medical/ surgical case study - lacey hastings,...

Running head: MEDICAL/ SURGICAL CASE STUDY 1

Medical/ Surgical Case Study

Lacey Hastings

Stenberg College

Medical/ Surgical Nursing Practice Theory

NURS 201-3

MEDICAL/ SURGICAL CASE STUDY 2

Medical/ Surgical Case Study

This case study was written to provide an in depth analysis of one of the writer’s patients

on the medical unit of Nanaimo Regional General Hospital.

Identifying Data and General Description

For confidentiality purposes the client will be referred to as only L.W. L.W. is a 31 year

old Caucasian European Canadian female, married with 1 child. She is an accountant, a non-

smoker, and non-drinker, and lives a healthy lifestyle. L.W. is fit, and takes care of her body. She

is a tall woman, with a fair complexion, and appears well put together prior to admission.

Chief Complaint/ History of Present Illness

The primary complaint that brought L.W. to the hospital was viral diarrhea, and what

appeared to be a reaction to a medication (Keflex). L.W had oral ulcers, a rash on her face, chest

and stomach, as well as an abscess on her thigh and stomach, and a fever (38). L.W. was

admitted with the diagnosis of diarrhea/SIRS (systemic inflammatory response syndrome)

(Nanaimo Regional General Hospital, 2013). L.W had nausea and vomiting upon admission to

the medical unit, and shortly began passing blood from her bowels (1-2 cups) and vomiting

blood/sputum. L.W. was in ‘agonizing’ pain, with the oral ulcers, and ‘gut wrenching’ pain in

her stomach.

At the beginning of L.W. stay, the hospitalists were unsure what was exactly going on,

was this in fact a drug reaction from the Keflex that was prescribed just before the diarrhea

started, or was it a coxsackievirus (hand foot- and- mouth disease)-which was the initial

diagnosis. However towards the end of L.W. stay she was noted to be diagnosed and treated for

inflammatory colitis or ‘inflammatory bowel disease’ (NRGH, 2013).


Past Medical/ Surgical History and Allergies

L.W. has a history of anxiety and depression, this was noted to be ‘significant’ in her

chart (NRGH, 2013). L.W. also has asthma, however does not currently take medication or use

an inhaler, and she has no acute signs or symptoms. She has eczema, and suggests she has ‘very

sensitive skin’. L.W.’s father also has a history of depression, and irritable bowel disease; which

she claimed not to be aware of prior to her diagnosis of inflammatory bowel disease.

L.W. does not have a surgical history, however underwent procedures while on the

medical floor that I will include. She had a CT scan of her chest, abdomen, and pelvis, which

showed diffuse thickening of the colon and rectum consistent with infectious or inflammatory

colitis (NRGH, 2013). She also had a sigmoidoscopy done; a sigmoidoscopy is a procedure in

which the inner lining of the lower large intestine is examined. Flexible sigmoidoscopy is

commonly used to evaluate gastrointestinal symptoms, such as abdominal pain, rectal bleeding,

or changes in bowel habits (WebMD, 2013). During the procedure, a doctor uses a

sigmoidoscope, a long, flexible, tubular instrument about 1/2 inch in diameter, to view the lining

of the rectum and the lower third of the colon (the sigmoid colon) (WebMD, 2013). The photos

and biopsy showed query severe inflammatory bowel disease (NRGH, 2013).

L.W. allergies to medications include: Erythromycin, Cephalexin, and although not added

or clarified, potentially Keflex. There is no food allergies known at this time.

Disease Process

Please see the attached Appendix A , Table 1 and 2 for Disease Processes.


Medications

The medications that L.W. is currently taking at home include Valcyclovir an antiviral

for the sores in her mouth; Valcyclovir decreases the severity and length of these outbreaks. It

helps the sores heal faster, keeps new sores from forming, and decreases pain (WebMD, 2013).

Tramadol, which is an opioid analgesic used to treat moderate-severe pain, and previously

Keflex which is an antibiotic used to fight bacteria and treat infection (WebMD, 2013).

The medications that L.W. received in the hospital included in the table below

Drug: Generic/ Trade Classification Route Dose & Frequency

Time Major side effects Reason for medication

Ceftriaxone/rocephin Cephalosporin-

antibiotic

IV 1g- Q24

hr.

