Nmih202 Developing Nursing Practice 1 Assessment Answers

Mrs Lopez is a 45-year-old, obese, Hispanic tourist who presents to the Emergency Department with acute abdominal pain. She has a recent history of abdominal pain over the past two weeks, gradually increasing in intensity. No known family history of any abdominal conditions. Mrs Lopez states she has accompanying symptoms of nausea and vomiting, pain radiating to her right shoulder, sweating and chills. When questioned about her social history, she states her diet has consisted of regular takeaway with an intolerance to fatty food and little exercise. Mrs Lopez is complaining of moderate abdominal pain. She is febrile at 38.2 degrees Celsius, with a blood pressure of 126/72 mmHg, a regular pulse of 128bpm, a respiratory rate of 22 breaths/min, and an oxygen saturation of 97% while breathing room air. The plan for Mrs Lopez is to admit her to the surgical ward for observation, medication management and surgery. Mrs Lopez is anxious and says she feels guilty about her lifestyle, which she considers has contributed to this admission today. Mrs Lopez will require a laparoscopic cholecystectomy

1. Risk Factors and Health Promotion What arc the modifiable and non-modifiable risk factors that may have contributed to Mrs Lopez's cholelithiasis and acute cholecystitis? Mrs Lopez requests assistance regarding her modifiable risk factors. Outline how you would approach Mrs Lopez regarding these including what health promotion information and referrals you would provide to her 

2. Pathophysiology Briefly describe in your own words (in the way you would explain it to a family member) the pathophysiology behind acute cholecystitis 

3. Homeostatic Mechanisms Outline the homeostatic mechanisms that result in the following symptoms Mrs Lopez is experiencing on your nursing assessment:

*Referred shoulder pain

*nausea and vomiting

*fever 

4. Nursing Care Outline and justify the nursing care required for Mrs Lopez with her initial presenting symptoms, placing this nursing care in order of clinical priority. 

5. Activities of Daily Living Consider the twelve (12) activities of living outlined in the Roper Logan & Tierney Model of Nursing and specifically discuss which of these activities of living may be influenced or altered for Mrs Lopez post operatively. Outline how the registered nurse could assist the patient to manage them. 

Risk variables can be of 2 types- modifiable and non-modifiable elements. Modifiable elements can be altered or traded though non-modifiable components don't have any extension for the change. On account of intense cholelithiasis, the modifiable components incorporates family history/hereditary inclination, ethnicity, sexual orientation, age while obesity, metabolic disorder, diabetes mellitus, dyslipidemia, drugs, such as, ceftriaxone, octreotide, thiazide contraceptives, low physical movement, rapid lessening in body weight, anorexia, total parental sustenance, various sicknesses: liver cirrhosis, Crohn's ailment, duodenal diverticulum and conduit, status post-gastrectomy, vagotomy brainstem, hyperparathyroidism, contamination of the biliary tree, constant hemolysis, pregnancy and eating routine (Treinen et al. 2014).

Hereditary frailty is a key component in considering the advancement of gallstones; family ponders demonstrating a recurrence of very nearly 5 times higher and a high risk in relatives of patients. In a review directed by specialists on a specimen of more than 43,000 sets of twins with gallstones vesicular symptomatic hereditary impacts were resolved in around 25% perceptions, while natural impacts imparted to those effects were specified in around 13 % of cases. The event of gallstones speaks to a perplexing cooperation of hereditary attributes and the get together shaped by the ecological elements, especially the quality eating regimen collaboration.

Another real risk component is the time of LV. The recurrence of identification of gallstones increments with age, particularly after 40 years; increase the risk of requiring surgery in this classification 4-10 times number of symptomatic cases convoluted that may require damage (Eachempati and Reed 2014).

Mrs. Lopez can improve her diet from take away fatty foods to the home-made normal balanced diet that must have optimum amount of fatty acids, carbohydrates, proteins and vitamins. Along with the proper balanced diet Mrs. Lopez should involve in physical activities like jogging, aerobics, for dissolving the excess far from her body. She needs to have proper sound sleep as she is facing from acute cholecystitis.

