Case Study 7 Online Case Study Nursing Assessment

Case Study 7

Case Presentation and Discussion

Barry is an 80-year-old male who was admitted for treatment of intravenous (IV) antibiotics for pneumonia and medical management of his rapid atrial fibrillation (RAF). Barry’s medical history included AF, hypertension, bowel cancer, colectomy in 2012 and hemorrhoids. During his admission Barry complained of abdomen pain; these cues were acted on with diagnostic tests finding a small bowel obstruction (SBO) with fecal loading distal to the obstruction. Barry had a nasogastric tube (NGT) inserted on free drainage, was ceased nourished and receiving IV therapy. The surgical team determined Barry was not a surgical candidate. Azagury et al. (2015) confirm non-operative management of SBO entails insertion of NGT, pain control, serial physical examination, fluid replacement and correction of any electrolyte in balances.

As the patient was for non-operative management of his SBO, my nursing assessment and interventions were focused on pain management, improving comfort and assessing for clinical deterioration. My nursing assessment began on inspection of Barry, I noted he looked extremely uncomfortable, was agitated, extremely pale, clammy, diaphoretic and groaning. Barry complained of pain in his abdomen and nausea. He rated his pain in numerical format, a subjective, five out of ten. As summarised by Topham and Drew (2017), a one-dimensional scale (like the numerical rating scale) does not adequately portray the complexity of the pain experience for the patient. The figure is a piece of data that needs to be put into context to create meaningful assessment information (Topham& Drew 2017). I continued with my nursing assessment to add context and cues to his situation to assess past the one figure for a more comprehensive pain assessment (Morone& Weiner 2013).

On auscultation of his bowel, I recorded two sounds within one minute; the sounds were low in intensity and sluggish. While hypoactive, this result was expected within the context of SBO, fecal loading and medical history of a partially resected transverse colon due to cancer in 2012. Breum et al. (2015) found an assessment of bowel sounds through auscultation to be generally low in accuracy with varying results depending on the assessor; however, I still included this skill in my assessment.  I softly palpated his abdomen and noted tightness and distension across the entire width. Barry found my palpation exasperated his pain when palpating the left upper quadrant.  He described the pain as sharp and constant. I aspirated his NGT tube, to assess for blockages, confirming patency. I aspirated an additional 50ml of green fluid and documented on his fluid balance chart. I assisted in repositioning Barry in assessing the severity of his hemorrhoids and skin integrity. Administration of PR aperients had been unsuccessful due to the inflammation around his anus causing difficult access. I noted fresh, frank blood at the site. 

 I assessed his vital signs as; a respiratory rate of 22, Sp02 of 93% on high flow oxygen via the Airvo set at 50 litres flow, 21% Fi02, blood pressure of 172/95, an irregular heart rate between 100-150bpm, temperature of 36.7, adequate urine output per hour (the patient had an indwelling catheter), and a subjective pain rating of five out ten. Barry had been digoxin loaded and was being treated with a beta blocker for his heart rate; his heart rate was trending up from assessing the previous hours on the dangers observations chart. A correlation between the presence of pain and hypertension and tachycardia is well accepted, as the autonomic nervous system may be activated during exposure to pain (Arbour et al. 2014). I feel in this patient’s scenario; his pain was well represented in his vital signs, and he was underrepresenting this using the numerical rating scale.

By undertaking the above nursing assessments, I was able to add cues to the information I already had received from handover reports and the patient charts to form a solid understanding of Barry’s current presentation (Levett-Jones et al. 2010). Recalling knowledge of anatomy and pathophysiology was crucial for understanding his SBO, and the poor outcomes associated with his extensive fecal loading and the present inability to provide adequate aperients or surgical input. The risks of an untreated bowel obstruction include intestinal strangulation, necrosis, and perforation (Breum et al. 2015); as a result, my nursing goal and main priority for Barry was to ensure his pain was adequately managed to provide comfort in a situation that was rapidly shifting to palliative approach. My assessments and advocacy lead to the patient being assessed by the acute pain team, a syringe driver introduced and with consent from the patient a referral being made to the palliative care team.

References

Arbour, C, Choinière, M, Topolovec-Vranic, J, Loiselle, CG &Gélinas, C 2014, 'Can Fluctuations in Vital Signs Be Used for Pain Assessment in Critically Ill Patients with a Traumatic Brain Injury?', Pain Research and Treatment, vol. 2014, p. 175794.

 Azagury, D, Liu, RC, Morgan, A & Spain, DA 2015, 'Small bowel obstruction: A practical step-by-step evidence-based approach to evaluation, decision making, and management,' Journal of Trauma & Acute Care Surgery, vol. 79, no. 4, pp. 661-668.

Breum, BM, Rud, B, Kirkegaard, T &Nordentoft, T 2015, 'Accuracy of abdominal auscultation for bowel obstruction,' World Journal of Gastroenterology: WJG, vol. 21, no. 34, pp. 10018-10024.

 Levett-Jones, T, Hoffman, K, Dempsey, J, Jeong, SY, Noble, D, Norton, CA, Roche, J & Hickey, N 2010, 'The 'five rights' of clinical reasoning: an educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients', Nurse Education Today, vol. 30, no. 6, pp. 515-520.

 Topham, D & Drew, D 2017, 'Quality Improvement Project: Replacing the Numeric Rating Scale with a Clinically Aligned Pain Assessment (CAPA) Tool,' Pain Management Nursing, vol. 18, no. 6, pp. 363-371.