NRSG378 Principles of Nursing Extended Clinical Reasoning Assessment Answer

Disease Pathophysiology and Patient Assessment

Kate Sansbury is a 22 year old female with complains of abdominal pain, nausea, vomiting and malaise. The pain initiated 3 days ago which could be managed through heat pack but late night, she experienced sharp abdominal pain. She has voided only once yesterday and her urine was found to be dark yellow in colour. Other physical features that were found due to the above problem were distended abdomen, cool and clammy skin, 8/10 pain on the lower right quadrant and mild work of breathing. Based on laboratory test examination, she was diagnosed with secondary peritonitis. The most common cause of secondary peritonitis is perforated appendicitis and it accounts for 1% of all urgent hospital admissions. It is a condition that leads to the inflammation of the peritoneum and secondary peritonitis takes place due to direct contamination of the peritoneum by spillage from gastrointestinal tract or any other organs. The mortality rate in secondary peritonitis depends on various factors such as patient’s age, presence of other cardiovascular or renal disease, severity of peritonitis and a non-appendicular source of infection (Ross, Matthay & Harris, 2018; Clements et al., 2021).

The pathophysiology of the condition involves the inflammatory response of the peritoneum to chemical and bacterial agents invading the peritoneal cavity. The peritoneum is a membrane that lines the abdominal wall and it is formed from monolayer of mesothelial cells. It creates a semi-permeable barrier through which water and solutes are exchanged. The peritoneum responds to bacterial agents by attempting to localize the infection. The bacteria spilled into the region can be recognized by innate immune response. The initial stage leads to influx of macrophages and increase in production of pro-inflammatory cytokines such as interleukin 1 and tumor necrosis factor. The inflammation of the region contributes to tissue edema, development of exudate and hypermotility of the intestinal tract. With the progression of the disease, the intestinal fluid leaks into the peritoneal cavity. This shift in fluid is the cause behind poor cardiac output and decrease in tissue perfusion leading to impaired cardiac and renal function (Ross, Matthay & Harris, 2018). Because of this change, Kate was found to have high heart rate and C-reactive protein. The inflammatory response is the cause behind sharp abdominal pain which was experienced by Kate too. According to Delibegović (2022), some of the microbial flora that leads to this type of infection are polymicrobial, polyaerobic and polyanaerobic flora. From the above discussion, it is identified that the macrophages play a critical role in coordinating overall inflammatory response.

Some of the nursing assessment that is important for Kate are as follows:

• Physical assessment to evaluate presence of tachycardia, hypotension, palpation to assess tenderness and listening to bowel sounds
• Taking medical history of patients and looking for presence of conditions such as ruptured appendix, acute necrotizing pancreatitis, peptic ulcer disease and cholecystitis
• Diagnosis test such as urinalysis, ABG values, serum test and abdominal x-ray examination and chest x-ray examination.

Identify Nursing and Patient Issues

Based on the evaluation of patient’s assessment results and lab-test results, three nursing issues have been identified that could affect the patient and increase risk for complications. The first high priority nursing issue is the risk of infection evidenced by increase in heart rate and breathing rate and decrease in urine output. This needs to be prioritised because it may lead to worsening of peritonitis. The desired outcome for Kate will be heart rate of 100 bpm or less, urine output of at least 30ml/hour and minimal tenderness during palpation. Currently, all these values were found to be abnormal for Kate and it reflects presence of peritonitis. Hence, the nursing priority will be strictly monitor patient and prepare patient for surgery. The study by Clements et al. (2021) shows that secondary peritonitis may lead to risk of septic shock for patient who do not receive any treatment. Severe sepsis can complicate the course of disease and even lead to mortality. Kate’s C-reactive protein value was also elevated during treatment and evidence shows that CRP value becomes high during peritonitis because of the inflammation (Keskin Gözmen & Serdaroğlu, 2023). Hence, such patients may require pharmacological intervention immediately.

The second nursing issue that has been identified is the presence of acute pain. The primary complain of Kate during ED admission was abdominal pain which she was experiencing since 3 days and this became sharp. It is a critical issue because on assessment, the patient pain level was found to be 8/10 on the right lower quadrant and it was worsening. Thus, pain management should be prioritized because it can worsen prognosis and lead to physical distress for Kate. Kumar et al. (2021) explain various causes behind acute pain such as irritation of the peritoneum due to bacteria, tissue trauma and abdominal distention. Thus, controlling pain and promoting comfort for patient is important. Thirdly, the patient is at risk of psychological distress due to lack of knowledge about the disease. She is taking drinks and smoking marijuana which can affect her surgical outcomes. Thus, prioritizing health education and education about the disease of patient is important.