Pathophysiology of Cholecystitis: 

Cholecystitis is aggravation of the gallbladder that happens most generally in light of a disincentive of the cystic pipe by gallstones emerging from the gallbladder (cholelithiasis). Edematous cholecystitis, the first stage (2–4 days): The gallbladder contains interstitial liquid with widened vessels and lymphatic. The gallbladder divider is oedematous. The tissue of the gallbladder is in place histologically, with oedema in the sub layer (Haas et al. 2016).

Necrotizing cholecystitis, second stage (3–5 days): The gallbladder consists of oedematous changes with ranges of discharge and corruption. At the point when the gallbladder divider is subjected to raise inward weight, the blood stream is hindered, with histological confirmation of vascular thrombosis and impediment. There are ranges of scattered rot, however it is shallow and does not include the thickness of the divider of the gallbladder.

Suppurative cholecystitis, third stage (7–10 days): The gallbladder divider has white platelets show, with regions of putrefaction and suppuration. In this stage, the dynamic repair procedure of aggravation is obvious. The developed gallbladder starts to contract and the divider is thickened because of sinewy expansion. The abscesses in the intra-wall are available and include the whole thickness of the divider. Abscesses of the pericholecystic are available in this stage (de Mestral et al. 2014).

Chronic cholecystitis: It develops after the rehashed event of placid ruptured of cholecystitis, and is described by mucosal decay and fibrosis of the gallbladder divider. It can likewise be brought about by ceaseless aggravation by extensive gallstones and may frequently prompt intense cholecystitis.

A type of intense cholecystitis is also present. There are four particular types of intense cholecystitis: (1) acalculous cholecystitis, is intense cholecystitis without cholecystolithiasis; (2) xanthogranulomatous cholecystitis, elaborated by the xanthogranulomatous widening of the gallbladder divider and hoisted intra-gallbladder weight because of stones, with burst of the Rokitansky-Achoff sinuses. This break cause spillage and bile passage into the gallbladder divider. The bile is ingested by histocytes, shaping granulomas comprising of frothy histocytes. Patients more often than not have side effects of intense cholecystitis in the underlying stage. (3) emphysematous cholecystitis, in which air shows up in the gallbladder divider because of contamination with gas-framing anaerobes, including Clostridium perfringens. This shape is probably going to advance to sepsis and gangrenous cholecystitis; it is frequently found in diabetic patients. (4) Torsion of the gallbladder. Torsion of the gallbladder is known to happen by intrinsic, procured, and other physical causes. An intrinsic variable is a gliding gallbladder, which is extremely portable on the grounds that the gallbladder and cystic pipes are associated with the liver by a melded tendon (Eachempati et al. 2014). Gained elements incorporate splanchnoptosis, decrepit humpback, scoliosis, and weight reduction. Physical elements bringing on torsion of the gallbladder incorporate sudden changes of intraperitoneal weight, sudden changes of body position, a pendulum-like development in the position of anteflexion, hyperperistalsis of organs close to the gallbladder, poop, and injury to the stomach area.

Homeostatic mechanisms:

Homeostasis can be defined as the body system mechanism that constructs a state of equilibrium between different interdependent elements that are the product of metabolic and physiological processes. There are many examples of homeostasis occurring inside human body, like thermoregulation or pH maintenance or salinity and water level and blood pressure. The main purpose behind the homeostasis in the body is to ensure that the external changes in the environment do not change or alter the internal mechanisms of the body. However, there are a number of clinical symptoms that are associated with the homeostatic mechanisms o human body, for example in this case study; there is a significant impact of homeostasis on the symptoms that the patient is exhibiting.

