NURBN3030 Management Of Deteriorating Patient

Hartmann’s procedure

The Hartmann’s procedure commonly known as proctosigmoidectomy in the medical field is a surgical procedure performed on the cancer of the colon and on inflammatory situations that occur around the rectum and the colon (Luchetta, 2016).

Mr. Kahil underwent proctosigmoidectomy in order to remove his rectum and a portion of his bowel this is usually an emergency surgical procedure in the cases where is obstructed or is raptured. This procedure led to the formation of a colostomy which is an opening at the end of the colon that is frequently caused by surgical procedures to remove a portion of the bowel.

The Hartmann’s surgical procedure aims to remove the affected tissue around the rectum and the colon and replacing it with a colostomy bag, this is to create an alternative storage for undigested food material leaving the body system. This type of surgical procedure is only recommended in situations involving severe infection, inflammation and cancer development around the large intestine, these conditions are usually brought about by underlying conditions as follows (Zarnescu et al, 2015).

Colon Cancer

Hartmann’s procedure allows for surgeons to get rid of the carcinoma cells present in the colon preventing further spread of the cancerous cells and also the development of diverticulitis. Mr. Kahil had a previous diagnosis of colon cancer, this made him more prevalent to proctosigmoidectomy.

Crohn’s Disease

This is a medical condition caused with symptoms ranging from presence of blood in stool cramping in the abdominal area associated with severe diarrhea. Hartmann’s procedure may be a last resort for this kind of condition (MacDonald, 2017).

Diverticulitis

This is evidently the most prevalent indication for Hartmann’s procedure this is brought about by an infection of the lining of the pockets in the colon (Neilson, 2015).

Ulcerative Colitis

This is a medical procedure characterized by blood stained diarrhea and abdominal pain brought about by inflammation of the bowel.

Complications of Hartmann’s procedure

The proctosigmoidectomy procedure can have devastating complications and a number of things might go wrong during the recovery process after the operation. Some of these complications may include a leaking colon, a blood clot in the leg caused by vein thrombosis and pulmonary embolism caused by the formation of a blood clot in the lungs (Brady et al, 2015). In some cases internal bleeding may be observed caused by damage of organs and tissues around the operated area, and the development of hernia as a complication (Hallam, 2018).

Causes of Clinical Deterioration Post Surgery

Mr. Kahil’s second medical assessment indicated that he was exhibiting symptoms a clinical deterioration, the various symptoms that were present with Mr. Kahil were the feeling of dizziness which is brought about by an insufficient supply of blood to the brain, other factors that were evident were the drop in temperature, blood pressure, pulse and rate of respiration all that are caused by different pathophysiological factors (Mohammmed et al, 2018) .

The reversible causes for the clinical deterioration of Mr. Kahils health are basically known as the 4 H’s and the 4T’s, the 4 H’s stand for hypothermia, hypovolemia, hypoxia and hypokalemia. Whereas the 4 T’s are abbreviated to mean tamponade, tension, thrombosis and toxins (Neilson, 2015).

Hypoxia

Mr. Kahil was clearly suffering from oxygen deficiency in the blood causing the drowsiness that was associated with his return to hospital. The human cells require oxygen to carry out normal functions, this oxygen deficiency is mostly evident in the arteries and veins where oxygen loading and offloading takes place, oxygen binds with hemoglobin found in the red blood cells to form an unstable compound called oxyhemoglobin which is thereafter transported to the various destinations of the cell to carry out the process of aerobic respiration to produce energy for regular functioning of the cell like taking in required nutrients (Sforza & Roche, 2016). A deficiency of oxygen in the arteries and other blood vessels is usually brought about by a shortness of breath as observed with Mr. Kahil. The condition indicating the reverse of hypoxia is known as normoxia, which translates to normal levels oxygen in the blood vessels.

The various physio pathological factors that cause Mr. Kahil to experience hypoxia are chronic obstructive pulmonary disease which causes the worsening of symptoms, pulmonary fibrosis caused by damaged lungs due to his frequent smoking habits and a congenital heart disease in adults associated with hypertension. Hypoxia is usually characterized by drowsiness and a shortness of breath usually caused by poor circulation of blood in the arteries (Labarca et al, 2019).

Tension (pneumothorax)

Mr. Kahil was evidently suffering from a collapsed lung; this caused his respiration rate to drop exponentially since his lungs could not expand sufficiently during inhalation of air. The collapsed lung is brought about by the entry of air between the lungs and the chest cavity causing the lung to give way creating a cavity. Sometimes the condition may develop further into atelectasis that is when one side of the lung collapses due to a blockage inside the lung (Roberts, 2015).

