• Subject Name : Nursing

Old Patient with Nausea and Vomiting and The Role of The Registered Nurse

Introduction of Mr. Douglas Case Study

Mr. Douglas a 70-year-old man was admitted to the emergency department as he was feeling unwell for 4 days at home due to vomiting and nausea. His observations are temperature 39, respiratory rate 24, oxygen saturation 92%, heart rate 120, 7/10 abdominal pain, blood pressure 90/60. He had abdominal distention and the bowel did not open for the last 4 days.

Systematic Assessment

A systematic assessment in nursing and health care is used to optimize the management and patient care. The assessment strategies include focused assessments, head-to-toe assessments, and ABCDE assessments (Immonen et al. 2019).

Respiratory (RESP) Assessment

As the patient is having a habit of excessive smoking for the past 30 years so he will be assessed for his airways. The test conducted would assess the respiratory muscle strength, lung function test using a spirometer, chest X-ray, and measurement of chest expansion. It was found that his respiratory functions and lung strength were poor. The breathing rate will be recorded that found to be 24 that is quite high than the normal value of 12-18 as the airways are inflamed (Riess et al. 2018).

Cardiovascular system (CVS) Assessment

Cigarette smoking developed free radicals on the vascular system that affected respiratory muscles with reduced blood supply. The circulatory system will also be assessed in which heart rate was found to be 120 which is a high value than the normal value of 60-80 beats per minute (Garrison et al. 2017). Smoking increases the heart rate as major arteries are tightened resulting in abnormal heart rhythm. It also changes blood pressure and the test showed a very low BP of 90/60 mmHg and low BP often leads to nausea. A cardiac output assessment test will also be conducted as a smoking old patient often has poor output values.

Kidney (RENAL) Assessments

A urine output assessment test will also be conducted as a smoking old patient often has poor output values. A normal value of 2.2 l/day is expected but as the patient is an alcoholic so his values will be different/high (Zhang et al. 2017). The patient will be assessed for blood glucose levels (BGL) of 90-120 mg/dl as with age the BGL varies (Zhang et al. 2017). His sodium, albumin, potassium levels will be assessed as the patient is an alcoholic and smoking addict.

Central nervous system (CNS) Assessment

As the patient is a long-term smoker and beer intake is also high so for his CNS assessments, a CT scan, arteriogram, and electroencephalography (EEG) will be taken for secondary assessments. The expected values of a normal old patient are – EEG 9.46 Hz (Biswas et al. 2019). This test detects the brain activity and smoking decreases it whereas in alcoholic patients the values are elevated.

Abdominal (ABDO) Assessment

As the patient is having no bowel movement for the last 4 days so he will be assessed for constipation. A detailed assessment of the stool and conduction of the digital rectal exam will provide detailed information about the problems faced by the patient. As per the patient’s condition, it is expected that he might show a dark-colored stool. In the case of an abdominal assessment, the patient will be checked for palpation of the abdomen to identify if there is any pain or not.

Other Assessments

The other assessments can be vitamin-D blood tests as a smoking or alcohol addict patient often has low levels of vitamin-D. ECG can also be performed to test heart function and it is expected that a patient like Mr. Douglas will show heart-related problems like elevated heart rate or less oxygen availability of the heart. A cut-annoyed-guilty-eye (CAGE) test can also be performed with Mr. Douglas. It is a simple test containing a questionnaire to know about the problems associated with alcohol (Lamichhane et al. 2019). This feedback from the patient can be very helpful to plan the treatment and management café plans for him. As the patient had a history of diverticulitis so a CT scan will ensure that whether he had developed this health issue again or not.

Priorities of Treatment

The priority for treatment is for the high respiratory rate. It can be treated by using an inhaler like albuterol as it opens the airways or administration of beta-blockers like bisoprolol or atenolol. As the patient is suffering from nausea and vomiting it is the role of a registered nurse (RN) to ensure that the patient’s body is getting proper oxygen levels. According to Kandula et al. (2019), the RN should do the following steps in beta-blockers administration: monitoring of older patients for the occurrence of mental confusion after administration, monitor/evaluation of the side-effects if any and check for allergies. The nursing interventions for a patient with nausea and vomiting are frequent liquid meals, educate the patient to avoid smell or food that causes nausea and a frequent blood electrolyte check-up. According to Riess et al. (2018), in the management of patients with nausea and vomiting sometimes the use of anti-anxiety drugs like benzodiazepines can play an important role as it also helps in making the patient feel more relaxed and calm. As the common causes of nausea and vomiting are fluids and electrolyte imbalance or infections and as the patient is also a smoker and alcohol addict so it should be ensured that there is no intake of alcohol or cigarettes by the patient, as these factors can deteriorate his health. 