Shoulder pain: 

Pain sensation in our body is controlled by the different ionic channels; K⁺ channels prove to be the most crucial elements determining neuronal excitability. The human body’s first line of response to any cellular abnormality is inflammation and presence of inflammation alters K⁺ channel in the nervous system associated with the pain pathway. Chronic pain is often associated with abnormality in the somatosensory system of the body, and abnormal K⁺ concentration in the can hyper-excite the neurones and cause unbearable pain sensation. Homeostatic mechanism helps in enforcing the balance in the body and it controls the action potential firing in the neurons to retain functionality (Stinton, and Shaffer 2012). Homeostatic regulation facilitates a neurone to decrease the excitability of the membrane when it receives an enormous input. This regulatory mechanism targeting intrinsic excitability stabilizes the neural network by regulating the K⁺ channel influx and out flux. When the homeostatic regulation fails to monitor K⁺ influx in the cell, the neuronal membranes super excite and pain sensation is produced. Insulin influx in the body can affect the K⁺ concentrations in te4 body and for the patient her dietary choices have resulted into insulin mediated K⁺ influx and interfered with the homeostatic regulation (Koller et al. 2012).

Nausea and vomiting:

Another physiological function regulated by the homeostatic regulation is the blood glucose levels in the body. Blood glucose levels are monitored in the pancreas using a specific glucose receptor, and the antagonistic actions between hormones, insulin and glucagon secreted by the alpha and beta cells of islets of langerhans maintain the blood sugar level in the body. The purpose of insulin is to break down and utilize glucose from the blood stream into metabolic and physiological functions such as respiration, and glucagon prevents hyperglycaemia in the body stimulating glycogenolysis so that starve from excess glucose utilization in the body (Othman et al. 2012).

However oil rich diet can interfere with the homeostatic equilibrium of the both hormones and can lead to hyperglycaemia. Low glucose concentrations can cause nausea and vomiting as symptoms, which is the case for the patient under consideration in the assignment.

Fever:

The major homeostatic regulation employed in the human body is the thermoregulation, the thermoregulatory centre in the hypothalamus serves to retain the temperature that is ideal for the human body to function, by the assistance of two key thermo-receptors, on in the hypothalamus and the other situated in the skin (Othman et al. 2012). The hypothalamus receptor controls the blood that pass through the brain and the receptor in the skin serves to monitor the external stimulus. The thermoregulatory receptors send multiple signals in the body that will ad in adjustment of the temperature in the body. In any kind of cellular malfunction, the body sends stimulus to the regulatory centre in the hypothalamus which in turn sends signals to the receptors in the skin and produces heat that is the external manifestation of the internal malfunction in the body (Brown et al. 2011).

Nursing care plan:

The patient under consideration in the case study is suffering from acute cholelithiasis, an inflammation in the gall bladder accompanied by the formation of gall stones made up of cholesterol and calcium bilirubinate (Smeltzer et al. 2010).

Symptoms: 

 Her symptoms include,

Moderate abdominal pain

High temperature

126/72 blood pressure

22 breaths per minute respiratory rate

97% oxygen saturation.

Diagnostic needs: 

Her diagnostic needs include,

Abdominal Xray to detect the presence of gall stones and fin out the reason for pain.

Biliary ultrasound to detect the presence of gallstones.

Oral cholecystography to detect general function and appearance of the gall bladder.

Endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography to differentiate the gall bladder issue with the patient (Smeltzer et al. 2010).

Care priorities for the patient: 

The patient is suffering from high fever and moderate abdominal pain. The nursng care priorities in the patient include,

Enforcing optimal pain management

Setting up resting environment for the patient

Maintaining fluid and electrolyte balance in the patient.

Provide information about the severity of her condition.

Discuss the treatment plan for her

Inform her about the cholecystectomy surgery needed for

Prevent any complication that might develop (Halabi et al. 2014). 

Nursing interventions: 

The nursing intervention in case of a any patient must be focussed on the specific care priorities of the respective patients. In case of Mrs. Lopez, the nursing interventions appropriate for her will include measures to minimize her pain and her anxiety.

Pain assessment utilizing pain assessment tools before and after administration of pain medication is the first step. Changing the posture of the patient into low Fowler’s position will also help in pain management (Halabi et al. 2014).Providing intravenous fluids will help in maintaining the fluid balance in the patient.Providing adequate amount of analgesia for the patient to minimize the pain levels is also the responsibility of the nurse.

