Nursing Patients with Acute Illness

Introduction to Darren Case Study

Patients suffering from conditions such as Cholecystitis suffer from conditions of abdominal pain, nausea and vomiting (Tara et al., 2017). This condition can be treated by an elective Laparoscopic Cholecystectomy surgery. Cholecystitis is basically inflammation in the liver and it can be managed and treated by a Cholecystectomy surgery. Purpose of the assignment is to provide a key discussion to the problem statement of “potential for pain related to surgical incision as evidenced by grimacing and a subjective pain score of >3/10 using the numeric pain rating scale”. This assignment revolve around the case study of Darren who is suffering from Cholecystitis. He has been administered to the hospital twice for abdominal pain and nausea. The assignment will primarily provide a justification to the problem statement and ten develop patient centered goals. The goals will be developed through the use of SMART framework which include the concept of specific, measurable, achievable, realistic and time bound goal. The assignment will then provide three nursing interventions for the patient followed by proper evaluation strategies for the interventions.

Justification of The Nursing Problem Statement

Cholecystitis is a medical condition represented by inflammation of the gallbladder (Lu et al., 2017). According to DEĞERLİ et al., (2017), gallbladder is a small and pear-shaped organ that is located beneath the liver. It is present on the right side of the abdomen and it hold digestive fluids for digestion of food in small intestines. Cholecystitis is a disease that is caused by conditions such as hepatitis, greater alcohol consumption, scarring of the bile ducts, cirrhosis due to viral hepatitis and primary biliary cholangitis with inflammation (Walczak-Galezewska et al., 2018). Darren is a social drinker who drink 2 heavy beers per day after work and it exceeds to 10 beers during weekends. According to Alghamdi et al., (2017), alcohol consumption is one of the most common cause for Cholecystitis and it can only be treated with a Cholecystectomy surgery. A laparoscopic cholecystectomy is surgical removal of the gallbladder by the use of a laparoscope and small incisions. These incisions can bring up severe pain and discomfort in the patients after surgery however, it is easy for the patients to recover after the surgery.

The problem statement indicate the potential for pain related to surgical incision after a laparoscopic cholecystectomy. Pain after the surgery can be as evidenced by grimacing and a subjective pain score (Cianci et al., 2017). The pain assessment score of >3/10 using the numeric pain rating scale can indicate mild severity of pain after the procedure (Kornilov et al., 2018). Laparoscopic cholecystectomy brings up severe unmanageable pain to the patients which can be seen through facial grimacing and subjective pain score (Walczak-Galezewska et al., 2018). Facial grimace is a type of facial expression that indicate pain and disgust. It can be pictured as squeezing the eyes shut, twisting the mouth and wrinkling the nose. The pain assessment scale is used to indicate the severity of pain by numerical analysis. A pain scale of 1-3 indicate mild pain with some discomfort in the patients (Kornilov et al., 2018). Darren has a medical history of gastric esophageal reflux and two episodes of abdominal pain that have induced mild discomfort in Darren. The pre-operative work up for Darren is focused on stabilizing pain and recording cholesterol level for Darren.

Patient Centered Goal

According to the SMART framework for setting up nursing goals, the goals should be specific, measurable, achievable, and realistic and time bound (Ogbeiwi, 2018). It is important for the nurse to identify the area of concern for the patient before setting up SMART goals. On proper analysis of the patient condition nursing goal for the patient will be to minimize pain scale of 3/10 to 1/10 and promote rest to the patient within 7 days of the surgery. The goal is designed to enhance patient comfort and speedy recovery after the surgery. Promoting rest and reducing the pain to minimum can impart comfort and it can provide greater health results for the patient.
Nursing intervention

It is important to set up priority based nursing interventions for the patients in order to reach the SMART goals within the desired time frame (Ogbeiwi, 2018). The three interventions for the patient will be initiating IV access and administering fluids, assessing gastrointestinal status, and assessing and managing pain with proper education about proper rest after the surgery (Malbrain et al., 2018). The IV access is used to administer medication for the patient after or during the surgery. It is the primary step that must be followed in pre-operative patients for preparing them for further procedure. It used also used to administer anesthesia in patients for preparing them for the surgery. And, subsequently the patient will be required to be on bowel rest program so the IV hydration is very important.

