Assessment Task 3

Integrated Nursing Practice 1 

a) Assessment data and pathophysiology

Weber & Kelley (2013, p. 7-8) have stated to collect subjective and objective data for relevant assessment of the chosen problem. Diagnosis relates to gastroenteritis and relevant data will be assessed (Chhabra et al., 2013, p. 795; Kumazaki, & Usuku, 2016, p. 2; Albrecht, Hartling, & Scott, 2017; Stuempfig, & Seroy, 2020).

Relevant assessment data:

Case Studies Scenario 1: Poppy Sutherland

Her Temperature: 38.2 °C, while normal should be 37°C (Kuiken & Huth, 2013). Pain: Present (4/10). SpO2 98% on room air was normal. Her heart rate: 118bpm was normal (Kuiken & Huth, 2013). Her tongue was dry, and lips were pale showing signs of dehydration. Capillary refill > 1 seconds was normal (Kuiken & Huth, 2013). Urine output: 0 ml for 8 hours while normal is 1 ml/kg/hour (Kaplan & Pradhan, 2013). She presented with vomiting, diarrhoea. Other children in surrounding environment also presented with similar symptoms.

Case Studies Scenario 2: Mary Smith

Her temperature: 37.8 °C, slightly above normal (Chester & Rudolph, 2011). Pain: Present (6/10), abdominal cramping. SpO2 96% on room air which is slightly below normal (Chester & Rudolph, 2011). Heart rate: 108 (irregular) above normal (Chester & Rudolph, 2011). Her tongue was dry and lips were pale. Capillary refill > 1 seconds. Urine output: 0 ml for 8 hours not normal (Kujubu & Aboseif, 2007). She presented with vomiting and diarrhoea. Her granddaughter was showing similar symptoms. She has a medical history of osteoarthritis knee.

Pathophysiology of Acute Gastroenteritis:

Diarrhoea in acute gastroenteritis can take place from “osmosis, active secretion, exudation, and abnormal motility” (Zachos, 2016, 12-15). The osmosis can happen when the nutrient transportation develops mutation and/or when an osmotic gradient having the characteristic of a reduced strength of absorbable solute initiates mucosal to the “luminal fluid flow” (Zachos, 2016, 12-15). When there is a gap on the luminal solutes such as (Sodium, Potassium, Hydrogen carbonate, and chlorine )Na⁺, K⁺, HCO3 and Cl− either get absorbed in excess or get hyper secreted from the pathologic response cause secretary osmosis (Zachos, 2016, 12-15; Bányai, Estes, Martella, & Parashar, 2018, p.4). When the intestinal epithelial barrier gets weakened the blood vessels pressure gets increases and there is leakage of electrolytes, leading to exudative diarrhoea (Zachos, 2016, 12-15; Bányai, Estes, Martella, & Parashar, 2018, p.4). Less motility in the small intestine leads to bacterial overgrowth decreasing bile salts which are essential for absorption of fat (Zachos, 2016, 12-15; Bányai, Estes, Martella, & Parashar, 2018, p.4).

“Rotaviruses, noroviruses, astroviruses, and enteric adenoviruses” are the major causes of viral gastroenteritis (Zachos, 2016, 12-15; Bányai, Estes, Martella, & Parashar, 2018, p.4). The intracellular (calcium) Ca+2 concentrations are raised when these viruses enter the small intestines epithelium and induce epithelial cell loss (Zachos, 2016, 12-15; Bányai, Estes, Martella & Parashar, 2018, p.4). The intestinal lesions which cause the intestinal surface area to reduce in size are responsible for the more and more decrease in the absorption of “water, ions and nutrients” (Zachos, 2016, 12-15; Bányai, Estes, Martella, & Parashar, 2018, p.4). Post synaptic density protein in the ion transporters present in the intestine affect the permeability of ions and small solutes affecting the tight junction function (Zachos, 2016, 12-15; Bányai et al., 2018, p.4).

