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NURS2007 Integrating Theory and Practice Case Study Assignment Answers

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Task 1: Identification of Symptoms

Cholecystitis can be identified by the physician by analyzing specific signs and symptoms among the patients and with the assistance of certain clinical tests. As per the case study, Rube was facing severe pain and a sensation of clutching was faced by the patient at her upper abdominal area. Additionally, the diagnosis has shown that she has a pain of 10/10 which indicates the extreme severity of the pain and the patient has shown that the prime centre of the pain is the upper quadrant area of her abdomen. Chan and El-Banna (2018) have researched this field and have mentioned that the pain in the central and upper right part of the abdomen is the major sign of gallbladder inflammation. Martelli and Lee (2016) have added that the pain of Cholecystitis may radiate to the back or the right shoulder of the patient. However, in this case, the patient has not indicated the radiation of the pain to the mentioned zone but she has described the pain as a horrible cramp. The patient has felt the sensation of stabbing. As per the idea of Chawla et al. (2015), inflammatory pain often feels like stabbing with a sharp object and is abrupt or sudden in nature. This is true for the cramp that has been faced by Ruby and this is one of the major symptoms which indicate the occurrence of Cholecystitis.

On the other hand, the occurrence of Cholecystitis has been assured with the identification of Murphy’s sign. As per the viewpoint of Sekimoto and Iwata (2019), the hand should be placed at the costal margin of the right upper arm and the patient has to take a deep breath. In this context, Dhir and Schiowitz (2015) have added that this manoeuvre creates severe pain with the presence of gallbladder inflammation, and the individual catches the breadth when the inflamed organ descends. However, no such feelings tackles place in the left part of the body with the same test which confirms acute Cholecystitis. As per the research paper of Poddighe and Sazonov (2018), vomiting and nausea is one of the major signs of gallbladder inflammation with repetitive upward peristaltic movement. The case study has revealed that the patient has vomited on and off for the last 12 hours. This sign has also indicated the occurrence of Cholecystitis.

Task 2: Pharmacological and Non pharmacological Therapies

Pharmacological therapies

The case study of Ruby Diamond, a patient of 43 years has been provided to analyze and identify the symptoms for diagnosis of Cholecystitis. As per the viewpoint of George et al. (2019), Cholecystitis is such a health issue that triggers inflammation of the gallbladder and formation of gallstone as well. In the previous section, the occurrence of excruciating stabbing cramp in the right upper quadrant of the abdomen has been identified. It is the responsibility of the caregiver to provide relief from the physical discomforts in the acute stage by treating as per the sign and symptoms of the clinical issue. Hence, in this case also, pain management is the major task which should be performed at the initial condition to make the part stable for further treatment. As per the idea of Hanson et al. (2018), The application of the analgesics of opioid groups helps in the management of moderate to severe pain.However, in the case of Ruby, a Morphine pain killer cannot be administered as the patient is allergic to the same. Hence, painkillers other than the said one can be administered of an open group. As per Liu et al. (2019) ibuprofen is one of the major analgesics of the opioid family which helps in the minimization of inflammation and pain. 200 mg IV Ibuprofen solution should be administered for 4 hours to minimize the acute severity of the pain.

On the other hand, the management of frequent vomiting and nausea should be managed. This can be helped with the administration of antiemetics molecules. As per the viewpoint of Besinger and Stehman (2016), an antiemetic drug is applied in the management of the upward peristalsis, nausea with various causes like motion sickness, stomach infection, inflammation to any part of the digestive system, morning sickness as well. The side effect of opioid drugs also invokes the issue of nausea which can be managed with the administration of antiemetics. Dopamine antagonists, Meclizine, serotonin 5-HT3 receptor antagonists are the different types of antiemetics used for the management of nausea for different causes. However, in this case, serotonin receptor antagonists should be administered and ondansetron should be the best option to manage the vomiting issue of Ruby. As per the view of Halushko et al. (2019), ondansetron is the competitive serotonin receptor (type 3) that helps in the minimization of nausea by blocking the initiation of serotonin reflex of vagal afferent in the small intestine of the patient. The case study revealed that the patient has suffered from the symptom of vomiting for the last 12 hours. Hence, it can be mentioned that in the minimization of the initial acute condition IV administration of ondansetron should be done followed by oral administration of the same.

Non-pharmacological therapy

Heat compress helps in the management of gallbladder pain. As per the viewpoint of Taavoni et al. (2016), heat therapy is done to manage pain as the enhancement of temperature of the painful area leads to the enhancement of the blood circulation. This leads to muscle flexibility and minimization of the sensation of the pain. The discomfort of the paint can be reduced and this provides relief from pain. As per the idea of Manworren (2015), in the case of gallbladder pain, the application of heat compress with a wet towel, heating pad or hot water bag can be done. This helps in the minimization of the spasm in the painful area for bile build up.

On the other hand, the implementation of distraction therapy can be done. As per the idea of Bukola and Paula (2017), distraction therapy is used to distract the mind of the patient with certain orgher agents in order to provide psychological comfort to the patient with excruciating pain. The exercise of controlled breathing and counting can be done, to distract Ruby from the feeling and agony of pain. The patient can be involved in the process of listening to music in order to distract her mind from the feeling of pain.

