia. NPO is a medical instruction meaning that care providers should withhold feeding the patient through oral means. The concerned care specialist should reinforce this with the patient and family members. ii. The head of the bed should remain elevated at a minimum of 30 to 45 degrees during feeding time. This position helps to minimize the risk of aspiration. The patient should remain in this position at least one hour after feeding is completed. The recommended jejunal feeding is ideal for continuous feeding (20-40 ml/hour). Oral care in the clinical setting is also recommended because it lowers the risk of pneumonia. iii. The suction equipment must be at the bedside and ready for use at all times. iv. The call light should also be within reach at all times. v. The designated formula should be infused via PEG tube at a controlled rate. vi. The tube placement and residual volume should be checked every 4 hours. If the volume is greater than previous hour infused volume, the aspirate should be re-instilled, infusion stopped for one hour and restarted at the previous rate. vii. Medication monitoring should be closely done for two weeks, and variances reported. viii. Daily weight should also be recorded at a particular designated time. The second priority diagnosis is the infection. The high dextrose and fat content of parenteral nutrition make them an ideal culture medium for fungal and bacterial growth. The primary sources of microorganisms for tube infections are the skin and the tube hub (Smeltzer, Bare, Hinkle, Cheever, 2010). The abbreviation for white blood cells is WBCs. As a rule, the white blood cell count should not exceed 10,000/mm3. An elevated WBC count indicates infection. WBCs are usually broken down into a differential count of each cell type. An acute infection is indicated by a high number of neutrophils (band and stab cells). This condition is also known as a “shift to the left.” There are other types of WBC (basophils and eosinophils) and these are common in allergic reactions. Another important WBC is lymphocytes, and they play an important role in developing immunity. Other WBC known as phagocytic monocytes play an important role of engulfing bacteria. A low WBC count (below 5000/mm3) indicates problems in producing cells from the bone marrow, which may happen during chemotherapy (Schuster, 2011). The following preventive measures may be taken i. Covering the PEG tube site with an occlusive gauze dressing that is usually changed using sterile technique every 24-72 hours. ii. Alternatively, cover the site with a transparent dressing and change it weekly. The transparent dressing is more comfortable to the patient (Smeltzer, Bare, Hinkle, Cheever, 2010). It is recommended that the dressings should be changed in every seven days unless they are damp, bloody, loose, or soiled. iii. The should trace all lines back to their origin before starting feeding the patient. iv. The preferred of delivering feeding continuously is through the feeding pump. In the present case, the care provider should avoid using the gravity method. v. A confirmation of name and strength of formula should be done. The rate and route of administration should also be confirmed. vi. Sterile water flush should be used, and the remaining sterile water discarded after each use. NB. In case of medication through PEG tube, the tube should be held as it is recommended during medication administration. The third potential priority nursing diagnosis identified in this area is failure of the patient and the family to accept the extended life span through tube feeding and ventilators b. Teaching Plan based on identified priority needs A teaching plan is ideal because it encourages patients to engage in self-care. Teaching is important because it prepares the patient for home administration of enteral feedings while the patient is still in the hospital. The case in question requires an individualized teaching plan because of its complexity. This teaching plan is prepared in consideration of various factors. The priority needs that have been identified above are going to be taken into consideration. Most of the teaching is done in the presence of the patient and the family or other caregivers. In this case, it is necessary to teach about self-care while her spouse and son are present. The nurse should teach while administering the feedings and drugs so that, the patient, her spouse, and son can observe the mechanics and participate in the procedure, ask questions, and express concerns. The teaching plan should mainly focus on the patient’s diet. The type of diet that is appropriate for each condition is listed on the Kardex (Schuster, 2011). The nursing diagnosis of imbalanced nutrition is very common. This is a problem area for many patients especially the ones who are obese. These patients always have knowledge deficits and problems in managing and adhering to prescribed diets. The same case applies to home care providers. The case patient should be fed on a low-sugar diet because she has shown signs of diabetes. The nurse should teach the patient and her family about the importance of low sugar diet. Diabetic patients have difficulties in breaking down sugar (glucose) for use by other body cells. The patient should minimize the intake of foods with high sugar concentration. To manage diabetes the total amount of calories must be controlled along with the portions of protein, fat, and carbohydrates in all food taken into the body. References Ayers, P., Adams, S., Boullata, J., Gervasio, J., Holcombe, B., Kraft, M., Marshall, N., Neal, A., Sacks, G., Seres, D. & Worthington, P. (2014). A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations. Journal of Parenteral and Enteral Nutrition, 38(3), pp. 296-333. Marks, J. & Dunkin, B. (2013). Principles of Flexible Endoscopy for Surgeons. New York: Springer Science & Business Media. Naik, V., Joshipura, N., Patel, N., Haribhakti, A. (2009). Complications Of PEG – Prevention And Management. The Internet Journal of Gastroenterology, 8(1). https://ispub.com/IJGE/8/1/8698 Rahnemai-Azar, A., Rahnemaiazar, A., Naghshizadian, R., Kurtz, A., & Farkas, D. (2014). Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World Journal of Gastroenterology, 20(24), 7739–7751. doi:10.3748/wjg.v20.i24.7739 Ramdass, D. & Mann, S. (2013). Buried bumper syndrome: a challenging complication of PEGs. Gastrointestinal Nursing Journal, 11(6), pp. 43-48. Rahnemai-Azar, .A., Rahnemaiazar, A., Naghshizadian, R., Kurtz, A. &Farkas , D. (2014). Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World Journal Gastroenterol, 20(24), pp. 7739–7751. Schuster, P. (2011). Concept Mapping. A Critical-Thinking Approach to Care Planning. New York: McGraw-Hill. Simon, S. & Remington, R. (2013). The Percutaneous Endoscopic Gastrosomy Tube: A Nurse’s Guide to PEG Tubes. MEDSURG Nursing, 22(2), pp. 27-83. Smeltzer, S., Bare, B., Hinkle, J. & Cheeve, K. (2010). Brunner & Suddarths Textbook of Medical-surgical Nursing. London: Lippincott Williams & Wilkins. Read More