The nurse must Incorporate other nonpharmocological pain management techniques. Assessment of vital signs including blood pressure, temperature and the rest in every hours is necessary as well (Lirici and Califano 2010).Assessment of mental sanity and consciousness should be done periodically

Last few steps of the nursing plan should include preparing the patient for the surgery and documenting her vitals, post surgery pain management and administration of analgesia, assessing the consciousness and mental stability of the patient and preparation of discharge goals (Lirici and Califano 2010).

Discharge goals for the patient: 

The discharge goals for the patient should focus on allowing her to experiences relief from pain. Homeostatic balance should return in her body system prior to her discharge. All medical complications must be eradicated and prior release from the hospital the patient must understand the regimen prepared for her health promotion (Warttig, Ward and Rogers 2014).

Activities for daily living: 

Lifestyle choices make a huge impact in health conditions of the individuals, better living always comes at the cost of a few sacrifices made in the life style choices. Studies suggest that recovery can be accelerated significantly if the patient follows a strict healthy daily regimen (Warttig, Ward and Rogers 2014). Based on this consensus, health care professionals have included a daily living plan, curated for the specific patients with particular needs; hat will facilitate speedy recovery for the patient and promote healthy living. There are a number of comprehensive nursing models that aid in the formulation of such specific regimens and Roper, Logan and Tierney model one such example that is used abundantly (Patton 2013).

This model comprises of 12 units of activities of living meant to promote optimal independence and empowerment in the patient alone with being the catalyst to accelerated recovery procedure (Dunnion and Griffin 2010). These activities are designed based on interventions that can ascertain independence in the areas that proved to be difficult in the beginning. It also encourages complete engagement and involvement of the patients into the activities that empowers them to be in control of their recovery and eliminates the restrictions put forth by their respective medical conditions to a large extent. It elevates the mental constrain and generates hope and optimism in the patients about their health condition and recovery plan (Cutcliffe, McKenna and Hyrkas 2010).

The instructions of the daily living can be very beneficial for the construction of a postoperative instruction set for the patients that undergo critical surgeries. For example in this case study, the patient under consideration, Mrs Lopez, was suffering from cholethiasis and had to undergo laparoscopic cholecystectomy surgery in order to get better. Her lifestyle has not been very healthy and her meals generally consisted of takeouts every single day and she needs to incorporate many changes in her lifestyle to promote healthy living. The basic daily living activities for her can include,

 The patient must inhabit a safe environment that does not hold any potential to harm her incision site. Care should be taken that children are kept away from her and her activities do not threaten opening up of the wounds (Elsherif and Noble 2011).

The patient must be given a measure to communicate with the assigned registered nurse at the time of need. She must follow through a strict dietary plan incorporating more fibre and eliminating excess oil and sugar rich food items. Liquid diet must be followed in the initial days, and RN must ensure that the patient has been informed in detail about her dietary plan.

Bathing regulations will also need to be followed and she should not wet the incision area, and the dressing must be changed periodically as well. The registered nurse must set up check up dates for the same with the patient (Alligood 2014).

The patient has had high fever as a symptom, and must maintain the temperature carefully; the registered nurse should describe to her all the necessary measures for doing the same. The patient should also converse with the registered nurse assigned to her in regular intervals about her progress and any difficulties that she may encounter in following these regulations (Elsherif and Noble 2011).

Conclusion: 

The modern lifestyle is all about running around and chase and this lifestyle has taken all the time that one can spend on their own self. The bad life style choices and negligence on the consequences of her life choices has put a considerably negative impact on the health conditions that she had developed. However, Mrs Lopez is certainly not the only one making these wrong choices. The majority of the tech savvy generation of today suffers from the same ailment. However, considering the new age frameworks that the healthy living models provide can be beneficial for this generation to take heed of their health without compromising their fast paced lives.

References: 

Alligood, M.R., 2014. Nursing theorists and their work. Elsevier Health Sciences.

