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Contexts of Practice: Complex Care

Table of Contents

Introduction.

Systematic assessment

Prioritiesassociated with treatment

Discharge Planning.

References.

Introduction to Mr. John Douglas Case Study

In this particular study, a septic shock case will be evaluated (Case 3). The case raises concerns about Mr. John Douglas, a 70-year-old man who was hospitalized in the emergency department after feeling sick for 4 days at home with nausea as well as vomiting. In this study, Mr. John Douglas will be assigned a systematic assessment, treatment priorities as well as discharge plan.

Systematic Assessment

ABDO assessment

Since Mr. John Douglas has generalized abdominal pain which is 7/10, ABDO assessment was subjected.The physical examination associated with John Douglas begins with an examination. Fermentation before resection as well as during abdominal resection ensures that the testers hear uninterrupted bowel sounds. Besides, if Mr. John Douglas' complaints are associated with pain, the palpation allows the examiner in the direction of collecting other data until the end. At the end associated with the physical examination, a system associated with four squares is helpful in the direction of dividing the abdominal parts into zones in the direction of considering which organs (quadrant) are involved(Prabhakar and Das 2018).It provides more precise information if Mr. John Douglas' complaints are associated with discomfort in a particular area. The areas include hypochondria, lumbar, iliac, hypochondria region, epigastria region, and Umbilicalas well as the hypogastric region. Percussion is performed in the direction of determining the size as well as density associated with structures as well as organs in the abdominal cavity as well as in the direction of detecting the presence associated with air or fluid.Using direct or indirect percussion gives better comfort to John Douglas (especially if he presents complaints associated with lower abdominal pain) (Engles et al. 2019).

Lab Tests for Abdominal Pain

Complete Blood Count (CBC): A CBC is a blood test help determining an infection in the body. Infections presencecan help determine the nature associated with the problem (Pitchumoni and Dharmarajan, 2020).

Liver Enzymes/Hepatic Function Test: Liver enzymes are tested in the direction of indicating a problem with liver function if they are improved.

Urinalysis: It looks for the urinedetermination and searches for an infection in the blood or urinary tract causing pain in kidneys, urinary tract, bladder, or urethra or in all four and is felt in the abdomen, lower-back portion, or pelvis as observed in the case of John (Prabhakar and Das, 2018).

Amylase as well as Lipase: This blood test checks the levels associated withpancreas enzymes. High dose indicatesinflammatory infection known as pancreatitis and is extremely painfuland the patient here John needs to be hospitalized (Park et al. 2020).

Stool test / Secret mucus test: It looks for blood in stool/feces that are not observable to the naked eye and helps to detect upper gastrointestinal problems (Pitchumoni and Dharmarajan, 2020).

Computed Tomography Scan:CT scan refers to non-invasive computed tomography scanwithout touching the human body surface. Many images associated are taken, and then a skilled radiologist reads it. This test’s image is enhanced using contrast, providing more detailed images that are not safe for most patients like John with kidney ailment (Daniels et al. 2020).

MRI: Magnetic resonance imaging produces non-invasive images associated with the human’s internalbody parts. Mr. John with certain implants and with a presence of metal cannot be tested through an MRI scan due to the use of very strong magnets as it can be harmful (Engles et al. 2019).

Pelvic Exam: This can be used in the direction of determining if an infection or disease process is causing pain in the case of John.

Rectal Exam: Rectal examination, or DRE, the examination associated with the finger. During this test, the examiner will place a gloved as well as an oiled finger on the anal area looking in favor of rectal tone, which holds the anal sphincter muscles together (Park et al. 2020).

Upper Endoscopy: This test is known as upper GI, panendoscopy, esophagogastroduodenoscopy, or upper endoscopy used toexamine the upper gastrointestinal tract from the inside. The camera uses an illuminated endoscope in the direction of inserting an endoscope into the mouthto examine the associated internal portion of the esophagus, stomach, as well as duodenum.

Colonoscopy: It allows the doctor in the direction of examining the inside associated with the colon with the helpof a device’shelp that uses both lights as well as a camera, including pictures displayed on a monitor (Park et al. 2020).

X-Ray associated with the Kidneys, Ureter, as well as Bladder (KUB): An X-ray is associated with an abdomen that looks at the kidneys, as well as bladder, the intestines as well as pelvic bonesalong with the spine (Daniels et al. 2020).

Ultrasound: This test uses a higher sound wave higher thanthe human ears can detect it helps in the direction of creating images associated with the inside of the human body.

Prioritiesassociated with Treatment

Assessing AP is a problem in the ED. All-inclusive history with detailed clinical examination, with the right kind of laboratory testing as well as radiologic imaging facilitates, are considered to be effective in John’s assessment.It tends to be guiding to admit Johnin the hospital to avail further care. If an ER nurse treatsthe patients suffering from trauma, injury, or a critical medical conditionthat requiresan urgent need for treatment by identifying the best and quickest way toward the stabilization of John’s condition henceforth minimize his pain. As Mr. John Douglas aged 70 male was admitted in an emergency after not feeling well for 4 days while being at home accompanied by nausea as well as vomiting. In this case, theassessment calculation associated with ED remains to be a challenging topic. A minute medical history of Mr. John along with his detailed clinical trials, aided by appropriate laboratory testing,that includes radiological imaginglet to the facilitation of an effective evaluation(OBE et al. 2016).