Task 3: Root Cause

It has been identified that Ruby Diamond is associated with the regular intake of oral contraceptive pills. As per the viewpoint of Gómez-Ramos et al. (2019), regular medication with oral contraceptives increases the risk of gallbladder inflammation and the development of gall stone as well. Progesterone and estrogen have a negative impact on the gall bladder of an individual and this promotes the formation of gallstones. As per the research work of Wilkins et al. (2017), the higher activity of estrogen initiates the increment in the formation of cholesterol and its subsequent precipitation inbile. This factor leads to the development of gallbladder stones and the occurrence of gall bladder stone initiates Cholecystitis. Additionally, Chauhan et al. (2019) has mentioned that the gallbladder motility is also enhanced with the activity of progesterone. This factor impedes the flow of bile juice and triggers the development of gall stone. Thisfactor has acted as a promoting aspect for the development of Cholecystitis of Ruby.

The age factor of the patient is one of the major aspects which trigger the issue of Cholecystitis.

 As per the idea of Shields and Sidhu (2018), the women above 40 are at high risk in the development of gall bladder issue and gall stone as well. Women having children above forty but lower than 50 are highly tagged with the risk of development of gallbladder inflammation. This has happened for Ruby. Additionally she has taken away the meal twice in a week. This has triggered a food gap which has initiated Cholecystitis.

Task 4: Essay

Introduction

Cholecystitis is one of the major diseases tagged with the inflammation of gallbladder and with the development of gall stone. This is widely noticed among the women of above forty. The aspects like overweight, food gap, fertility and age are the major factors that impart the threat over the health of gall bladder and bile secretion. Most of this site has been noticed for the patient, Ruby Diamond, of the provided case study. The target of this study, is to analyze the treatment process of the acute Cholecystitis of the mentioned patient and to evaluate the benefits and risks of the same.

Discussion

The application of the drugs of the opioid group has been thought as the best option for minimization of the pain for the patient. The management of the pain issues of visceral origin and even the pain of cancer can be managed with the administration of opioid painkillers. Baldo and Rose (2020) has analyzed the pharmacokinetics of opioid drugs and have mentioned that the drug influences the Serotonin kinetics. The serotonin reuptake inhibition is done by this molecule or intra-synaptic serotonin gets increased by inhibiting gamma-aminobutyric acidergic presynaptic inhibitory neurons. This minimizes the sensation of pain in the body by intervening within the pain pathway. Hence, from this angle, it can be mentioned that the selection of opioid treatment is beneficial for the patient. However, the opioid drug application has some side effects which include high acid reflux and gastritis. Additionally, the issue of nausea and vomiting may take place. The patient is already in the condition with an acute urge of upward peristalsis. Hence, this side effect may invoke risk for the management of the patient.

On the other hand, distraction therapy is suitable for the child patients and is not for the adult patients. Hence from this angle, this non pharmacological intervention may not help the patient to a higher extent. Additionally, the heat therapy may invoke damage to the tissue of the body and can create negative impact over the gall blade inflammation. Hence, from this angle, it can also be analyzed that this type of therapy may invoke risk and subsequent deterioration of the patient. Hence, this type of therapy should be replaced and managed with pharmaceutical interventions. The application of tranquilizers may help the patient to get rid from the sensation of pain and vomiting. Hence, this can also be done to manage the initial acute stage of Cholecystitis.

Conclusion

At the concluding section, it can be commented that the treatments process of the patient have both beneficial risk aspects. The administration of opioid drugs helps in the minimization of pain. However, opioid drugs also have negative effects which include acid reflux, nausea which should be managed. However, the modulation of the pain pathway helps in the providence of instant pain relief to the patients and this is needed to manage the acute condition of Ruby Diamond. Additionally, it has been identified that distraction therapy is not that much applicable for the adult patients as the process has less response in the adult psychology. Hence, an alternative should be frame d to manage the non-pharmaceutical approach of therapy.

Recommendation

Gastric irritation and vomiting are the major side effects tagged with the opioid administration. This could be managed with charging of acid-blocker and antiemetics molecules. As per the suggestion of Çelebi (2016), the management of acid reflux can be done with the acid blockers like esomeprazole, Rabeprazole, omeprazole or pantoprazole. This should also help in the digestion of the patient and to minimize the nausea as well. In the case of any intolerance regarding the opioid drug, the painkiller of other groups rather than opid can be administered. This includes the use of acetaminophen, which may help the patient. Antiinflammatory drugs for gallbladder may be prescribed.

In the context of distraction therapy, the application of radio-wave for pain minimization or binaural frequency therapy can be recommended. This may help the adult patient to get relief for the time being. This should help in the management of the patient more efficiently from different angles.

Reference

Baldo, B.A. and Rose, M.A., 2020. The anaesthetist, opioid analgesic drugs, and serotonin toxicity: a mechanistic and clinical review. British Journal of Anaesthesia124(1), pp.44-62.