0900c-diff(diarrhea), allergic reaction, seizures, chest pain, trouble breathing

Suspected infection- this was d/c shortly after starting

Fluconazole/diflucin Azole Antifungal

PO 200mg 0900 Severe stomach/abdominal pain, nausea/vomiting, fast/irregular heartbeat, fainting

Treat fungal and yeast infections. Sores in mouth

Benzydamine/difflam-hydrochloride

Locally acting non-steroidal anti-inflammatorywith local anesthetic and analgesic properties

PO

Rinse

PRN PRN Nausea or vomiting, burning, or numbness in mouth, throat irritation.

relieves pain and inflammation associated with a sore throat or mouth sores

Nystatin/nilstat antifungal PO

liquid

100,000 units

0900

1300

1800

Diarrhea, nausea or vomiting

Used to treat fungus infection of the mouth

Morphine Opioid/narcotic PO PRN PRN- Allergic reaction, To treat


q 4

hours

slowed heartbeat, shortness of breath, severe vomiting, decreased awareness or responsiveness, fever

Moderate-severe PainStomach and mouth sores

Acetaminophen/Tylenol

Antipyretic/ analgesic

PO PRN PRNToo much acetaminophen may cause serious (possibly fatal) liver disease and liver problems. Persistent nausea/ vomiting.

fever

Dalteparin/fragmin type of heparin

Anticoagulant ‘blood thinner’

injection 5000 IUOnce daily

1600 Unusual or prolonged bleeding, unusual or easy bruising, unusual pain or swelling, allergic reaction, fainting, seizures.

Treat/prevent blood clots

Dimenhydrinate/gravol antiemetic IV PRN PRN Constipation, dizziness, allergic reaction, confusion, blurred vision, difficulty passing urine

Nausea and vomiting

zopliconeSedative hypnotic PO

5mgHS

2100 Behavior changes, confusion, anxiety, wheezing, tightness in chest

short-term and symptomatic relief of sleep disturbances

(Vallerand & Sanoski, 2013)

Nursing Physical Assessment

While competing a head-to-toe assessment, L.W. temperature was 38, radial pulse was

80, strong and regular, Respirations were easy at 16 per minute. BP was 108/71. Neck veins flat

at 45 degree angle. Apical pulse S1, S2 clear without rubs or murmurs. Radial and pedial pulses


strong and regular. L.W. was alert and oriented x4, she was pleasant and calm. Her hand and leg

strength was strong bilaterally. Capillary refill to hands and toes returns 2 sec. bilaterally. Skin

turgor returns less than 1 second, skin is warm, but very pale, rash on face, abscess on buttocks

and thigh. Lung sounds clear bilaterally, good air entry, oxygenation- 97 on room air. Pt. c/o not

being able to void this a.m. Bowel sounds present and active x 4 quadrant; pt. having diarrhea,

with blood approx. 1-2 cups, frank red. Nausea and vomiting present. No peripheral edema. L.W.

c/o pain in mouth (sores), 8/10, throbbing pain, worse when eating and drinking; also c/o pain in

stomach, 7/10, ‘gut wrenching’ pain, worse with diarrhea and vomiting.

Lab Results

The out of range significant lab results from L.W stay at the hospital are provided in the

table below

Lab Test Normal Range Clients’ results

Purpose of the test Indications about the client

Hemoglobin120 to 155 grams per liter)

105 To assess overall health. Usually done as part of complete blood count (MayoClinic, 2013)

Could indicate anemia. L.W.Was losing blood due toInflammatory bowel disease.

RBC’s3.90-5.03 trillion cells/L

3.34Typically ordered as part of a complete blood count (CBC) and may be used as part of a health checkup to screen for a variety of conditions (Mayoclinic, 2013)

Anemia- Blood loss

WBC’s 3.5-10.5 billion cells/L

11.5Complete Blood Count Inflammation- Inflammatory

Bowel disease

(MayoClinic, 2013).