Abdominal Pain Nursing Care Plan

Subjective Data

Several tests are required to determine the condition of Mr. John as initially his current generalized subjective data after entering into the emergency department was showing as T39, Heart Rate 120, Respiratory Rate-24, Blood Pressure 90/60, along with his oxygen sats that is above 92%. His GCS was observed to be 15 and the weights 88kgs with a decreased appetite (Lexne et al. 2020).

Objective data

His objective data shows that he was having abdominal pain with a pain index of 7/10 with a complaint of no bowels opening for the last 4 days alongsidepossess abdominal distention. A patient like Mr. John is presented to the emergency outpatient department with similar symptoms of abdominal pain, a lengthy workup is needed to be able to determine the cause in the first hand, and henceforth leads to pathophysiology. Generalizing abdominal pain is instrumental in complicating the clinical terms or interventions with patients having abdominal distention, and diverticulitis (Jangland et al. 2016).

Going further after his admission he was put into several tests. This test is very effective in determining whether Mr. John Douglas is suffering from the gastrointestinal tract or constipation gases or has kidney stones which may be the cause associated with the pain. This test examines the abdomen as well as determines if there are any problems with the tissues as well as organs. Ultrasound can sometimes detect gallbladder problems as well as is often used in the direction to assess the kidneys. Upper Endoscopy will help to determine the cause of his stomach pain caused due to stomach ulcers or acid reflux. It requires anesthesia, during the procedure John needs to be sedated and is carried out by a trained physician. He will be examined for rectum blood masses potentially examining his prostate. With a small stool sample that is needed to be obtained during this exam letting to an occult stool test performance to detect the reason for Constipation (Jangland et al. 2016).

Colonoscopy can be helpful in John's case as inspects large intestine for pain or bleeding sources, allowing taking biopsy samples by performing certain other types of minor procedures in the course of the examination. It requires anesthesia, during the procedure making John fall unconscious throughout the examination and is carried out by a trained physician.Contrasts are useful in the direction of enhancing the images, but can no longer be used safely for John with suspected kidney ailments. It indicates that the liver is working successfully in the direction of removing harmful toxins from the body. Taking too many drugs that are harmful in the direction of the liver, drinking alcohol, or the development of the natural disease can cause liver damage as well as are painful. If there is an infection in the blood, the cultures, as well as sensitivity, are usually determined in the direction of the type associated with infection as well as the best treatment(OBE et al. 2016).

Nursing Interventions as well as Rationales

An RN needs in the direction of being basic as well as detailed so that RN know not only how it can be treated, but also how it has changed. (For example, appendicitisin Mr. John Douglas case may receive a signal for pain as well as the need for emergency relief).

Controlling of pain: all clinically approved repositioningheat or cold medications (muscle relaxing analgesics)

Mr. John with pain has difficulty participating in treatment, relaxation, sleep, as well as healing. Actively did what was needed in the direction of treating the pain, as well as informed the attending physician as appropriate for the inability in the direction of providing adequate relief (Feo et al. 2019).

Assess the consistency in terms of bowel movements color, frequency, as well as its amount

This will help the RN to make significant clinical decisions. Accurate reporting associated with bowel movements is important. It also ensures accurate intake followed by output records.

Ensuring hydration in the right amounts and requiresfluid’s intravenous

Patients with abdominal pain may have decreased appetite, may suffer from NPO, or may not drink fluids. Establish as well as promote proper fluid balance, which may require donor notice for oral as well as venous fluid intake in the direction of maintaining fluid balance (Feo et al. 2019).

Assessing of bowel movements sounds

A regular inspection is required in the direction of knowing their properties todetect changes. If Mr. John Douglas hears intestinal bowel sounds but does not do so now, it is important in the direction of finding the suspecting ailment as well as is required to inform the provider. Mr. John Douglas may not feel any symptoms (Engles et al. 2019).

Facilitation of restoring normal bowel movement patterns

Abdominal pain can be the result associated with gastrointestinal problems. It is, therefore, important in the direction of treating problems such as nausea, vomiting, constipation, as well as diarrhea as soon as possible (Park et al. 2020).

Record intake as well as output

John may do not take the right kind of fluids and foods; these may lead to the lack of John’s urinary as well as bowel output. The right kind of I&O is considered to be essential to make clinical decisions (Prabhakar and Das, 2018).

Prevent infection

Pathogens (e.g. gastroenteritis) can result in abdominal pain. It is essential in the direction of promoting manual hygiene as well as infection prevention in the direction to prevent it from spreading and pose a threat to John's treatment plan. It is hereby required to assessabdominal behavior that reports changes in size as well as quality accordingly (Lexne et al. 2020).