The second nursing intervention for the patient is set to assess the gastrointestinal status for the patient. Since the patient in the case study have a history of gastric esophageal reflux so it become important for the nurse to manage any kind of deterioration in the patient. The intervention will include the nurse to look for any kind of distention. Listen to frequent belching and feel any kind of abdominal rigidity after the surgery (Major et al., 2017).

Third intervention for the patient will be to assess the pain scale for the patient and manage it accordingly. Moreover, the patient will be educated about the importance of resting so that he can recover fast from the condition. According to Reach et al., (2017), it is important for the nurses to educate and aware the patients about the steps that can help them achieve treatment goals within the stipulated time frame. Patients undergoing cholecystectomy surgery can experience severe pain and hence it must be managed by administering required medicine, assisting the patient with desirable position and promoting bed rest for comfort. Educating the patient about the positions that can comfort him can certainly be effective for the patient.

Evidence Based Evaluation

According to the standard 7 of registered nurse standards for practice NMBA (2017), the registered nurse is expected to evaluate and monitor the progress of the patient toward desirable goals and outcomes of the treatment. The evidence based evaluation of the nursing interventions can be used to revise the treatment plan for the patients which can be effective fort their health (Potter et al., 2016). The five steps of the evidence-based evaluation involve asking a clinical question, obtaining the best research literature, critically appraise the evidence, and integrate the evidence according to the preferences of the patient and evaluation of the outcomes (Straus et al., 2018). The patient will be primarily assessed for the IV administration of the fluids. According to Kapoor and Hahn (2019), the intravenous fluids are administered to replace water, salt and sugars in patients that cannot eat due to a surgery. It is important for the nurses to evaluate success of the IV administration by acute observations of the patient vitals. The success of the therapy can be evaluated by analyzing the cholesterol level in the body. Decreased cholesterol will indicate success of the process.

Second evaluation strategy involve the nurses to analyze gastrointestinal status for the patients. The evaluation of the abdomen include proper inspection, percussion and palpation near the region of the surgery. Evaluation of the abdomen or the gastrointestinal track can reveal any form of bulges or peristalsis that can indicate complications. According to Pan et al., (2018), analyzing the success of the cholecystectomy indicate proper evaluation of the changes that comes to the patient after the surgery. Since Darren has a medical history of gastric esophageal reflux of the esophageal reflux will be evaluated to analyze if the patient have regular GI function.

Finally, the evaluation strategy for pain assessment is based upon the numerical pain assessment tool. A pain scale of 7-10 represent severe pain, 4-6 represent moderate pain and 1-3 represent mild pain. The assessment will be compared from the initial pain readings to the final readings and the result will be evaluated in form of efficiency or inefficiency of the treatment (Stephens et al., 2019).

Conclusion on Darren Case Study

In conclusion, it can be stated that patients suffering from severe abdominal pain can undergo a number of health complications. This can result in conditions such as Cholecystitis which require surgeries such as the gall bladder removal as a treatment option. Laparoscopic cholecystectomy is an effective medical procedure that can result in mild pain and discomfort to the patient. However, it can be managed by proper rest and pain management strategies. The goal that was developed for Darren was focused upon reducing pain and enhancing comfort. The interventions were based upon priority for the patient. Primary intervention was to manage and access the IV administration, second was assessment of the GI tract and final intervention was pain management and education to the patient. The evaluation was done by proper monitoring and evidence based practice for the patient care in terms of treatment goals and outcomes. Evaluation of the IV fluid administration was done by comparing the effectiveness of the procedure before and after the surgery. Moreover, checking for reduced cholesterol level was another strategy that was used to analyze the effectiveness of the interventions.