Treatment


While L.W. was in the hospital she was receiving antifungals, antibiotics, antiemetics,

pain control and towards the end when finding out she had inflammatory bowel disease she was

started on a steroid for inflammation (NRGH, 2013). She was on continuous IV D5NS w 40 meq

KCL @ 125 ml which is used for fluid and electrolyte replenishment and caloric supply (RxList,

2013). She was given a regular diet and then switched to a small pureed diet which was easier on

her mouth and her stomach, and she was seeing a dietician while on the floor (NRGH, 2013). We

were taking L.W. vitals BID and temp QID, and continuously monitoring her nausea, vomiting,

diarrhea, and pain. We were monitoring her hemoglobin and RBC’s, as she was losing blood

through her bowels and vomiting. L.W. was mainly on bed rest , with activity as tolerated

(AAT). We assisted her with ADL’s, however she is a young woman and independent so we set

up her hygiene supplies and she did this on her own. L.W. would get very anxious about being in

the hospital and not knowing what was wrong, and her heart would start “racing”, so we spent

some time teaching her about deep breathing, and relaxation techniques. L.W. was involved in

her care; she wanted to know what she was taking, and why she was taking it. She would involve

in her care and treatment, she wanted to know everything that was going on, what her tests

results were, what her vitals were, etc. She would notify us of any changes that she noticed or

felt, and would let us know what PRN’s were working for her and which weren’t, what we could

do to make her comfortable, etc. There was good communication with L.W. and a definite ‘team’

approach.

Teaching, and Discharge Planning

Upon finding out that L.W. in fact has inflammatory bowel disease, which was inflamed,

L.W. was discharged to Victoria General and referred for tertiary care to see a gastroenterologist

(NRGH, 2013). Thus the discharge instructions will come from the specialist at Victoria


General, she would follow up with her GP. Just prior to her discharge from NRGH L.W. was

started on hydrocortisone IV, a steroid for inflammation (NRGH, 2013).

Writer’s Reflection

This was a very interesting case, and I learnt a lot while caring for this patient, and while

reflecting and analyzing through this case study. This case was so interesting because it was a

mystery at the beginning, what was happening to this poor lady? When she came to the hospital

she was sure it was a reaction to an antibiotic, she had a rash, fever, nausea, vomiting, diarrhea,

and thus this seemed to be the first consensus. However after being on the floor, the consensus

changed to the thought of her having hand-foot-and-mouth disease or ‘coxsackie’ virus. It

seemed as though this ladies whole body was under attack, she was placed on contact precaution,

as they weren’t sure whether this was a contagious virus. When L.W. started passing a lot of

blood through her bowels, and then vomiting with blood, the consensus again shifted. I quickly

noticed it is like putting pieces together in a puzzle. You have to look at the whole picture, piece

by piece to get a good idea of what is going on.

With vitals, assessments, lab values, tests, and procedures (Ct scan, sigmoidoscopy), the

pieces start to come together. Thus L.W. was diagnosed with inflammatory bowel disease. What

I did learn was that with inflammatory bowel disease, the digestive system becomes scarred due

to excessive inflammation, and ulcers can develop (NHS, 2013). Over time these ulcers develop

into tunnels, or passageways, that run from one part of your digestive system to another or, in

some cases, to the bladder, vagina, anus or skin- these passageways are known as fistulas (NHS,

2013). Larger fistulas can become infected and cause symptoms such as: a constant, throbbing

pain , a high temperature (fever) of 38°C (100°F) or above , and blood or pus in your faeces

(stools) (NHS, 2013). Fistula can also develop on your skin, as well as skin lumps or sores-


which could be the explanation for the abscesses present on her buttocks and thigh. (NHS, 2013).

With this inflammation or obstruction from inflammatory bowel disease, one can also feel

nausea/vomiting, and have abdominal pain and cramping (NHS, 2013). Although the exact cause

of her mouth ulcers were not determined I did find some resources that note mouth ulcers can be

symptoms associated with inflammatory bowel disease (Medline Plus, 2013; Mayo Clinic,

2013).

Thus I was able to see the connections of some of the complications of inflammatory

bowel disease, and some of L.W. signs and symptoms. Finally the puzzle came together, and she

was able to get the treatment she needed.

Priority Nursing Diagnosis and Goals

Please see attached the attached Appendix B for a short term nursing diagnosis and goal,

Appendix C for a long-term nursing goal, and Appendix D for a community focused nursing

goal.

References


Lewis, S. L., Heitkemper, M. M., Dirkson, S. R., Butcher, L., & O’Brian, P. G. (2010). Medical-

surgical nursing in Canada assessment and management of clinical problems (2nd ed.).

Toronto, Canada: Mosby Elsevier.

