Nursing- Mr Barker- Case Study -Assessment Answer

Nursing Case Study Assignment

Case Scenario

Mr Barker is a 48-year-old male who presented to the Emergency Department (ED) four months ago with an anterior ST segment elevation myocardial infarction (STEMI). He was thrombolysed at your hospital and referred to a tertiary referral hospital for a rescue Percutaneous Coronary Intervention (PCI). He was successfully re-vascularised and discharged home on a regime of aspirin 100mg daily, prasugrel 10mg daily, Atorvastatin 40mg daily, Metoprolol 50mg bd and Lisinopril 5mg daily.

Mr Barker decided to celebrate his successful recovery post MI with a holiday in Bali. All went well until the last couple of days of his holiday, when he became unwell with nausea, vomiting and diarrhoea. His illness had settled after a week of rest at home. For the past two days Mr Barker has had intermittent chest pain with no radiation but he has felt nauseated. When assessed (using PQRST) he states the pain is scoring 8/10, worse at night, burning in nature and he has slight relief after drinking milk. His vital signs on admission are BP 119/68, heart rate 46bpm, temp 36.8, SpO2 100% on room air and respiratory rate of 16 breaths per minute.

According to the hospital policy, Mr Barker’s pain is treated as chest pain; however, normal ECG’s and negative troponins over the past twenty-four hours have excluded this as a cause of his pain. Mr Barker has been admitted to your ward for management of his pain. On his last admission, Mr Barker’s blood results showed haemoglobin level of 14.4 g/dL, platelets 268× 10⁹/Land normal white cell count. On this admission his haemoglobin is 11.3 g/dL, platelets 204× 10⁹/Land white cell count 12.7× 10⁹/L.

Overnight Mr Barker complains of lower abdominal pain and urgency to move his bowels, but he has not yet been able to pass a stool, just flatus. Approximately 2 hours later your colleague notices he has been missing from his bed for some time. When she checked the bathroom she found Mr Barker slumped on the toilet. He was cool, pale and sweaty but rousable. There was faecal matter in the toilet mixed with a large volume of frank blood

Mr Barker’s vital signs at this time are BP 67/39, heart rate 100bpm, temp 35.1, SpO2 89% on room air and respiratory rate of 29 breaths per minute. The medical team urgently assesses Mr Barker, a fluid resuscitation is commenced and Mr Barker is taken for an urgent endoscopy. During the endoscopy Mr Barker is found to have two actively bleeding gastric ulcers. During the endoscopy these are injected with adrenaline and the bleeding has now ceased. Mr Barker was also found to have helicobacter pylori present in his gastric ulcers.

Mr Barker’s condition was stabilised, he commenced a regime of antibiotics to treat the helicobacter pylori and discharged home after a few days.

Assignment Task

Part A:

Develop a concept map using the information from the case study that demonstrates:

Your understanding of the pathophysiological processes associated with active gastrointestinal bleeding;

Integrates your assessment data from Mr Barker’s case study which impact on the patient’s problems; (Mr Barker’s medical and social history for example: lifestyle, culture, age and ethnicity and activities of living should be considered when you assess to identify the patient’s problems).

Part B:

Consider how you will develop a person centred holistic care planusing the information in the case study. Write up the care plan in the form of a report giving a rational for the issues you have chosen to include in the care plan. A minimum of four (4) issues/problems needs to be considered, these should take into account age, socio economic status, patient education needs and pathophysiology.

Points to consider:

• You must use current literature, less than 10 years old, textbooks, journal articles and/or other peer-reviewed resources.
• No more than three (3) web-based resources are to be used for this assignment.

Introduction

he need for comprehensive extra nursing care

Mr. Barker will be accorded utmost care to ensure that he recuperates from active gastrointestinal bleeding. It is important to consider the age, socio-economic status, patient education needs and patho-physiological factor in the course of providing the patient with care. First, there is need for patient comfort. The therapy can be done through analgesia. The care-provider should be good at airway, breathing, and circulation resuscitation. Additionally, the car will involve continuous assessment of the patient’s fluid and electrolyte status. The assessment is vital given the fact that the bleeding can sometimes be caused by a different ailment other than gastrointestinal bleeding. Therefore, it is important for the caregiver to engage the nurse in case of any deviation of the patient’s response to the care given. The patho-physiological process should be understood by the caregiver to enhance accurate monitoring of Mr. Barker. Such bleeding can arise from alcohol abuse hence the need for continuous monitoring of the patient’s progress. The other issue to consider in the curse of caring for Mr. Barker is risk stratification.

Risk of underlying ailments

According to Starling et al (2014, p.37),the use of the Glasgow Blatchford score is vital in the assessment of all gastrointestinal bleeding patients. The risk assessment process will serve as a satisfactory way of managing the gastrointestinal ailment of the patient. A thorough assessment including duodenal and gastric ulcer tests should be done to ensure that they do not result in the bleeding. Moreover, Mallory-Weiss syndrome and pre-endoscopic therapy can cause bleeding. For instance, a pre-endoscopic therapy, which involves an unusually high dosage of PCI requires clinical assessment. The Glasgow Blatchford model proposed a prediction of death among the GI patients. The assessment was based on the severity of the ailment and the frequency of bleeding experienced by the patient. Endoscopy should be applied to Mr. Barker in case the bleeding persists. The patent should also be provided with liver, eggs, milk and fortified breakfast cereals. The food will help the patient recover from blood loss. Moreover, marmite and meat will helps the patent recover from blood loss. Mr. Barker requires continuous monitoring and attendance of the clinic because of his condition. The expenditure on the GI patient increase with age hence Mr. Barker’s care will be expensive because of his age, 48 years old. Villanueva et al (2013, p.19) asserts that more than 50% of people over 45 years old require further therapy on gastrointestinal bleeding. The personalized care of the patient will include regulated exercising.