There are various types of a collapsed lung or pneumothorax whereby a patient may have one type or more at a time. The first type of tension is the simple pneumothorax whereby the lungs aren’t moved around and all the tissues and organs are intact, then comes primary spontaneous tension where the lungs move without any clear indication for the cause this later transforms into the secondary spontaneous tension whereby the movement of the lungs may be brought by a disease, the fourth type is the tension pneumothorax where the space between the lungs and chest wall is completely filled with air causing a rise in pressure to the chest (Hikichi et al 2019). The last type of pneumothorax is the traumatic pneumothorax; Mr. Kahil was clearly experiencing tension in his body causing him to exhibit the various symptoms that could have become more severe if not diagnosed early.

The pathophysiological factors that contributed to Mr. Kahil’s development of tension were majorly his diagnosis with lung disease in the form of chronic obstructive pulmonary disease (COPD), and were greatly elevated by the fact that he was a chronic smoker of tobacco (Zhao et al, 2020).

Nursing assessments

Nursing assessments are a set of tests carried out to collect vital information of the physiological, sociological and psychological conditions of an admitted patient from the day of the admission and is carried out progressively throughout the patients stay at the medical facility, nursing assessments are carried out in three stages the first which is the;

Admission Assessment 

The admission test is carried out by a nurse on the first day the patient is admitted at the medical facility and is done almost immediately upon arrival. This assessment must not be conducted any later time after 24 hours for it to be legible for admissions test since the patients symptoms may progress with their stay at the medical facility (Tuominen et al, 2019).

Medical practitioners are required to maintain absolute discretion with the patients’ medical information to enhance trust and confidence of the patient with their care giver. This information on patients is usually stored in the hospitals database systems for easy referencing.

Patient’s Medical History

The nurse or the medical practitioner is required to question Mr. Kahil about the reasons for his subsequent admission, past occurrences in relation to the current situation. The nurse is required to identify if the patient is on any other kind of medication, whether they have allergies or reactions and document this information.

Physical Assessment

To allow the nurse complete assessment of the patient a physical examination is paramount. The primary assessment gathers information on the breathing standards and circulation, here information like weight, height, temperature, respiratory rate, pulse to finalize the physical examination as conducted to reach the outcome for Mr. Kahils symptoms

Shift Assessment

Progressively during the stay of Mr. Kahil at the hospital information on his symptoms are carried out spontaneously throughout the beginning of every shift to assess his progress (Ameel et al, 2020). This assessment is used to derive a care plan for the patient during his admission up until their discharge. The nurse uses observation method to collect data on the appearances of Mr. Kahil taking into account his social abilities, posture and complaints. Some of the assessment data entail:

• Circulation and pulse; this focuses on the rate, rhythm and the power of the pulse.
• Temperature; this emphasizes on the peripheral and the central temperatures of the body for Mr. Kahil the temperature had dropped significantly.
• Breathing; the information collected relates to the respiratory rate, the rhythm bilateral movement and entry of air.
  
  

Focused Assessment

This emphasizes on the detailed medical assessment on specific body organs causing the problems to certain body systems (Reddy, 2016).

Neurological Systems

This study seeks to investigate the sensory functions seizures and irritability; the medical practitioners will look into the level of cognitive sense of a patient. As was the case of drowsiness with Mr Kahil.

Respiratory Systems

The respiratory assessments include a history with shortness of breath, respiration rate and a monitor of oxygen concentrations in the blood.

These sets of nursing assessments were essential for assessing the clinical deterioration of Mr. Kahil recovery process as the symptoms are monitored right from admission progressively through the various shift and into more advanced and focused assessments to determine the severity of his condition (McGaughey et al, 2017)

Nursing Interventions

There are three main types of nursing interventions that may be implemented by a medical practitioner, these nursing interventions include the dependent nursing intervention which is also known  as the physician-initiated intervention, the second intervention is the independent intervention and the last is the collaborative nursing intervention (Smith, 2014). All of which are essential nursing interventions to be applied in the monitoring of the recovery process of Mr. Kahil.

Dependent Nursing Intervention

This is the type of nursing intervention that requires a doctor’s instructions or advice from other medical practitioners as the medical intervention carried out by the nurse are part of the medical treatment process initiated by the doctor. This process incorporates the administration of medicine and the dressing of wounds as instructed by the doctor and this kind of nursing intervention makes the nurse liable to legal implications (Smith, 2014). The nurse strictly administers medication to Mr. Kahil in accordance to the instructions of the doctor.

