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Case Study:

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by

Mellisa Squires

on 1 October 2013

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Transcript of Case Study:

Case Study: Living with Crohn's Disease
Duration:
IV Bolus
Adverse Reactions:
IV Drug Therapy
Gentamicin
Blair's Story
Case Study:
Mackenzie's Story
Context and Culture
13 years old diagnosed with Crohn's Disease
Lives with a single mom
Fast food meals
Has trouble making friends at school
Worried about starting school this fall with a potential ileostomy
Mackenzie's Story

Acute LLQ pain
Distended abdomen
Vomiting
Tachypneic
Pale and lethargic
Weight loss
History of Crohn's, polycystic ovarian
syndrome (surgery for removal of cysts)
Anemia
What is Crohn's Disease?
Idiopathic inflammatory bowel disease (IBD)
Abnormal local immune response against normal flora of gut
Affects any portion of the GI tract (esophagus to anus)
Most often involves the ileum and colon
Further Assessment?
2. Vitals
- T=38.9, P=135, RR=32, BP= 79/50
3. Respiratory Assessment
- Chest clear, no adventitious sounds
- Tachypneic
- Shallow breaths
- O2 sat >97% RA
Further Assessment?
4. Abdominal Assessment
- Distended
- Bowel sounds diminished
- Nausea and vomiting
5. Pain Assessment
- 5/10
6. Neurovascular Assessment
- Poor skin turgor
- Warm centrally, cool peripherally
- Sluggish capillary refill
What do you think
is the main priority?
Pain?
Dehydration?
Oxygen?
Bowel obstruction?
WHY?
Dehydration
Vomiting
Weight loss
Decreased blood pressure
Tachycardic
Tachypneic
Sluggishness
What are other indicators
of dehydration?
Consequences of
Dehydration
Dizziness
Confusion
Delirium
Shock
Organ Failure
Unconsciousness
Death
Treatmeant for Moderate-Severe Dehydration?
#1 Treatment=
IV Solution?
Isotonic Solution .... why?
Goal is to restore intravascular volume
Increases fluid in extracellular (intravascular) space
Therefore increases blood pressure & Peripheral Perfusion
Need to know?
Allergies
= Strawberries & Codeine
Blood Pressure (vitals)
Correct administration of IV Bolus
Intravenous Bolus
Medication rights
Precautions for adverse reactions
REPTILE
Presenting Symptoms:
Fluid Loss Indicators:
Respiratory Depression
- Abnormal breath sounds
- SOB
Fluid Volume Excess
- Peripheral swelling
- Increased blood pressure
- Jugular vein distention
- Abnormal lung sounds: Crackles
Electrolyte Imbalance
IV Site reactions
What are they?
Check vitals and Patient stats q15
Precautions:
IV Bolus:

