Clinical Issues in both patients
This assignment will discuss about the developmental similarities and the differences between Anna and George, with two different clinical conditions but pertaining to somewhat similar symptoms like diarrhea, vomiting, fluid intolerance and abdominal cramping. Anna is a 4 years old girl who has been admitted to the ED with the symptoms of Gastroenteritis and the George who is 86 years old and had a medical history of gastro esophageal reflux. After the comparison of the pathophysiology of both the conditions SMART goals has been chosen depending upon which the nursing interventions have been developed.
The clinical issue that had been chosen for this case is abdominal cramping experienced by both Anna and George. Anna has been reported to be administered with paracetamol and oral syrup, yet her abdominal discomfort and cramping has not been resorted. Her pain score states that she is experiencing moderate to severe pain and might upgrade to severe if appropriate actions are not taken (Chen et al., 2014). Her vital signs indicated temperature 38.2 0 C, BP 88/50, HR 118, R 22, SpO2 98% . The case study reveals that Anna is drowsy and cries when woken, which might be due to her consciousness against pain. It has to be remembered that abdominal cramping, watery stool and severe dehydration are the common clinical manifestations of viral gastroenteritis (Chen et al., 2017). Fever in gastroenteritis is due to the inflammation in the stomach (Dalby-Payne & Elliott, 2011). Pain due to inflammation in stomach can be defined by the fact that when inflammation occurs the chemicals from the white blood cells are released in to the blood and the tissues causing swelling (Caperell, Pitetti, & Cross, 2013). Swelling might push against the nerve endings to send pain signals, thus causing pain. Fever is also an innate response towards any inflammation in the body (Kim, 2013).
It has to be remembered that both adults and children have a compromised immune system that makes them susceptible to all kinds of infections (Chen et al., 2017). It can be seen that diarrhea and vomiting have disrupted the electrolytic balance of the body that has led to hypotension. High respiratory rate and heart rate can be due to an impaired availability of oxygen in the body (Farthing et al., 2013).
As per the case study it can be seen that George McAdams already has a past medical history of GORD or gastro-esophageal reflux disease. Acid reflux has been found to generate symptoms of severe abdominal pain, watery stool and vomiting (Katz, Gerson & Vela, 2013). This is mainly caused when due to the weakening of the ring of the bottom of the esophagus, due to which the esophagus might lose its functionality and might cause esophageal spasms (Katz, Gerson & Vela, 2013). It is evident that similar to Anna George also cannot tolerate oral fluid and had been suffering from severe dehydration. The vital signs as stated in the case study are- Temperature 38.2 C, HR 108 (irregular), BP 105/60, RR 22, and SpO2 99%. Although both Anna and George had been suffering from abdominal cramp but the pathophysiology of each of the condition are different. In GERD the lining of the stomach weakens that causes the food and the stomach acid to go back in the esophagus and the mouth of the patient (Whitehurst, Mcgivern & Carbunaru, 2013). It has to be mentioned that GERD worsens with age and due to age related physiological changes, such as thickening of the esophagus muscles, becomes sensitive due to decades of acid reflux (Katz, Gerson & Vela, 2013).
Development of SMART goals
Development of the SMART goals helps critically decide some specific goals that are measurable, acceptable and realistic and time bound. The importance of the setting appropriate goals for the patients had been regarded as an essential step in the NMBA nursing standard. As per standard 5 of nursing it is essential to assess the patient and plan the goals before implementation (Nursing and Midwifery Board of Australia – Professional standards, 2018).
SMART goals for Anna is to decrease the abdominal cramping within the next 4-5 hours, to an intensity of 4 out of 10 by pain management medication like paracetamol and fluid restoration therapy . The specific goal is to reduce the pain. The reduction in the pain intensity can be measured by pain assessment scale. The goal is achievable as orally supplemented paracetamol shows its analgesic effect within 4- 6 hours and reduces pain and fever.
Similarly the SMART goals for George are to reduce the pain by the 2 out of 10 by the administration of the Tylenol orally within 5-10 hours. The goal is measurable as any reduction in the pain can be evident from the pain assessment scale. This would help in the reduction of the pain sensation by blocking the release of the prostaglandins in brain. The goal is realistic as administration of Tylenol would help to subside the pain in George within an hour.
The chosen priorities for drawing the interventions are pain management for both Anna and George. However due to the different clinical issues of the two patients the strategies might differ slightly.
The first step is the pharmacologic management of pain. Hence initially it is necessary to assess the amount of pain followed by proper dosage of paracetamol, considering her age and the risk factors (Macaluso & McNamara, 2012). Dosage calculations should be done using proper algorithms and should be cross-checked to prevent any drug related adverse reactions (Kim, 2013). The rationale for choosing paracetamol for Anna is that it is a non-opoid analgesic with least side effects( Parashar, Nelson, & Kang, 2013). Dosages for the paracetamol should be as per the weight of the child are an important step while giving paracetamol. Patient less than 50 kg is limited to 3gms (Binder, Brown,Ramakrishna, & Young, 2014).
The case study also states that Anna had been suffering from fluid volume deficit. Patients experiencing vomiting can become dehydrated and experience abdominal pain (Binder, Brown,Ramakrishna, & Young, 2014). Hence it is necessary to monitor the urinary output, electrolytes in the patient (Farthing et al., 2015). Children who are severely dehydrated should be given with isotonic solutions (normal saline 0.9% or Ringer’s Lactate) (Farthing et al., 2015).