b) Age and developmental based differences

Both the cases present have similar symptoms with the major difference being their age (Bányai, Estes, Martella, & Parashar, 2018, p. 1-8). Both the age group are highly susceptible to getting infected and having viral gastroenteritis as they are in the age group of being vulnerable due to either undeveloped immune systems or the old age group where the immunity has been on the decreasing side (Bányai et al., 2018, p. 1-8). Due to dehydration, loos of fluids both were drowsy state although still responsive to stimulus (Bányai et al., 2018, p. 1-8).

c) SMART framework, goal

The S.M.A.R.T framework will be applied i.e. “Specific, Measurable, Achievable, Results-focused, Timely” (Shaw et al., 2015).

Specific Goal: Stabilizing the fluid imbalance for both the patients (Ciccarelli, Stolfi, & Caramia, 2013, p. 146).

Measurable: Their urine output measured can indicated whether the treatment is working or not.

Attainable: The fluid stabilization can be achieved by oral rehydration therapy

Relevant: The treatment is relevant for better recovery.

Time-Bound: The treatment doesn’t require a long period and can be managed at home.

To treat the patients with Oral Rehydration therapy as recommended by WHO (Ciccarelli, Stolfi, & Caramia, 2013, p. 146).

  1. Oral or IV isotonic fluids (Iro, Sell, Brown, & Maitland, 2018, p. 2; Ciccarelli, Stolfi, & Caramia, 2013, p. 146).

  2. Since the child is not compliance with oral, nasogastric tube will be used (Iro, Sell, Brown, & Maitland, 2018, p. 2; Ciccarelli, Stolfi, & Caramia, 2013, p. 146).

  3. If the NG tube fails, then will be proceeded with intravenous rehydration (Iro, Sell, Brown, & Maitland, 2018, p. 2; Ciccarelli et al., 2013, p. 146).

  4. The fluids being provided to the child will provided between 3-6 hours starting from 30ml/kg and then progressing further (Iro et al., 2018, p. 2; Ciccarelli, et al., 2013, p. 148).

  5.  Antisecretory drugs: The prescribed antisecreotry drugs to paediatric patients acts on the principle of reducing water present in the intestine and decreasing secretion of the electrolytes through reduction of cAMP concentration in the intracellular space (Ciccarelli, Stolfi, & Caramia, 2013, p. 148). The major benefit of using this drug is controlling the hyper-secretion without compromising the intestine’s motility functions (Ciccarelli et al., 2013, p. 148).

  6. Antiemetic: Usage of ondansetron should be done with precaution, especially in small children (Ciccarelli, Stolfi, & Caramia, 2013, p. 149). It is used widely while treating gastroenteritis if the patient has vomiting episodes (Ciccarelli, Stolfi, & Caramia, 2013, p. 148). Ondansetron has proven to have a higher efficacy rate than either giving the patient placebo or metoclopramide (another antiemetic) (Ciccarelli et al., 2013, p. 149-150).

  7. Zinc supplements: Zinc is needed to improve the intestinal epithelial barrier capacity as well as repair of the tissue lesion and enhance the host’s cell-mediated immunity (Ciccarelli, Stolfi, & Caramia, 2013, p. 151).

  8. Probiotics: The probiotics also said in the same as “food supplements” help in increasing the microbial balance of the intestine proving to have overall beneficial to the host, and acting as a barrier if there is an outbreak in the community, also helping in reducing the duration of suffering and quickening the recovery period (Ciccarelli, Stolfi, & Caramia, 2013, p. 151).