The clinical and endoscopic procedures are vital caring for the patient. In fact, hospitalization of Barker will not be required because the patient is stable. Continuous administration of antibiotic regimens is vital. The age of Barker makes his condition worse because the care provided to the elderly is expensive and requires specialized care. Additionally, the testing for any cormobidity disease is vital because it helps in sustaining the stability of the patient. Moreover, the patient will require an assessment, which will establish low-risk endoscopic findings. Transfusion should be minimized to provide an opportunity for the patient to naturally recover from the ailment. There is need for a regular determination of hematocrit and haemoglobin levels. The initiative is important because it helps in ascertaining the state of the patient at a particular time. The testing also informs the medic of the need for transfusion. In fact, the essence of the acre provided is prevention of re-bleeding given that bleeding is the major effect of GI. The care provided for Mr. Barker will enhance efficient utilization of the hospital resources.

The histamines are responsible for the acceleration of acid production in the stomach. The other antibiotic which can be used to treat the H.pylori infection is the Bismuth subsalicylate. It functions through the coating of ulcers. Additionally, the drug protects from stomach acidity. It is vital for the patient to undergo H.pylori test after four weeks of hospitalization. Such a test confirms whether the treatment done was successful or otherwise. It can provide reliable information pertaining to the response of Mr. Barker to drugs. The care provided will also underscore the risk of re-bleeding. The patient has a history of bleeding. For this reason, there is a high likelihood that re-bleeding will occur. For this reason, it is prudent to explore alternative therapy on re-bleeding prevention. The education level of the patient determines guaranteed recuperation from GI. The reckless use of over-the-counter drugs is fatal. Some pharmacists do not provide prior information even to the elderly, pertaining to the side-effects of using non-steroidal non-inflammatory drugs. The general education on certain drugs is important because some rogue pharmacists provide inadequate and misleading information with an aim of generating drug revenues. It is important to solicit funds for the medical sustenance of Mr. Barker because of the extra care required for prevention of any imminent bleeding.

High cost of care

The caring of the patient is expensive because Barker will also require surgical repair of perforated viscous. The antibiotics administrated to the patient should be prescribed by the medic subject to the stage of recuperation of the patient. The use of percutaneous corollary intervention is vital to ensure that Barker is free from segment elevation myocardial infarction. The initiative ensures that thrombus formation does not occur. In this regard, continuous monitoring and testing of segment elevation myocardial infarction should be done. In case of a positive test on the ailment a PCI will be conducted and aspirin 100mg daily, prasugrel 10mg daily, Atorvastatin 40mg daily, Metoprolol 50mg bd and Lisinopril 5mg daily provided (Holst et al, 2014, p.1387). The other form of care necessary for the patient will be the catheter insertion for the purpose of monitoring hemodynamic cardiac performance. The procedure is vital because it protects the patient from the reaction of any underlying diseases including the segment elevation myocardial infarction to the drugs of treating H.pylori infection. Moreover, there is need for Foley catheter placement for a continuous evaluation of the urinary performance (Villanueva et al (2013, p.17). The initiative is vital because it provides reliable information pertaining to renal perfusion. Additionally, the endoscopic haemostatic therapy is vital in case of re-bleeding of Barker.

The elective performance of endoscopy is cost effective because the patients are provided with alternatives to hospitalization. Most cases of bleeding are attributed to the peptic ulcer disease. The bleeding is caused by non-steroid non-inflammatory drugs. Moreover, H.pylori infection caused Barker’s bleeding. In this regard, non-steroidal no-inflammatory drugs are offered to the old without proper guidance and prescriptions. Barker’s case is also related to the excessive in-take of such drugs. Unfortunately, the in-take of such drugs forms part of the many causes of GL besides the H.pylori infection. However, for the case of the patent H.pylori infection and gastric ulcers were identified as the cause of bleeding. According to Starling et al (2014, p.33),it is imperative to offer a GI patient the appropriate antibiotic drugs including the proton pump inhibitors. The drugs are vital in the treatment of GI because they stop the production of acid from the stomach. Additionally, Histamines blockers can be used in the course of offering post-admission care upon Mr. Barker.

Obsession with leisure

Restraining Barker from trips until he is stable and cleared by a medic will serve as a therapy. The move will provide ample opportunity for the body to respond to the drugs while the patient is monitored. Intermitted chest pain is a symptom of GI. Therefore, the caregiver should report a similar complaint by the patient to his doctor. The assumption the hospital had that Baker had chest pain was wrong. For this reason, it is vital to establish the actual cause of ay mild discomfort while under the outpatient care. A decrease of blood level should be countered with infusion of the endoscopic fluid. The prompt infusion will ensure a sustainable blood level hence a reduction of collapsing. A faecal matter mixed with frank blood is an indication of gastrointestinal bleeding. Therefore, the caregiver should take note of such an eventuality. The inability to pass stool was a serious impairment, which the medics could have prioritized. Therefore, Barker should be rushed to hospital in case he is cool, has lower abdominal pain and urgency to move his bowels and pale.