The given study talks about Ms. Faye, a 44-year-old female. She is a mother of three children and is a widow since the past year. She works in management. She presented with persistent pain in her abdomen and was admitted for a diagnostic checkup for the same. She encountered an episode of hematemesis the evening before admission and has had episodes of epigastric pain-mild and intermittent since the past three months as well. The pain had become increasingly continuous lasting for hours together since the past one week before admission. She has a history of rheumatoid arthritis since the past two years and has been on Prednisolone for the same. She has no other history of disease.
This case study will discuss her signs and symptoms, treatment protocol to be followed along with the nursing interventions required based on the clinical reasoning cycle.
Acknowledgement of the patient’s situation
Ms Faye is a 44-year old woman. She presented for a check –up and work-up on her hematemesis and epigastric pain. She showed a history of rheumatoid arthritis for which she was on Prednisolone for the past two years. She also takes Aspirin occasionally for her headache as well. On admission, she presented with epigastric pain since past week that resolved on eating something and an episode of hematemesis as well. She was kept on intravenous fluid and a nasogastric tube as well. She experienced a massive bleed in her upper gastrointestinal tract two days after her admission to the hospital. Diagnostic gastroscopy revealed the presence of peptic and gastric ulcers.
Ms. Faye is a widowed woman who is living alone with her three children since the past one year. She has only one health issue – rheumatoid arthritis for which she is on Prednisolone since the past two years. She also occasionally experiences headaches for which she takes Aspirin occasionally. She has been experiencing epigastric pain since the past 3 months and she is not very particular about her eating as well. She smokes 1 pack of cigarettes every day. She has lost around 4.5 kg of weight in the past 6 weeks and currently only weighs 45 kgs. On assessment, her blood pressure was 150/88 and a diagnostic gastroscopy revealed the presence of gastric and pyloric ulcers as well. Her hemoglobin was 5.8 gm which are towards the lower side along with a hematocrit value of 21% which is slightly towards the higher side. She also experienced an episode of a massive bleed in her upper gastrointestinal tract while in the hospital. She underwent surgery for the same- gastrojejunosotomy along with a vagotomy and hemigastrectomy and blood transfusion as well. She is still hospitalized and is worried about her children and asking for cigarettes as well.
Gastrointestinal bleed and associated perforation has become an issue of major concern in patients of rheumatoid arthritis. The occurrence of GI disturbance along with the presence of pyloric and gastric ulcers is indicative of concerns related to the medications involved in the treatment of rheumatoid arthritis. Prednisolone which she is consuming shows side effects in terms of gastrointestinal disturbances especially in the upper gastrointestinal tract (Wilson et al. 2019). The risk of developing ulcers and having gastrointestinal disturbances greatly increases in the case of Mrs. Faye because of her lifestyle- irregular dietary patterns, cigarette smoking along with Aspirin consumption as well (Lee et al. 2017). Aspirin and Prednisolone when taken together can cause damage and harm to the GI tract (De abajo et al. 2013).
Post hemigastrectomy and gastrojejunostomy and vagotomy, her primary concerns are malnutrition resulting from the same and weight gain that is required along with her lifestyle modification and dietary monitoring. Her medication for rheumatoid arthritis also needs to be managed and monitored. Alternatives for prednisolone or gastric protecting drugs need to be given as well. The risk of upper gastrointestinal tract disorder – bleeding and perforation or ulceration increases atleast two times by using oral steroids and low dosage Aspirin together (De abajo et al. 2013). Her symptoms of epigastric pain, severe weight loss along with hematemesis were suggestive of gastric ulcers and potential GI bleed as well. A combination of her existing condition- lifestyle including – less diet, smoking history along with the use of Aspirin(NSAID) when on prednisolone(corticosteroid) predisposes her to the development of gastric ulcers and potential GI bleeds as well (Lee et al. 2017).
With regards to her health setting, she is currently post-operative hemigastrectomy along with gastrojejunostomy and vagotomy and is currently bed-ridden and admitted in the hospital. She is wanting to have cigarettes and is restless in her bed as well.
Processing the available Information
On the basis of her updated medical history, Mrs. Faye has rheumatoid arthritis for which she was on prednisolone for the past two years. She developed epigastric pain and gastric ulcers followed by an episode of hematemesis and upper GI bleed as well. She was immediately operated upon and blood transfusion done as well. There have been substantial risks of upper and lower GI disorders associated with rheumatoid arthritis that have been reported. The risk of incident upper GI events (specifically bleeds, perforations, ulcerations and esophagitis, and sometimes upper bowel obstruction as well) remains increased in patients with rheumatoid arthritis as compared to non-rheumatoid arthritis subjects (Myasoedova et al. 2012). It is usually said that corticosteroids induce gastrin release and also cause hyperplasia of parietal cells along with associated increased acid secretion and decreased gastric mucus synthesis in the stomach along with suppression of the synthesis of prostaglandin and arachidonic acid as well. This is possibly the mechanism which leads to the peptic ulcer formation in patients consuming corticosteroids (Narum et al. 2014).