The other priority is the treatment of low blood pressure for which the doctor or registered nurse (RN) should administer him with drug midodrine to elevate the still blood pressure and drug fludrocortisone to raise the blood pressure. These drugs restrict the blood vessels from expanding resulting in high blood pressure (Garrison et al. 2017). Low blood pressure can induce the feeling of nausea so the roles of RN in such cases are: the blood pressure should be checked before and after medication/drug administration and maintaining a proper documented ISBAR. This ensures that there is effective information transfer from one health care service provider to another ensuring effective and quality care of the patient. According to Lacy et al. (2018), a patient with low BP and vomiting issues should be provided with more fluids, the RN should conduct regular blood tests and ECG to explore the progress report. The management of such patients may include advice to wear compression stockings and regular exercises. The RN should also keep assessing for diarrhea and fever as the patient is suffering from vomiting. In evaluation, the RN should regularly monitor the vital signs like blood pressure, urinary output, heart rate, and many others.

Another priority is for the treatment of high heart rate for which Mr. Douglas should be administered with anti-arrhythmic medications in combination with beta-blockers and calcium channel blockers to normalize the elevated heart rate. Moreover, catheter ablation can also be used if the patient does not show positive outcomes of drug therapy to reduce his high heart rates (Packer et al. 2018). A pacemaker can also play an important role in treating high heart rates. According to Biswas et al. (2019), the RN should monitor the signs and symptoms for cardiac dysrhythmias, regular heart rate check-up before and after drug/medicine administration. The RN should assess for chest pain, cardiac output, and conduct cardiac imaging to evaluate the progress of the patient. While using the pacemaker for the patient the RN should ensure that there is no risk of injury or infection to the patient. If the patient is administered with calcium channel blockers then there should be regular monitoring of edema, dyspnea, and other related health complications. According to Packer et al. (2018), the older patient has a decreased sense of thirst so the patient should be encouraged and monitored those he intakes more liquid. This will help in improving the bowel movement of the patient and maintain the balance disturbed due to vomiting as well.

Another priority is the treatment of bowel movement. As the patient is having no bowel movement for the past 4 days and facing vomiting issues as well so good monitoring of his fluid-electrolyte balance can help in treating him. After he had his first stool, a stool examination should be conducted, and accordingly, the medications should be changed. A regular abdominal X-ray should be performed to assess the health status of the patient. According to Fakhr-Movahedi et al. (2016), effective communication in older patient care is very important for their improved health and effective care services. The older patients should be given more time for their feedbacks, the RN should sit and talk face-to-face to the patients and ensure the patient involvement in decision-making so that the collaborative efforts of patients and health professionals can result in positive outcomes and delivery of quality care. According to Zhang et al. (2017), in old patients, the intake of fresh and dried fruits, nuts, high-fiber foods, beans, and a sufficient amount of water can help in stimulating bowel movements. However, it should be ensured that the patient does not involve smoking or alcohol intake. If the patient continues to have chronic constipation problems then the patient can be provided with stool softeners, laxatives like senna, ex-lax, or others, and non-absorbable solutions (Zhang et al. 2019). Moreover, all the patient information should be with the patient about his treatments, with senior doctors and other associated health professionals. According to Fakhr-Movahedi et al. (2016), while managing the care for old patients the RN needs to ensure family involvement as well so that the old patient does not feel lonely and he/she should be provided with care for daily activities like feeding, turning and motion. The patient should be under 24/7 supervision and it should also be ensured that there is of risk of fall/injury to him/her and any other risk of infections so a regular track of health status needs to be maintained and documented.

Discharge Planning

A discharge plan is to be prepared as soon as the patient is admitted to the hospital. It is planned as per the health status and the progress report of the patient. If the patient is has shown improved results and is almost well then he/she can be discharged as per the discharge plan guidelines. In this case, after the bowel movement starts and problems of nausea and vomiting are resolved with all the vital signs like BP, BGL, heart rate, and others under normal range the patient can be discharged. According to Nelson (2012), self-determination – the patient and health professionals should ensure that everyone is involved in the evaluation and informed decision-making process. So that even at the patient’s residence he receives quality care by evaluating his vital signs regularly and informing the nurse if any health deterioration occurs with a regular visit to the physician. The patient is not well educated so that care plans should be well explained to him as well his family members so that after discharge he does not face any issue, thereby maintain equity. He should be advised to do regular exercises, no smoking, no alcohol, no meal/medicine skipping, and his family members should be asked to ensure/monitor the same. As the patient is old so he should be supported and treated with respect and dignity, ensuring the right and access principles, in his daily medication administration or other activities. 