Reference for Darren Case Study

Alghamdi, K. A., Rizk, H. A., Jamal, W. H., Bakhshween, A. A., Maqboul, A. A., Saggaf, A. M., ... & Basourrah, M. K. (2019). Risk Factors of Gangrenous Cholecystitis in General Surgery Patient Admitted for Cholecystectomy in King Abdul-Aziz University Hospital (KAUH), Saudi Arabia. Materia Socio-Medica31(4), 286.

Cianci, P., Tartaglia, N., Fersini, A., Capuzzolo, S., Giambavicchio, L. L., Ambrosi, A., & Neri, V. (2017). Acute Cholecystitis: Diagnostic Pitfall and Timing of Treatment. Updates in Gallbladder Diseases, 23.

DEĞERLİ, V., Korkmaz, T., MOLLAMEHMETOĞLU, H., & Ertan, C. (2017). The importance of routine bedside biliary ultrasonography in the management of patients admitted to the emergency department with isolated acute epigastric pain. Turkish Journal of Medical Sciences47(4), 1137-1143.

Kapoor, I., & Hahn, R. G. (2019). Fluids and electrolyte management. Essentials of Geriatric Neuroanesthesia, 271-278.

Kornilov, N., Lindberg, M. F., Gay, C., Saraev, A., Kuliaba, T., Rosseland, L. A., & Lerdal, A. (2018). Higher physical activity and lower pain levels before surgery predict non-improvement of knee pain 1 year after TKA. Knee Surgery, Sports Traumatology, Arthroscopy26(6), 1698-1708

Lu, Y. A., Chiu, C. H., Kong, M. S., Wang, H. I., Chao, H. C., & Chen, C. C. (2017). Risk factors for poor outcomes of children with acute acalculous cholecystitis. Pediatrics & Neonatology58(6), 497-503.

Major, G., Pritchard, S., Murray, K., Alappadan, J. P., Hoad, C. L., Marciani, L., ... & Spiller, R. (2017). Colon hypersensitivity to distension, rather than excessive gas production, produces carbohydrate-related symptoms in individuals with irritable bowel syndrome. Gastroenterology152(1), 124-133.

Malbrain, M. L., Van Regenmortel, N., Saugel, B., De Tavernier, B., Van Gaal, P. J., Joannes-Boyau, O., ... & Monnet, X. (2018). Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy. Annals of Intensive Care8(1), 66.

Ogbeiwi, O. (2018). General concepts of goals and goal-setting in healthcare: A narrative review. Journal of Management & Organization, 1-18.

Pan, L., Chen, M., Ji, L., Zheng, L., Yan, P., Fang, J., ... & Cai, X. (2018). The safety and efficacy of laparoscopic common bile duct exploration combined with cholecystectomy for the management of cholecysto-choledocholithiasis: an up-to-date meta-analysis. Annals of Surgery268(2), 247-253.

Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing-E-Book. USA:Elsevier health sciences.

Reach, G., Pechtner, V., Gentilella, R., Corcos, A., & Ceriello, A. (2017). Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. Diabetes & Metabolism43(6), 501-511

Stephens, T. J., Bamber, J. R., Beckingham, I. J., Duncan, E., Quiney, N. F., Abercrombie, J. F., & Martin, G. (2019). Understanding the influences on successful quality improvement in emergency general surgery: learning from the RCS Chole-QuIC project. Implementation Science14(1), 1-14

Straus, S. E., Glasziou, P., Richardson, W. S., & Haynes, R. B. (2018). Evidence-Based Medicine E-Book: How to Practice and Teach EBM. USA:Elsevier Health Sciences.

Tara, F., Mohammadzade Vatanchi, A., Pourali, L., & Alamtian, A. (2017). Acalculous Cholecystitis Presenting as Intractable Hypere-mesis during Pregnancy: A Case Report. Journal of Midwifery and Reproductive Health5(3), 1018-1020.

Walczak-Galezewska, M. K., Skrypnik, D., Szulinska, M., Skrypnik, K., & Bogdanski, P. (2018). Conservative management of acute calculous cholecystitis complicated by pancreatitis in an elderly woman: A case report. Medicine97(25).

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