Barie, P.S. and Eachempati, S.R., 2015. Acute acalculous cholecystitis. In Acute Cholecystitis (pp. 187-196). Springer International Publishing.

Brown, L.M., Rogers, S.J., Cello, J.P., Brasel, K.J. and Inadomi, J.M., 2011. Cost-effective treatment of patients with symptomatic cholelithiasis and possible common bile duct stones. Journal of the American College of Surgeons, 212(6), pp.1049-1060.

Cutcliffe, J.R., McKenna, H. and Hyrkas, K., 2010. Nursing models: Application to practice.

de Mestral, C., Rotstein, O.D., Laupacis, A., Hoch, J.S., Zagorski, B., Alali, A.S. and Nathens, A.B., 2014. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Annals of surgery, 259(1), pp.10-15.

Dunnion, M.E. and Griffin, M., 2010. Care planning in the emergency department. International emergency nursing, 18(2), pp.67-75.

Eachempati, S.R. and Reed, L. eds., 2015. Acute Cholecystitis. Springer International Publishing.

Eachempati, S.R., Cocanour, C.S., Dultz, L.A., Phatak, U.R., Albarado, R. and Todd, S.R., 2014. Acute cholecystitis in the sick patient. Current problems in surgery, 51(11), pp.441-466.

Elsherif, M. and Noble, H., 2011. Management of COPD using the Roper-Logan-Tierney framework. British Journal of Nursing, 20(1), p.29.

Haas, I., Lahat, E., Griton, Y., Shmulevsky, P., Shichman, S., Elad, G., Kammar, C., Yaslovich, O., Kendror, S., Ben-Ari, A. and Paran, H., 2016. Percutaneous aspiration of the gall bladder for the treatment of acute cholecystitis: a prospective study. Surgical endoscopy, 30(5), pp.1948-1951.

Halabi, W.J., Kang, C.Y., Ketana, N., Lafaro, K.J., Nguyen, V.Q., Stamos, M.J., Imagawa, D.K. and Demirjian, A.N., 2014. Surgery for gallstone ileus: a nationwide comparison of trends and outcomes. Annals of surgery, 259(2), pp.329-335.

Koller, T., Kollerova, J., Hlavaty, T., Huorka, M. and Payer, J., 2012. Cholelithiasis and markers of nonalcoholic fatty liver disease in patients with metabolic risk factors. Scandinavian journal of gastroenterology, 47(2), pp.197-203.

Lirici, M.M. and Califano, A., 2010. Management of complicated gallstones: results of an alternative approach to difficult cholecystectomies. Minimally Invasive Therapy & Allied Technologies, 19(5), pp.304-315.

Othman, M.O., Stone, E., Hashimi, M. and Parasher, G., 2012. Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits. Gastrointestinal endoscopy, 76(3), pp.564-569.

Patton, D., 2013. Strategic direction or operational confusion: level of service user involvement in Irish acute admission unit care. Journal of psychiatric and mental health nursing, 20(5), pp.387-395.

Sippey, M., Grzybowski, M., Manwaring, M.L., Kasten, K.R., Chapman, W.H., Pofahl, W.E., Pories, W.J. and Spaniolas, K., 2015. Acute cholecystitis: risk factors for conversion to an open procedure. Journal of Surgical Research, 199(2), pp.357-361.

Smeltzer, S.C.C., Bare, B.G., Hinkle, J.L. and Cheever, K.H. eds., 2010. Brunner & Suddarth's textbook of medical-surgical nursing (Vol. 1). Lippincott Williams & Wilkins.

Stinton, L.M. and Shaffer, E.A., 2012. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver, 6(2), pp.172-187.

Treinen, C., Lomelin, D., Krause, C., Goede, M. and Oleynikov, D., 2015. Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies. Langenbeck's Archives of Surgery, 400(4), pp.421-427.

Warttig, S., Ward, S. and Rogers, G., 2014. Diagnosis and management of gallstone disease: summary of NICE guidance. BMJ: British Medical Journal (Online), 349.