Discharge Planning

Discharge Instructions:

Contact treatment facility immediately:

  • Vomits blood or unable to stop vomiting
  • Blood in the bowel movements looking like tar
  • Bleed from the anus.
  • If John’s stomach enlarges with stiffness and pain
  • Severe abdominal pain.
  • Stop gas passing with irregular bowel movements.
  • Feeling weak, restless, or unconscious

John needs to contact his healthcare provider if:

  • He feels feverish.
  • Newly developed symptoms and not responding to medicines.
  • Questions or concerns

Medicines

It will reduce the pain, treat infection, as well as manage symptoms if taken as directed. He will be instructed to call the doctor in case the medication is not helping or having side effects also required to mentionany form of allergy. He will be instructed to keep a list of his medical intakes and present them by listing during follow-ups. Emergency medication needs to be kept handy (Schultz et al. 2019).

Manage John’s symptoms

Applying heat on his abdomen for 30 minutes every 2 hours as directed will decrease the muscle spasms as well as pain. Stress needs to be managed to recommend relaxation techniques as well as deep breathing exercises as it causes abdominal pain. Getting sleep and exercise in abundance is a must in this case. Limiting alcohol consumption can trigger abdominal pain and the healthcare provider must direct the safe limit associated with drinking. He will be instructed to quit smoke as nicotine in cigarettes can lead to a damaged esophagus as well as impact the stomach and also assist treatment and counseling plan to help him quit(Dündar et al. 2018).

Change the foodseating habits according to the given direction

No junk or highly cooked food as instructed to eat easily digestible smaller meals with dietary fiber including fruits, vegetables, whole foods as well as lemons. To remove or stop diarrhea as well as bloating, John will be instructed to not drink soft drinks, fructose-rich foods, or caffeine-based beverages. Drinking of purified water in plentyhelps to avoid dehydration. It will be also instructed that he must restrict the fluid intake as per the healthcare provider's instruction (Schultz et al. 2019).

References for Mr. John Douglas Case Study

Daniels, J., Griffiths, M. and Fisher, E. (2020).Assessment and management of recurrent abdominal pain in the emergency department. Emergency Medicine Journal, 37(8), 515-521. doi: http://dx.doi.org/10.1136/emermed-2019-209113

Dündar, Z. D., Dogrul, A. B., Ergin, M. and Dogrul, R. T. (2018).Abdominal Pain in Older Patients.In Geriatric Emergency Medicine (pp. 217-234).Springer, Cham.

Engles, S., Saini, N. S. and Rathore, S. (2019). Emergency focused assessment with sonography in blunt trauma abdomen. International Journal of Applied and Basic Medical Research, 9(4), 193.doi: 10.4103/ijabmr.IJABMR_273_19

Feo, R., Donnelly, F., Athlin, Å. M. and Jangland, E. (2019).Providing high-quality fundamental care for patients with acute abdominal pain. Journal of health organization and management.doi: https://doi.org/10.1108/JHOM-02-2018-0037

Jangland, E., Kitson, A. and MuntlinAthlin, Å. (2016). Patients with acute abdominal pain describe their experiences of fundamental care across the acute care episode: A multi‐stage qualitative case study. Journal of advanced nursing, 72(4), 791-801.doi: https://doi.org/10.1111/jan.12880

Lexne, E., Brudin, L., Marteinsdottir, I., Strain, J. J. and Nylander, P. O. (2020). Psychiatric symptoms among patients with acute abdominal pain: Patients with organic dyspepsia report more psychiatric symptoms and rate poorer general health compared to patients with other specific abdominal diagnoses and non-specific abdominal pain at an emergency ward. Scandinavian Journal of Gastroenterology, 55(7), 769-776. doi: 10.1080/00365521.2020.1782464

OBE, R. C., Charters, A., Dawood, M. and Bennett, P. (Eds.).(2016). Oxford handbook of emergency nursing.Oxford University Press.

Park, J. W., Lee, H., Jeon, B. J., Pyon, J. K. and Mun, G. H. (2020). Assessment of the Risk of Bulge/Hernia Formation after Abdomen-based Microsurgical Breast Reconstruction with the Aid of Preoperative Computed Tomographic Angiography-derived Morphometric Measurements. Journal of Plastic, Reconstructive & Aesthetic Surgery.doi: https://doi.org/10.1016/j.bjps.2020.05.019

Pitchumoni, C. S. and Dharmarajan, T. S. (2020). Abdominal pain. Geriatric Gastroenterology, 1-10.doi: https://doi.org/10.1007/978-3-319-90761-1_43-1

Prabhakar, S. and Das, S. (2018, December).Role of ultrasound abdomen in evaluation of abdomen in dengue fever in children with severity assessment correlating with serological and laboratory parameters.European Congress of Radiology 2019.doi: 10.26044/ecr2019/C-0152

Schultz, H., Larsen, T. S., Möller, S. and Qvist, N. (2019).The Effect of Patient-Controlled Oral Analgesia for Acute Abdominal Pain after Discharge. Pain Management Nursing, 20(4), 352-357. Doi:https://doi.org/10.1016/j.pmn.2019.02.004

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