References for Mr. Douglas Case Study

Biswas, D., Karabin, B. and Turner, D., 2019. Role of nurses and nurse practitioners in the recognition, diagnosis, and management of neurogenic orthostatic hypotension: A narrative review. International Journal of General Medicine, vol. 12, pp.173. https://dx.doi.org/10.2147%2FIJGM.S170655

Fakhr-Movahedi, A., Rahnavard, Z., Salsali, M. and Negarandeh, R., 2016. Exploring nurse’s communicative role in nurse-patient relations: A qualitative study. Journal of Caring Sciences, vol. 5, no.4, pp.267.https://dx.doi.org/10.15171%2Fjcs.2016.028

Garrison, S.R., Kolber, M.R., Korownyk, C.S., McCracken, R.K., Heran, B.S. and Allan, G.M., 2017. Blood pressure targets for hypertension in older adults. Cochrane Database of Systematic Reviews, no. 8, pp. 1-43. https://doi.org/10.1002/14651858.CD011575.pub2

Immonen, K., Oikarainen, A., Tomietto, M., Kääriäinen, M., Tuomikoski, A.M., Kaučič, B.M., Filej, B., Riklikiene, O., Vizcaya-Moreno, M.F., Perez-Cañaveras, R.M. and De Raeve, P., 2019. Assessment of nursing students' competence in clinical practice: A systematic review of reviews. International Journal of Nursing Studies, vol. 100, pp.103414. https://doi.org/10.1016/j.ijnurstu.2019.103414

Kandula, M., Karthika, P. and Abraham, R., 2019. Nurses action towards cardio vascular emergencies. Asian Journal of Nursing Education and Research, vol. 9, no. 1, pp.121-126.http://dx.doi.org/10.5958/2349-2996.2019.00024.7

Lacy, B.E., Parkman, H.P. and Camilleri, M., 2018. Chronic nausea and vomiting: evaluation and treatment. American Journal of Gastroenterology, vol. 113, no. 5, pp.647-659. http://dx.doi.org/10.1038/s41395-018-0039-2

Lamichhane, N., Thapa, D.K., Timsina, R.R., Shrestha, L.V., Sharma, R. and Subedi, A., 2019. Problematic alcohol use in Pokhara, Nepal as assessed by CAGE questionnaire. Journal of Psychiatrists' Association of Nepal, vol. 8, no. 1, pp.55-60.https://doi.org/10.3126/jpan.v8i1.26338

Nelson, K. J., 2012. A good practice guide: Safeguarding student learning engagement. Retrieved from:http://safeguardingstudentlearning.net/wp-content/uploads/2012/04/LTU_Good-practice-guide_eBook_20130320.pdf

Packer, D.L., Mark, D.B., Robb, R.A., Monahan, K.H., Bahnson, T.D., Moretz, K., Poole, J.E., Mascette, A., Rosenberg, Y., Jeffries, N. and Al-Khalidi, H.R., 2018. Catheter ablation versus antiarrhythmic drug therapy for atrial fibrillation (CABANA) trial: Study rationale and design. American Heart Journal, vol. 199, pp.192-199. https://doi.org/10.1016/j.ahj.2018.02.015

Riess, H., Ay, C., Bauersachs, R., Becattini, C., Beyer-Westendorf, J., Cajfinger, F., Chau, I., Cohen, A.T., Khorana, A.A., Maraveyas, A. and Renni, M., 2018. Use of direct oral anticoagulants in patients with cancer: practical considerations for the management of patients with nausea or vomiting. The Oncologist, vol. 23, no. 7, pp.822-839. http://dx.doi.org/10.1634/theoncologist.2017-0473

Zhang, Y., Xia, X. and Zhuang, X., 2018.Effect of quantitative assessment‐based nursing intervention on the bowel function and life quality of patients with neurogenic bowel dysfunction after spinal cord injury. Journal of Clinical Nursing, vol. 27, no.5-6, pp.e1146-e1151. https://doi.org/10.1111/jocn.14198

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