Prior to administering:
Confirm the order with physician
Check for allergies
Current medications and compatibility
Calculate the drip rate
Hand hygiene
Sterile technique
Rights of medication administration
Documentation of patient's current status
Case: Update
Mackenzie's status
Has been visited by General Surgery + gastroenterologist
Surgery is not needed at present time
Remain NPO
Will be admitted once bed is available
XRAY: Sub-acute small bowel obstruction with inflammation
No Gynecological involvement
New Orders:
Blood Cultures
Start on Ampicillin, Gentamicin, Flagyl IV
Insert Nasogastric Tube
Nasogastric Tube
Short-term nutrition
Importance of proper NG Insertion:
Decreases distress/discomfort for patient
- gagging & vomiting
Decreases risk of mucosal & structural damage
Decrease risk of tube misplacement, particularly in
respiratory tract
Ways to check NG Placement
Measuring the PH of aspirate using pH indicator
strips to ensure tube is in stomach
Radiological Imaging
Allows bowel to rest
IV Drug Therapy
Ampicillin
Action: Interferes with bacterial cell wall replication
- Cell wall becomes osmotically unstable
- swells & bursts from osmotic pressure
Side Effects: Nausea, vomiting, diarrhea, coma, seizures
Uses: Effective for gram pos & gram neg cocci
- gram pos & gram neg bacilli
Used for intrabdominal infections
Action: Interferes with protein synthesis in bacterial cell= inaccurate peptide sequences= bacterial death
Side Effects: Dizziness, fatal liver toxicity, neurotoxicity, deafness, hepatic necrosis
Uses: Severe systematic infections of GI tract & more
- pseudomonas aeruginosa, proteus, kelbsiella, serratia, salmonella, e-coli, citrobacter, shigella & more
IV Drug Therapy
Metronidazole (Flagyl)
Blood Results
Hgb= 85 g/L
WBC= 18 x 10^9/L
K= 3.2 mEq/L
Na= 132 mEq/L
Action: Binds and disrupts DNA structure, inhibiting bacterial nuclei acid synthesis
Side Effects: Headache, dizziness, seizures, nausea, vomiting, diarrhea, anorexia
Uses: Bacterial anaerobic infections
Why were all three drugs ordered and not
just one of the three?
Normal Ranges
(115-160)
(4.0-10.0)
(3.5-5.0)
(135-145)
Explain the blood results that are shown.
Why does she have low K and NA?
Why are the WBC increased?
Why is the Hemoglobin increased?
New Order:
Urinalysis
What is it?
Pathology of Crohn's Disease
Patchy transmural inflammation in the lining of the digestive system
Tissue inflammation may be the result of the secretion of cytokines by CD4+ cells
Dominant manifestations:
Analysis of urine by physical, chemical, and microscopic means to test for presence of disease, drugs, etc.
Can be used to detect urinary tract infections, kidney disease, and diabetes
Why is it significant r/t Dehydration?
Can be used as a test to detect dehydration
Appearance: Dark yellow can indicate dehydration
Specific Gravity
- Determines how concentrated the urine is
- Test result will be high if dehydrated
- recurrent episodes of diarrhea, cramping, abdominal pain, fever lasting days to weeks
- melena 50% of cases- usually mild
Intestinal wall is rubbery and thick- r/t edema, inflammation, fibrosis, and hypertrophy of muscularis propria
Pathology
Debilitating Consequences
Mucosal damage- r/t inflammatory process
Fistula formation: excessive scarring causing ulcers which over time expand into channels or passageways
- loops of bowel, bladder, vagina or perianal skin
Intestinal Obstruction- massive intestinal bleeding, toxic dilation of the colon
Increased risk of carcinoma
Prednisone
Mackenzie is taking Prednisone BID
Action: Decreases inflammation by suppression of migration of leukocytes, fibroblasts
Classification: Corticosteroid
Side Effects: circulatory collapse, embolism, GI hemorrhage, thrombocytopenia
Uses: Severe inflammation, suppresses immune system
How is this drug applicable to Mackenzie's condition?
Community Resources
Validation
Crohn's and Colitis Foundation of Canada
Support Group (Real Canadian Superstore)
- individuals with IBD AND their caregivers
- self-referral/drop-in
- Facebook group (personal stories, resources)
GUTSY walk for Crohn's and Colitis
- Funding towards IBD research
- Supporting each other's IBD experience
Orlando's Theory of Validation
1. Function of professional nursing: Finding out and meeting the
patient's immediate needs for help
2. Presenting Behavior: Must recognize situation is problematic
- Presenting behavior may be a plea for help
3. Immediate Reaction (Internal Response)
- Perceives with one of five senses
- Stimulates automatic thought
- Thought stimulates automatic feeling
4. Nursing Process Discipline
- Nurse does not assume any aspect of their reaction is correct until they check validity of it by exploring
with patient
5. Improvement- Resolution
- Did the nurse's activity serve to help the patient's need
Validation:
Communication Techniques
SOLAR
Sitting in comfortable position
Open Posture
Leaning Forward
Eye Contact
Relax
Open-ended questions
Empathetic Understanding
Health Teaching
Analyzing stressors and sources of worry
Validation
Crohn's Disease: Diet
Important to have a well-balanced diet to avoid malnutrition and dehydration
Diet:
Identify trigger foods and eliminate them from your diet
Identify safe foods that cause the least irritation
Eat smaller, more frequent meals throughout the day
Try lactose-free products, as many IBD sufferers appear to be lactose intolerant
Reduce sugar and artificial sweeteners if they aggravate your gut
Avoid drinking a lot of fluid during a meal; try to wait until you are finished eating
Reduce fat intake as it might be hard to digest
No such thing as an "IBD" diet because everyone has unique tastes, different triggers, and is affected in different parts of GI tract
Be mindful of hard-to-digest foods
-Foods containing insoluble fibre (skin of fruit, whole grains, brown rice)
- Seeds and nuts
- Raw fruits, raw veggies, nuts