Currently Kate has been hospitalized due to secondary peritonitis and she is undergoing preparation for emergency appendectomy and peritoneal cleanout. This process can affect her two important activities of living. Firstly, it will affect her part-time work and education. Currently, she is working part-time in a bookshop and she studies veterinary nursing full-time. Kate may lose her source of income and it may affect her studies as she will not be able to attend her placement which is due soon. Hence, it may increase distress level and affect her psychosocial life. Post-operatively, Kate will have to take rest at home for many days and it may lead to income and productivity loss. The productivity loss could be due to absenteeism from workplace and failure to attend important events. It can create financial pressure and make the patient vulnerable to stress (Hah et al., 2021). In addition, appendectomy and hospitalization may lead to activity limitation which could affect independence of patient and her quality of life. Previous, Kate was physically active and she was doing exercise four days a week. However, prolonged hospitalization could affect her physically and lead to decrease in functional capability. It may lead to weight gain and other problems for her.

Discuss the Pharmacological Management

Kate was diagnosed with secondary peritonitis and pharmacological intervention needs to be prioritized to provide immediate relief from symptoms and control infection rates. The common pharmacological intervention for management of peritonitis is antibiotic therapy. The cefotaxime is effective against 98% of causative organism. Badawy et al. (2013) shows that cefotaxime as a first line therapy for bacterial peritonitis. It is a beta-lactam antibiotic which is classified as a third-generation cephalosporin. This drug is approved to treat gram-positive, gram-negative and anaerobic bacteria. It is useful in treating strains of bacteria in the lower respiratory tract, intra-abdominal infections, septicaemia and joint infections. The drug exerts it action by binding with penicillin-binding proteins (PBPs) via beta-lactam rings and inhibiting the activity of transpeptidation in peptidoglycan cell-wall synthesis. It demonstrates affinity for PBPs cell wall proteins. It contributes to inability to form a bacterial cell wall that can lead to autolysis of the bacteria. Some important nursing consideration is giving patient education on adverse effects and contradication to penicillines. Hence, Kate needs to be checked for penicillin infection. In addition, the dose needs to be adjusted for patients with renal and hepatic dysfunction. The nurse should also educate patient about the importance of adhering to treatment. Careful monitoring is also required during pregnancy (Padda & Nagalli, 2020).

Clindamycin is also a drug indicated for treatment of patient with secondary peritonitis. The drug is known to indicated for use in treatment of various types of infection such as septicaemia, lower respiratory infection and intra-abdominal infection. Clindamycin acts by inhibiting protein synthesis by binding to the 23S RNa of the 5S subunit. By this mechanism, it prevents peptide bond formation. During oral administration, absorption takes place when clindamycin palmitate hyrodlyzes to the gastrointestinal tract. It is then distributed across the body. Clindamycin bound to protein and metabolized in the liver by CYP 3A4 and CYP 3A5. The peak time of activity is within 60 minutes during oral administration. When giving intramuscularly, the peak concentration of the drug is achieved within 1-3 hours. Nurses should consider educating patient about adverse-effects such as erythema, burning and oily skin. There is a need to consider about the contraindications of drugs such as those with history of ulcerative colitis. The patient should be monitored for changes in bowel and resolution of symptoms. Kate should also be given fluid and electrolyte replacement therapy (Murphy, Bistas & Le, 2018).

Nursing Interventions

Kate is undergoing preparation for appendectomy. There are many important intervention that the patient will require in the first 24 hour after the surgery. The first important nursing intervention that needs to be prioritized is vital sign assessment of patient immediately after surgery. Documentation of vital sign in the post-operative phase is most important as it can help in predict complications. It can help to understand patient’s response to the surgery. During the first 24 hours, the observation should be done after every 15 minutes or frequently (Haahr‐Raunkjaer et al., 2022). In case of Kate, she needs to be actively monitored for presence of tachycardia and hypotension. Thus, it can contribute to risk of serious adverse events.

In addition, pain management should be prioritized in the first 24-hours. It would mean actively assessing patient for pain and administering opioid analgesic drugs. The study by () gives evidence on the use of multimodal analgesic treatment. Analgesic and local anesthetic is often administer in combination for treatment of post-operative pain. Use of morphine via PCA, local anesthetics and non-steroidal anti-inflammatory drugs can relieve pain in patients during the intra and post-operative phase (Alsharari et al., 2023). The main goal of post-operative pain management is to decrease negative consequences associated with acute post-surgical pain and support the patient to make a smooth transition to normal practice. For this reason, opioid analgesic therapy is main treatment for acute postoperative pain. Such intervention can minimize adverse outcome and also provide relief to patient from adverse physiologic effects. Similarly, for Kate, administration of analgesic drugs need to be prioritized (Waddimba et al., 2022).

The third high priority intervention is the administration of antibiotic to control infection after appendectomy. The common antibiotic drugs given to pfatients are metronidazole or ceftraizone after the first 48 hours after appendectomy. Evidence shows that around 25-30% of patients undergoing appendectomy suffers from increased risk of postoperative infection. Thus, perioperative antibiotic prophylaxis is important to control infection rates. Most of the guidelines recommend providing 5 days of postoperative antimicrobial therapy. It can be discontinued when the patient meets the discharge criteria (van den Boom et al., 2018). Thus, nurses have a critical role in timely administering antibiotics and evaluating outcomes such as risk of surgical site infection and length of hospital stay.