d) Two interventions

1) Preventive Methods

Clean drinking water and improvement in sanitation (Iro, Sell, Brown, & Maitland, 2018, p. 2; Parashar, Nelson, & Kang, 2013, p. 3-5; Ciccarelli, Stolfi, & Caramia, 2013, p. 134; Bányai, Estes, Martella, & Parashar, 2018, p. 7-8). For children giving them with the oral vaccine for rotavirus seems to be a highly effective preventative method (Parashar, Nelson, & Kang, 2013, p. 3-5; Ciccarelli, Stolfi, & Caramia, 2013, p. 145). Providing as much children as possible with vaccine will lead to the group acquiring her immunity and leading to an overall decrease in rest of the children getting infected even if they haven’t taken their vaccination shot (Parashar, Nelson, & Kang, 2013, p. 4; Ciccarelli, Stolfi, & Caramia, 2013, p. 145). There should be proper provision of water for drinking and food preparing (Ciccarelli, Stolfi, & Caramia, 2013, p. 134). Everyone in the patient’s vicinity should be aware of proper hand-hygiene techniques to be implemented (Ciccarelli, Stolfi, & Caramia, 2013, p. 134). The toiled facilities should be adequate so no effect from human waste is occurred (Ciccarelli, Stolfi, & Caramia, 2013, p. 134).

The towels used by the children should not be shared with the rest of the household (Ciccarelli, Stolfi, & Caramia, 2013, p. 145). Since other children also presented with similar symptoms in the child’s school, it should be avoided for the time being and only go back after there has no report of diarrhoea for 48 hours (Ciccarelli et al., 2013, p. 145). Usage of swimming pool should be prevented by the children for two weeks (Ciccarelli et al., 2013, p. 145). There are also suggestions to use “probiotics” which are available as food supplements and which have shown to decrease the incidence of diarrheal infection in small children (Ciccarelli, Stolfi, & Caramia, 2013, p. 145-146). The probiotics have the benefit of keeping the internal system of intestine (Ciccarelli, et al., 2013, p. 145-146). The probiotics help in increasing the resistance of the intestine towards the infective pathogens either by competition or inhibition and has effects on both innate immunity and acquired immunity as well (Ciccarelli, Stolfi, & Caramia, 2013, p. 145-146).

2) Vaccination Information

Norovirus and Rotavirus constitute the majority of viral cause of viral gastroenteritis in the age group of 5 years of younger (Lugg et al., 2015, p. 456-460; Zachos, 2016, 12-15; Iro, Sell, Brown, & Maitland, 2018, p. 1; Bányai, Estes, Martella, & Parashar, 2018, p. 7-8). Most of the children in this age group will experience gastroenteritis and will have to visit a health care centre (Lugg et al., 2015, p. 456-460; Iro, Sell, Brown, & Maitland, 2018, p. 1; Bányai, Estes, Martella, & Parashar, 2018, p. 7-8). Providing them with information and clearing their misconception about routine vaccination is also important as some parents believe getting their children vaccinated will harm them (Lugg et al., 2015, p. 456-460; Albrecht, Hartling, & Scott, 2017, p. 2; Iro, Sell, Brown, & Maitland, 2018, p. 2; Bányai, Estes, Martella, & Parashar, 2018, p. 7-8). Due to the relatively short duration of acute gastroenteritis, the parents don’t consider this illness to be a severe one (Lugg et al., 2015, p. 456-460). Caregivers should be provided with adequate knowledge about the signs and symptoms of paediatric acute gastroenteritis, and if and when they should contact the GP, or visit an emergency department (Albrecht, Hartling, & Scott, 2017, p. 3-6; Bányai, Estes, Martella, & Parashar, 2018, p. 7-8).

e) Efficacy of The Interventions to Carers

The carers will be informed on keeping the environment safe, clean and patients have probiotics. Since both have the same underlying pathology, to evaluate the intervention efficacy will be similar as well (Ciccarelli, Stolfi, & Caramia, 2013, p. 145). After the treatment undertaken by the each case patients, the main viewpoint will be to use preventative measures; in the coming few days as the episodes of diarrhoea and vomiting gets reduced, the patient’s improving outcome will testify to the efficacy of the intervention (Iro, Sell, Brown, & Maitland, 2018, p. 2; Ciccarelli, Stolfi, & Caramia, 2013, p. 146; Parashar, Nelson, & Kang, 2013, p. 3; Bányai, Estes, Martella, & Parashar, 2018, p. 7). Use of probiotics in both the age group will prove beneficial if there is an outbreak in the community and the patients have developed their innate immunity to withstand the infection outbreak (Iro, Sell, Brown, & Maitland, 2018, p. 2; Ciccarelli, Stolfi, & Caramia, 2013, p. 146; Parashar, Nelson, & Kang, 2013, p. 3; Bányai, Estes, Martella, & Parashar, 2018, p. 7).