Foundational
Concepts
1. Ways of Knowing
2. Culture and Context
3. Time and Transition
4. Personal Meaning
During an cute episode of "IBD":
Ways of Knowing
Empirical
CNO: EThics
■ client well-being
Nurses used their assessment skills and technical skills (IV Bolus) learned from nursing school, clinical experience, and fellow registered nurses in order to appropriately assess Mackenzie
Personal
Nurses are able to understand themselves (values) in order to more efficiently empathize with Mackenzie's feelings of worry about school
Ethical
Nurses knowledge is derived from an ethical framework
College of Nurses of Ontario
CNO Ethics
respect for life ■
Identify patient's values in regards to quality of life at the beginning of nurse-client therapeutic relationship
Increased ability to advocate
maintaining commitments ■
Nurse identified resources and support, such as the Crohn's Support Group for individuals with Crohn's and caregivers, applying to both Mackenzie and her mom
truthfulness and fairness
Nurse is able to discuss Mackenzie's direct questions about her diagnosis including diet education to decrease the chance of future dehydration
Promoting and preserving self-esteem and confidence in Mackenzie r/t school and a potential ileostsomy
client choice
Nurse presenting Mackenzie with the informed decision on the IV Bolus and antibiotics, etc
Privacy and Confidentiality
Keeping patient's body covered up except for area of assessment when performing them
Not sharing Mackenzie's personal information with anyone outside the healthcare team
Context and Culture
Context and Culture
Culture :
Aesthetic
Context
Young 13 year old starting high-school
Newly diagnosed
Worried about making friends
Single mother
Mother is busy with demanding career
Having previous surgery/ovarian cysts
Hospitalization
Mother is busy with career, unable to cook
Current diet: Fast food
- The attitudes and behavior characteristic of a particular social group
- The circumstances that form the setting for an event, statement, or idea, and in terms of which it can be fully understood and assessed.
Time and Transition
13 years old
Self-image (finding themselves)
Puberty
knowledge-base
Going into High school
Out of comfort zone
New teachers/new peers
Increased stressors
what are some other examples?
Personal Meaning
What does it mean to Mackenzie?
How about her mom?
being different from everyone else
Having restrictions on part of her life
such as Diet
Body Image- potentially having an ileostomy bag (pool parties, etc)
Making a lifestyle change to be able to provide Mackenzie with appropriate diet
Make time to support her daughter
Understand meaning of disease
Suffering and Sorrow
Diagnosis
Thank-you
Are there any questions?
1. Health History
Triple Therapy?
Each antibiotic targets a different set of bacteria that are commonly found in the GI tract
Ordering all 3 drugs at the same time ensures that most of the infectious bacteria originating in the GI tract are treated
Prevents risk for further infection and bacterial growth
Blood Work Significance
Hemoglobin is low due to Mackenzie's anemia.
WBC's are high indicating possible infection and inflammation
Potassium and sodium are low indicating electrolyte imbalance r/t dehydration
Community Resources
Crohn's and Me
Offers an online forum to ask and reply to individuals concerns
Diet guides
Living with Crohn's blog stories
Resourceful & supportive of emotions throughout progression of disease
Nurses may use artistic demonstration to assist with health teaching for pediatric patients
Ex: Diagrams, models, IV doll, drawings, etc
Early Diagnosis/Progression of Crohn's Disease
- newly diagnosed with Crohn's disease
Treatment
- Future surgery (ileostomy)
Disease Progression
- Complications (bowel obstruction, fistukas)
- Remission periods (flare-ups)
Pain
- LLQ, ulcers, trigger foods
Loss
- bowel function, self-esteem
Full transcript