Nursing interventions for pain management
Similarly for George one of the interventions is the management of abdominal pain. In order to manage pain in George Tylenol could be given (Katz, Gerson & Vela, 2013). Tylenol belongs to a class of analgesics that reduces the formation of the prostaglandins in the brain and helps in reducing the pain. Hence adjusted dosages of Tylenol could be given to the George. Furthermore it has to be mentioned that Elderly people already suffer from various complications related to adverse drug reactions. Tylenol as a pain reliever has been found to have very little side effects.
The second intervention for George is the electrolyte therapy to restore the fluid balance (Hooper et al., 2012). 20–25 ml/kg/day fluid for older patients should be taken in to consideration. 25–30 ml/kg/day sodium chloride 0.18% in 4% glucose with 27 mmol/l potassium per day can administered to patients of George’s age. Excess amount of fluid might lead to urinary incontinence (Macaluso, & McNamara, 2012).
The outcome measure of the treatments can be understood by the use of the pain score assessment. FLACC scale can be used for Anna for understanding any reduction in the pain and Numeric rating scale can be used by George to describe any reduction in the pain (Stevens et al., 2014). It is the duty of the nurses to assess pain or provide nursing interventions like application of pain medications and rehydrating the patients. For appropriate interventions nurse are required to practice evidence based practice applying their critical thinking skills and clinical reasoning (Nursing and Midwifery Board of Australia – Professional standards., 2018). This is in compliance with the NMBA nursing standards that ensure nurses to perform assessment perfectly and then apply evidence based practice.
Conclusion
In conclusion it can be said that in spite of the clinical symptoms remaining same the clinical of each of the patients are different and the difference in the intervention is much due to the difference in the age and tolerance level. Pain management and maintaining the electrolyte balance to reduce the pain can be considered as the first line of nursing interventions for patient suffering from abdominal pain. The dosage of both the medications and fluid therapy depend upon the condition, age and the weight of the patients. However, a comparison of two case studies has helped to identify the underlying pathophysiology of each of the condition and implement the nursing NMBA standards in the evidence based practice. Such a study will be of immense importance in the future professional practice.
Nursing interventions for electrolyte therapy
References
Binder, H. J., Brown, I., Ramakrishna, B. S., & Young, G. P. (2014). Oral rehydration therapy in the second decade of the twenty-first century. Current gastroenterology reports, 16(3), 376. https://doi.org/10.1007/s11894-014-0376-2
Bresee, J. S., Marcus, R., Venezia, R. A., Keene, W. E., Morse, D., Thanassi, M., … &Slutsker, L. (2012). The etiology of severe acute gastroenteritis among adults visiting emergency departments in the United States. Journal of Infectious Diseases, 205(9), 1374-1381.doi: 10.1097/MPG.0000000000000375
Caperell, K., Pitetti, R., & Cross, K. P. (2013). Race and acute abdominal pain in a pediatric emergency department. Pediatrics, peds-2012. https://pediatrics.aappublications.org/content/early/2013/05/15/peds.2012-3672.short
Chen, S. Y., Tsai, C. N., Lee, Y. S., Lin, C. Y., Huang, K. Y., Chao, H. C., … & Chiu, C. H. (2017). Intestinal microbiome in children with severe and complicated acute viral gastroenteritis. Scientific reports, 7, 46130. Retrieved from https://www.nature.com/articles/srep46130
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
Churgay, C. A., & Aftab, Z. (2012). Gastroenteritis in children: part I. diagnosis. American family physician, 85(11), 1059. https://doi.org/10.1016/j.ajem.2012.05.056
Dalby-Payne, J. R., & Elliott, E. J. (2011). Gastroenteritis in children. BMJ clinical evidence, 2011. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275314/
Farthing, M., Salam, M. A., Lindberg, G., Dite, P., Khalif, I., Salazar-Lindo, E., …&Krabshuis, J. (2013). Acute diarrhea in adults and children: a global perspective. Journal of clinical gastroenterology, 47(1), 12-20. doi: 10.1097/MCG.0b013e31826df662
Hooper, L., Abdelhamid, A., Attreed, N. J., Campbell, W. W., Channell, A. M., Chassagne, P., …& Gaspar, P. M. (2015). Clinical symptoms, signs and tests for identification of impending and current water?loss dehydration in older people. Cochrane Database of Systematic Reviews, (4). DOI: 10.1002/14651858.CD009647
Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the diagnosis and management of gastroesophageal reflux disease. The American journal of gastroenterology, 108(3), 308. https://www.nature.com/articles/ajg2012444
Kim, J. S. (2013). Acute abdominal pain in children. Pediatric gastroenterology, hepatology & nutrition, 16(4), 219-224. https://doi.org/10.5223/pghn.2013.16.4.219
Macaluso, C. R., & McNamara, R. M. (2012). Evaluation and management of acute abdominal pain in the emergency department. International journal of general medicine, 5, 789. doi: 10.2147/IJGM.S25936
Nursing and Midwifery Board of Australia – Professional standards. (2018). Retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx
Parashar, U. D., Nelson, E. A., & Kang, G. (2013). Diagnosis, management, and prevention of rotavirus gastroenteritis in children. Bmj, 347(7204), 1-10. doi: 10.1097/MCG.0b013e31826df662
Stevens, B. J., Harrison, D., Rashotte, J., Yamada, J., Abbott, L. K., Coburn, G., … & Le May, S. (2012). Pain assessment and intensity in hospitalized children in Canada. The Journal of Pain, 13(9), 857-865. https://doi.org/10.1016/j.jpain.2012.05.010
Whitehurst, T. K., Mcgivern, J. P., & Carbunaru, R. (2013). U.S. Patent No. 8,452,407. Washington, DC: U.S. Patent and Trademark Office
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