References

Albrecht, L., Hartling, L., & Scott, S. D. (2017). Pediatric acute gastroenteritis: Understanding caregivers’ experiences and information needs. Canadian Journal of Emergency Medicine, 19(3), 198-206. https://doi.org/10.1017/cem.2016.363

Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175-186. https://doi.org/10.1016/S0140-6736(18)31128-0

Chhabra, P., Payne, D. C., Szilagyi, P. G., Edwards, K. M., Staat, M. A., Shirley, S. H., ... & Vinjé, J. (2013). Etiology of viral gastroenteritis in children< 5 years of age in the United States, 2008–2009. The Journal of infectious diseases, 208(5), 790-800. https://doi.org/10.1093/infdis/jit254

Chester, J. G., & Rudolph, J. L. (2011). Vital signs in older patients: age-related changes. Journal of the American Medical Directors Association, 12(5), 337–343. https://doi.org/10.1016/j.jamda.2010.04.009

Ciccarelli, S., Stolfi, I., & Caramia, G. (2013). Management strategies in the treatment of neonatal and pediatric gastroenteritis. Infection and Drug Resistance, 6, 133–161. https://doi.org/10.2147/IDR.S12718

Iro, M. A., Sell, T., Brown, N., & Maitland, K. (2018). Rapid intravenous rehydration of children with acute gastroenteritis and dehydration: A systematic review and meta-analysis. BMC Pediatrics, 18(1), 44. https://doi.org/10.1186/s12887-018-1006-1

Kaplan, B. S., & Pradhan, M. (2013). Urinalysis interpretation for pediatricians. Pediatric Annals, 42(3), e45-e51. https://doi.org/10.3928/00904481-20130222-09

Kujubu, D. A., & Aboseif, S. R. (2007). Evaluation of nocturia in the elderly. The Permanente journal, 11(1), 37–39. https://doi.org/10.7812/tpp/06-098

Kumazaki, M., & Usuku, S. (2016). Norovirus genotype distribution in outbreaks of acute gastroenteritis among children and older people: An 8-year study. BMC Infectious Diseases, 16(1), 643. https://doi.org/10.1186/s12879-016-1999-8

Lugg, F. V., Butler, C. C., Evans, M. R., Wood, F., & Francis, N. A. (2015). Parental views on childhood vaccination against viral gastroenteritis—a qualitative interview study. Family Practice, 32(4), 456-461. https://doi.org/10.1093/fampra/cmv035

Parashar, U. D., Nelson, E. A. S., & Kang, G. (2013). Diagnosis, management, and prevention of rotavirus gastroenteritis in children. British Medical Journal, 347, f7204. https://doi.org/10.1136/bmj.f7204

Shaw RL, Pattison HM, Holland C, Cooke R. (2015). Be SMART: Examining the Experience of Implementing the NHS Health Check in UK Primary Care. BMC Family Practice. 16 10.1186/s12875-014-0212-7

Stuempfig, N. D., & Seroy, J. (2020). Viral Gastroenteritis. https://www.ncbi.nlm.nih.gov/books/NBK518995/

Weber, J. R., & Kelley, J. H. (2013). Health assessment in nursing. Lippincott Williams & Wilkins.

Van Kuiken, D., & Huth, M. M. (2013). What is' normal?'Evaluating vital signs. Pediatric nursing, 39(5), 216.

Zachos, N. C. (2016). Chapter 1.1 - Gastrointestinal Physiology and Pathophysiology. In L. Svensson, U. Desselberger, H. B. Greenberg, & M. K. Estes (Eds.), Viral Gastroenteritis (pp. 1-21). Boston: Academic Press. https://doi.org/10.1016/B978-0-12-802241-2.00001-8

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