She is bed-ridden in the hospital currently and is on a nasogastric tube as well. Due to all these issues mentioned above, she should be monitored and proper counseling and care should be provided to her to maintain her nutritional status and help in her dietary modifications along with counseling for lifestyle modifications- cigarette smoking and proper use of drugs and drug interactions as well because it is said that non-steroidal anti-inflammatory drug (NSAID) use along with smoking were potential risk factors for development of peptic ulcer disease and GI bleeds in patients with autoimmune disease on long-term corticosteroids therapy (Narum et al. 2014).
Identification of problems and issues
The major problems and issues identified related to Mrs. Faye include her nutritional status post-operatively and prevention of further malnutrition and her lifestyle modification along with management of her rheumatoid arthritis as well (Karagiyorgos et al. 2015). Her poor dietary intake along with her cigarette smoking needs to be addressed. This can be achieved through lifestyle modification and reducing the risk factors associated with peptic ulcer formation and GI bleeds. Also, alteration of medication in her treatment for rheumatoid arthritis along with the use of gastro-protectant drugs as well should be done.
Establishment of Goals
The goals are decided based on the priority issues that have been discussed and are planned on the basis of appropriate nursing diagnosis made. It includes:
The first most important nursing intervention is to maintain the patency of the nasogastric tube as this will help in provision of rest to the GI tract post-operatively. She should also note the drainage amount and its character and look for potential bleeds or discharges in the tube as well to look out for any post-op complications and to rule out any further incident of GI bleeding. Also, she should monitor her fluid and food intake –orally after function returns to check for complications like delayed emptying or obstruction or any more bleeds. This will require re-insertion of her nasogastric tube. Monitoring of her nutrition and weight to make sure adequate nutritional support is provided and malnutrition is prevented. The progress in diet and the associated modification should also be monitored and properly explained and counseled to the patient and her family as well (Khamaysi et al. 2013).
Next, emotional support and counseling for her lifestyle improvement and smoking cessation should be given along with education on drug interactions and management of her rheumatoid arthritis as well.
The present condition of Mrs.Faye needs to be evaluated along with monitoring of her vitals and any complications in the form of bleeds or GI disturbances as well. Her lifestyle modifications including dietary modifications and smoking cessation as well need to be evaluated as well.
I have learnt significant management of both rheumatoid arthritis and post-operative care provided to patients in cases of GI bleeds and how lifestyle modifications and dietary control help in control of the disease and are significant contributors to management apart from pharmaceutical or surgical interventions. Effective skills in clinical reasoning and developing its cycle help the nurses in delivering the best quality in provision of care to the patients (Koivisto et al 2016).
De Abajo, F. J., Gil, M. J., Bryant, V., Timoner, J., Oliva, B., & García-Rodríguez, L. A. (2013). Upper gastrointestinal bleeding associated with NSAIDs, other drugs and interactions: a nested case–control study in a new general practice database. European Journal of Clinical Pharmacology, 69(3), 691-701.
Holder, A. G. (2018). Clinical reasoning: A state of the science report. International Journal of Nursing Education Scholarship, 15(1).
Karagiorgos, N. D., & Hyser, M. J. (2015). Upper Gastrointestinal Hemorrhage. In Common Surgical Diseases (pp. 125-128). Springer, New York, NY.
Khamaysi, I., & Gralnek, I. M. (2013). Acute upper gastrointestinal bleeding (UGIB)–initial evaluation and management. Best Practice & Research Clinical Gastroenterology, 27(5), 633-638.
Koivisto, J. M., Multisilta, J., Niemi, H., Katajisto, J., & Eriksson, E. (2016). Learning by playing: A cross-sectional descriptive study of nursing students' experiences of learning clinical reasoning. Nurse Education Today, 45, 22-28.
Lee, S. P., Sung, I. K., Kim, J. H., Lee, S. Y., Park, H. S., & Shim, C. S. (2017). Risk factors for the presence of symptoms in peptic ulcer disease. Clinical Endoscopy, 50(6), 578.
Myasoedova, E., Matteson, E. L., Talley, N. J., & Crowson, C. S. (2012). Increased incidence and impact of upper and lower gastrointestinal events in patients with rheumatoid arthritis in Olmsted County, Minnesota: a longitudinal population-based study. The Journal of Rheumatology, 39(7), 1355-1362.
Narum, S., Westergren, T., & Klemp, M. (2014). Corticosteroids and risk of gastrointestinal bleeding: a systematic review and meta-analysis. BMJ Open, 4(5).
Wilson, J. C., Sarsour, K., Gale, S., Pethö‐Schramm, A., Jick, S. S., & Meier, C. R. (2019). Incidence and risk of glucocorticoid‐associated adverse effects in patients with rheumatoid arthritis. Arthritis Care & Research, 71(4), 498-511.
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