The fourth high priority intervention is management of wound sites and dressings. Use of aseptic non-touch technique is important for changing or removing dressing. The instruction of the physician is important to determine the way by which dressing should be addressed. Some wounds need to be untouched after 48 hours. Other wound can be cleaned using sterile saline. Patients in the post-operative period are at high risk of infection. The incision site is at high risk of contamination from bacterial. Proper wound dressing can avoid bacterial infection. Bandages made of soft materials are ideal for patient with appendectomy. The nurses have a duty to careful remove the bandage and put on fresh dressing without causing any damage to the incision site. Metronidazole solution can be used in the treatment and management of infection after appendectomy. It can applied either by infiltrating the wound or by simply washing the exposed wound tissue (Islam et al., 2020). 

References

Alsharari, A. F., Alshammari, F. F., Salihu, D., & Alruwaili, M. M. (2023, March). Postoperative Pain Management in Children Undergoing Laparoscopic Appendectomy: A Scoping Review. In Healthcare (Vol. 11, No. 6, p. 870). MDPI.

Badawy, A. A., Zaher, T. I., Sharaf, S. M., Emara, M. H., Shaheen, N. E., & Aly, T. F. (2013). Effect of alternative antibiotics in treatment of cefotaxime resistant spontaneous bacterial peritonitis. World Journal of Gastroenterology: WJG , 19 (8), 1271.

Clements, T. W., Tolonen, M., Ball, C. G., & Kirkpatrick, A. W. (2021). Secondary peritonitis and intra-abdominal sepsis: an increasingly global disease in search of better systemic therapies. Scandinavian Journal of Surgery , 110 (2), 139-149.

Clements, T. W., Tolonen, M., Ball, C. G., & Kirkpatrick, A. W. (2021). Secondary peritonitis and intra-abdominal sepsis: an increasingly global disease in search of better systemic therapies. Scandinavian Journal of Surgery , 110 (2), 139-149.

Delibegović, S. (2022). The pathophysiology of peritonitis. Veterinaria , 71 (2), 133-152.

Haahr‐Raunkjaer, C., Mølgaard, J., Elvekjaer, M., Rasmussen, S. M., Achiam, M. P., Jorgensen, L. N., ... & Aasvang, E. K. (2022). Continuous monitoring of vital sign abnormalities; association to clinical complications in 500 postoperative patients. Acta Anaesthesiologica Scandinavica , 66 (5), 552-562.

Hah, J. M., Lee, E., Shrestha, R., Pirrotta, L., Huddleston, J., Goodman, S., ... & Schofield, D. (2021). Return to work and productivity loss after surgery: a health economic evaluation. International Journal of Surgery , 95 , 106100.

Islam, A. M. M., Akhter, N., Imam, M. Z., Rahman, M., & Rumi, J. U. M. (2020). Efficacy of Local use of Metronidazole Solution among Acute Appendicitis Patients for the Prevention of Wound Infection after Appendectomy: A Randomized Control Trial. Journal of National Institute of Neurosciences Bangladesh , 6 (1), 54-58.

Keskin Gözmen, Ş., & Serdaroğlu, E. (2023). High C‐reactive protein and number of previous episodes at diagnosis increase the risk of catheter removal in peritoneal dialysis‐related peritonitis in children. Therapeutic Apheresis and Dialysis , 27 (2), 328-334.

Kumar, D., Garg, I., Sarwar, A. H., Kumar, L., Kumar, V., Ramrakhia, S., ... & Kumar, B. (2021). Causes of acute peritonitis and its complication. Cureus , 13 (5).

Murphy, P. B., Bistas, K. G., & Le, J. K. (2018). Clindamycin.https://www.ncbi.nlm.nih.gov/books/NBK519574/

Padda, I. S., & Nagalli, S. (2020). Cefotaxime. https://www.ncbi.nlm.nih.gov/books/NBK560653/#:~:text=Indications-,Cefotaxime%20is%20a%20beta%2Dlactam%20antibiotic%20classified%20as%20a%20third,%2Dnegative%2C%20and%20anaerobic%20bacteria.

Ross, J. T., Matthay, M. A., & Harris, H. W. (2018). Secondary peritonitis: principles of diagnosis and intervention. Bmj , 361 .

van den Boom, A. L., de Wijkerslooth, E. M., van Rosmalen, J., Beverdam, F. H., Boerma, E. J. G., Boermeester, M. A., ... & Wijnhoven, B. P. (2018). Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): study protocol for a randomized controlled trial. Trials , 19 (1), 1-10.

Waddimba, A. C., Newman, P., Shelley, J. K., McShan, E. E., Cheung, Z. O., Gibson, J. N., ... & Petrey, L. B. (2022). Pain management after laparoscopic appendectomy: Comparative effectiveness of innovative pre-emptive analgesia using liposomal bupivacaine. The American Journal of Surgery , 223 (5), 832-838. 

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