MayoClinic. (2013). Inflammatory bowel disease (IBD). Health Information. Retrieved from:

http://www.mayoclinic.com/health/inflammatory-bowel-disease/DS01195

MedlinePlus.(2013). Crohn's disease. National Insititute of Health. Retrieved from:

http://www.nlm.nih.gov/medlineplus/ency/article/000249.htm

National Health Service. (2013). Crohn's disease – Complications. Retrieved from:

http://www.nhs.uk/Conditions/Crohns-disease/Pages/Complications.aspx

Stuart, G. (2009). Principles and Practice of Psychiatric Nursing. (9th ed). St.Louis, Missouri:

Mosby Elesvier.

Vallerand, A.H., Sanoski, C.A. (2013). Davis’s Drug Guide for Nurses. (13th ed). Philadelphia,

PA: F.A. Davis Company

WebMD. (2013). Inflammatory Bowel Disease Health Center. Retrieved from:

http://www.webmd.com/ibd-crohns-disease/


TEXTBOOK DESCRIPTION OF DISEASE PROCESS

CLIENTS PRESENTATION OF DISEASE PROCESS

Diagnosis-

Inflammatory Bowel Disease

Diagnosis-

Inflammatory bowel disease

Etiology/ Pathophysiology-Disorder of the gastrointestinal tract, characterized by idiopathic inflammation and ulceration (Lewis et al, 2010).Causes remain unknown, potential causes are infectious agents, autoimmune responses, environmental influences, or genetics (Lewis et al, 2010)

Etiology-

Dad has irritable bowel syndrome

Clinical Signs and symptoms-Bloody, diarrhea and abdominal pain are the major symptoms; other symptoms include fever, fatigue, weight loss, anemia, and dehydration.

Clinical Signs and symptoms-

Bloody diarrhea, abdominal pain, fever, vomiting, mouth ulcers, abscesses, fatigue, dehydration

Appendix A

Table 1- Disease Processes

DepressionEtiology/ PathophysiologyPsychiatric and medical illness. Significant abnormalities can be seen in many body systems, including electrolyte imbalances, neuropsychological alterations, dysfunction or faulty regulation of ANS activity, adrenocortical, and thyroid changes, and neurochemical alterations in neurotransmitters (Stuart, 2009). Causes are unknown, can be life events, genetics,, medical comorbidity etc.

Etiology-

Again, father had depression. Possible life events- this was not clarified

Clinical signs and symptoms-Feelings of sadness or unhappiness, feelings of helplessness or worthlessness. Irritability, anxiety, agitation, trouble thinking or slowed thinking, indecisiveness, change in appetite, etc. (Stuart, 2009).

Clinical signs and symptoms-Anxiety, fatigue and change in appetite- although this was due to her medical condition. Unhappiness and sadness, was partly due to hospitalization and being sick, however could be partly due to depression.


TEXTBOOK DESCRIPTION OF DISEASE PROCESS

CLIENTS PRESENTATION OF DISEASE PROCESS

Diagnosis- Anxiety (Generalized) Diagnosis- Anxiety

Etiology/ Pathophysiology-Psychiatric disorder involves excessive, unrealistic worry and tension (Stuart, 2009). May be caused by environmental factors, medical factors, genetics, brain chemistry, substance abuse or a combination of these (Web MD, 2013).

Etiology-Unknown.

Could be from depression, could be genetics. Seems to be worse while in hospital, could be related to medical factors.

Clinical Signs and symptoms-Restlessness, on edge, fatigue, difficulty concentrating-mind going blank, ongoing worry, muscle tension, irritability (Stuart, 2009).

Clinical Signs and symptoms-Worry, restlessness, heart racing, trouble breathing.

Table 2- Disease Processes continued

Nursing Diagnosis

Related To:Etiology/Risk

Factors

Defining (S/S) Characteristics

Desired Outcomes (Goals) Interventions

Rationale forInterventions


Diarrhea Inflammation, irritation- Inflammatory Bowel Disease.

Frequent and persistent watery stools.

Blood mixed with diarrhea.

Abdominal pain-urgency and cramping

L.W. will report reduction in frequency of stools, return to more normal stool consistency.

Identify/avoid contributing factors.

1.Observe and record stool frequency, characteristics, amount, and precipitating factors

2.Promote bed rest, provide bedside commode.