Besinger, B. and Stehman, C.R., 2016. Pancreatitis and Cholecystitis. Alcohol25(35), pp.9-12.

Bukola, I.M. and Paula, D., 2017. The effectiveness of distraction as procedural pain management technique in pediatric oncology patients: a meta-analysis and systematic review. Journal of Pain and Symptom Management54(4), pp.589-600.

Çelebi, A., Aydın, D., Kocaman, O., Konduk, B.T., Şentürk, Ö. and Hülagü, S., 2016. Comparison of the effects of esomeprazole 40 mg, rabeprazole 20 mg, lansoprazole 30 mg, and pantoprazole 40 mg on intragastrıc pH in extensive metabolizer patients with gastroesophageal reflux disease. Turk J Gastroenterol27(5), pp.408-414.

Chan, E. and El-Banna, A., 2018. A case report of epiploic appendagitis as a mimic of acute Cholecystitis. International journal of surgery case reports53, pp.327-329.

Chauhan, V.V., Shah, B.A., Mahadik, S.J. and Videkar, R.P., 2019. Evaluation of relationship of body mass index with severity of Cholecystitis. International Surgery Journal6(3), pp.868-875.

Chawla, A., Bosco, J.I., Lim, T.C., Srinivasan, S., The, H.S. and Shenoy, J.N., 2015. Imaging of Acute Cholecystitis and cholecystitis-associated complications in the emergency setting. Singapore medical journal56(8), p.438.

Dhir, T. and Schiowitz, R., 2015. Old man gallbladder syndrome: gangrenous Cholecystitis in the unsuspected patient population. International journal of surgery case reports11, pp.46-49.

George, J., Besant, S., Cleveland, T. and Al-Mukhtar, A., 2019. Pseudoaneurysm of the Inferior Pancreaticoduodenal Artery Due to Cholecystitis. Reports—Medical Cases, Images, and Videos2(1), p.11.

Gómez-Ramos, J.J., Ascencio-Rodríguez, M.G., Marín-Medina, A., Jimenez, M.A.A., Johal, V. and Esteban-Zubero, E., 2019. Focal Nodular Hyperplasia in a Young Male as an Incidental Finding Associated With Acute Lithiasic Chronic Cholecystitis. Case Report and Literature Review. Iberoamerican Journal of Medicine1(1), pp.16-21.

Halushko, O.A., Mamchich, V.I., Donets, V.V. and Chayka, M.A., 2019. Features of anaesthetic support in laparoscopic surgeries for acute Cholecystitis. EMERGENCY MEDICINE, (5.100), pp.45-49.

Hanson, K.T., Thiels, C.A., Polites, S.F., Gazelka, H.M., Ray-Zack, M.D., Zielinski, M.D. and Habermann, E.B., 2018. The opioid epidemic in acute care surgery—Characteristics of overprescribing following laparoscopic cholecystectomy. Journal of Trauma and Acute Care Surgery85(1), pp.62-70.

Liu, N., Huang, W., Tang, M., Yin, C., Gao, B., Li, Z., Tang, L., Lei, J., Cui, L. and Zhang, X., 2019. In-situ fabrication of needle-shaped MIL-53 (Fe) with 1T-MoS2 and study on its enhanced photocatalytic mechanism of ibuprofen. Chemical Engineering Journal359, pp.254-264.

Manwarren, R.C., 2015. Multimodal pain management and the future of a personalized medicine approach to pain. Aorn Journal101(3), pp.307-318.

Martelli, M.G. and Lee, J.Y., 2016. Parasitic Infection of the Gallbladder: Cystoisospora Belli Infection as a Cause of Chronic Abdominal Pain and Acalculous Cholecystitis. Journal of the Mississippi State Medical Association57(6), p.174.

Poddighe, D. and Sazonov, V., 2018. Acute acalculous Cholecystitis in children. World journal of gastroenterology24(43), p.4870.

Sekimoto, R. and Iwata, K., 2019. Sensitivity of Murphy’s sign on the diagnosis of acute Cholecystitis: is it really so insensitive?. Journal of HepatoBiliaryPancreatic Sciences26(10), pp.E10-E10.

Shields, H.M. and Sidhu, H., 2018. Two Cases of Acute Cholecystitis and Symptomatic Choledocholithiasis in Two Women Less than 40-Years-of-Age with Hormonal Intrauterine Devices. Case Reports in Gastrointestinal Medicine2018.

Taavoni, S., Sheikhan, F., Abdolahian, S. and Ghavi, F., 2016. Birth ball or heat therapy? A randomized controlled trial to compare the effectiveness of birth ball usage with sacrum-perineal heat therapy in labor pain management. Complementary therapies in clinical practice24, pp.99-102.

Wilkins, T., Agabin, E., Varghese, J. and Talukder, A., 2017. Gallbladder dysfunction: Cholecystitis, choledocholithiasis, cholangitis, and biliary dyskinesia. Primary Care: Clinics in Office Practice44(4), pp.575-597.

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