3.Identify foods and fluids that precipitate diarrhea, e.g., raw vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products

4.Restart oral fluid intake gradually. Offer clear liquids hourly; avoid cold fluids.

5.Observe for fever, tachycardia, lethargy, leukocytosis, decreased serum protein, anxiety, and prostration.

1.Helps differentiateindividual disease and assesses severityof episode.

2.Rest decreasesintestinal motility and reduces the metabolic rate when infection or hemorrhage is a complication. Urge to defecate may occurwithout warning andbe uncontrollable,increasing risk of incontinence/falls iffacilities are not close at hand.

3.Avoiding intestinal irritants promotes intestinal rest.

4. Provides colon rest by omitting ordecreasing the stimulus of foods/fluids. Gradual resumption of liquids may prevent cramping and recurrence ofdiarrhea; however,cold fluids canincrease intestinal motility.5. identify toxicMegacolon orPerforation/peritonitis

Appendix B

Table 3- Short term care plan for L.W.

Appendix C

Table 4-Long term care plan for L.W


Nursing Diagnosis


Factors


Desired Outcomes

(Goals)Interventions

Rationale for Interventions

Pain- Acute Hyperperistalsis

prolonged diarrhea

skin/tissue irritation,

perirectal excoriation,

fissures and fistulas

Mouth sores

(Inflammatory Bowel disease)

Colicky/cramping- abdominal painPt. states ‘gut-wrenching pain’8/10

Stinging, burning pain in mouth (sores), unable to eat. 8/10

Restlessness

Facial grimacing- non- verbal expressions of pain

L.W. will report pain is relieved and controlled.

She will appear relaxed and able to sleep/rest appropriately

1-Encourage L.W. to report pain.

2. Utilize PRN’s- morphine, Tylenol, and antifungal mouth rinses

3. Review factors that aggravate or alleviate pain.

4. Note nonverbal cues, e.g., restlessness, reluctance to move, abdominal guarding, withdrawal, and depression. Investigate discrepancies between verbal and nonverbal cues

5. Provide comfort measures (e.g., back rub, reposition) and diversional activities

6. Implement prescribed dietary modifications, e.g., commence with liquids and increase to solid foods as tolerated.

1 she may try to toleratePain, rather than requestAnalgesics.

2.Control, relieve pain

3. May pinpointprecipitating oraggravating factors(such as stressful events,food intolerance) oridentify developing complications.

4. Body language &nonverbal cuesmay be both physiological and psychological andmay be used inconjunction with verbal cues to determine extent/severityof the problem

5. Promotes relaxation, refocuses attention, and may enhance copingabilities.

6. Complete bowel rest can reduce pain andcramping.

Appendix D

Table 5- Community care plan for L.W.


Nursing Diagnosis


Factors


Desired Outcomes (Goals) Interventions

Rationale forInterventions

Anxiety Threat to self-concept (perceived or actual)

Threat to/change in health status, socioeconomic status, role functioning, interaction patterns (new diagnosis)

Pain- abdominal

History of anxiety and depression

Exacerbation of acute stage of disease

Increased tension and distress

Heart racing- expressed concerns about her health and being in the hospital/ changes (new diagnosis)

Increased pulse rate

Obsessing over signs and symptoms

L.W. will appear relaxed and report anxiety reduced to a manageable level.

L.W. will verbalize awareness of feelings of anxiety and healthy ways to deal with them.

1.Note behavioral clues, e.g., restlessness, irritability, withdrawal, lack of eye contact, demanding behavior.

2.Encourage verbalization of feelings. Provide feedback.

3.Acknowledge that the anxiety and problems are similar to those expressed by others. Actively-Listen to L.W. concerns.

4. Help L.W. identify/initiate positive coping behaviors used in the past

5. Assist L.W. to learn new coping mechanisms, e.g., stress management techniques (deep breathing, imagery, etc.).

1.Indicators of degreeof anxiety/stress

2.Establishes atherapeutic relationship. Assists L.W. in identifying problemscausing stress.

3. Validation thatfeelings are normalcan help reduce stress/isolation

4. Successfulbehaviors can be fostered in dealing with current problems/stress, enhancing L.W.’ssense of self-control.

5.Learning new waysTo cope can be helpful in reducingstress and anxiety- andenhancingdisease control; whenin the community

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