Independent Nursing Intervention

This is the type of nursing intervention where the nurse does not require instructions from the doctor or any other medical practitioner to care for the patient. The nurse is supported under the jurisdiction of the actions regulated by state boards of nursing & nurse practice acts to support ADLs, health education, health promotion & counseling. The environment may also be managed by nurses by maintaining a safe, therapeutic environment, promoting rest of the patient by minimizing noise, maintaining cleanliness. The nurse is may intervene by active listening to the patient promoting a level of trust between Mr. Kahil and the nurse (Bekelman et al, 2018).

The nurse is also required to promote adequate oral intake either in the case of dosage or food to ensure a happy and full patient allowing them to focus entirely on the recovery process of Mr. Kahil. The independent nursing intervention entails the following; mobility therapy, alcohol abuse control, positioning therapy, postpartum care, sleep pattern control and the patient’s compliance with diet.

Collaborative Nursing Intervention

This is the kind of nursing intervention in which there is an active involvement of the various discipline of the medical field. The nurse usually plays an intermediary role between the two medical practitioners with an interest on the same patient for example a doctor cannot independently treat a patient with neurological disorder without consultation from a neurologist, neither can he treat a patient with a fractured bone without the insight from a physical therapist is this case a nurse acts as a bridge between the two medical practitioners and the patient in this case Mr. Kahil.

These nursing interventions are all crucial in the smooth recovery of Mr. Kahil as they impact directly and indirectly on the factors to reduce the clinical deterioration as witnessed evident with Mr. Kahil’s conditions.

Prescription of Intravenous Isotonic Crystalloid Fluids.

Intravenous fluids are usually prescribed for patients whose needs cannot be met by oral intake of medication. These crystalloid solutions are made up of the plasma volume expanders that contain electrolyte crystals such as sodium and potassium that have the ability of dissolve fully into solution allowing the solution to move through the membranes of the cell.

The human body is made up cells that are composed of over 50% water; it is responsible for regulation of the internal body temperature through the processes of respiration and sweating. The loss of fluid an increase in the levels of hypovolemia, hypoxia, hypokalemia, hypothermia, tamponade, thrombosis and toxins to accumulate in the body this is due to the fact that the electrolytes become imbalanced and cognitive operation of the brain is compromised.

The blood gets concentrated in the vessels sending signals to the kidney for water retention; this concentration of blood causes the heart to become pressured adding more risk to the patient. The administration of crystalloid fluids is used to resuscitate patients who have lost the fluid count or are severely dehydrated. The three types of crystalloids are the hypotonic crystalloids, hypertonic crystalloids and isotonic crystalloids (Van Regenmortel et al 2018).

 Effect of intravenous isotonic crystalloid fluids

There are certain complications that arise from the administering of intravenous isotonic crystalloid fluids. Some which are minor while others may lead to the development of other complications (Orbegozo Cortés, 2014). The various complications that may arise from use of crystalloid fluids are;

Hypochloremia Metabolic Acidosis. This condition is caused by a large volume of crystalloid fluids intake by the Mr. Kahil, especially the isotonic crystalloids which cause a decrease in plasma bicarbonate concentration and a subsequent increase in the plasma chloride concentration forming an anion gap (Neilson, 2015).

Fluid Overload. This kind of fluid overload is usually associated with certain factors as the age of a patient as is more prevalent to the elderly populations as was evident with Mr. Kahil since he was above the age of 70 making him more vulnerable to develop this condition. Other factors that may lead to a fluid overload are the underlying chronic diseases as such the cardiovascular diseases related to hypertension and Chronic Obstructive Pulmonary Disease commonly as (COPD) all which are conditions present with Mr. Kahil at the time of his visit at the hospital (Han et al, 2015).

Crystalloid Edema. When the crystalloid fluid is not distributed instantly throughout the extracellular space between plasma and the interstitial area which is brought about when the radius of the electrolyte is too small, this causes the fluid to accumulate at the periphery thus leading to peripheral edema.

Nursing Evaluations to Prevent Clinical Deterioration

Nursing evaluations are a set of judgements that are used to determine the effectiveness of the nursing assessments and intervention to prevent clinical deterioration of the patient (Lee et al, 2020). For this case study we will review three nursing evaluations to ensure that Mr. Kahil recovers efficiently without any signs of clinical deterioration;

• Adequate bed rest, Mr Kahil is in dire need for sufficient bed rest to ensure the return of stabilization of his vital organs conditions as pulse and respiration rate as well as the blood pressure to normal.
• Avoiding destructive habits, avoiding smoking habits will promote blood circulation in the heart Mr. Kahil has chronic habit of smoking that is generally causing the clinical deterioration of his conditions. For Mr. Kahil to recover steadily he has to avoid all temptations for smoking.
• Taking protein rich diets, this will enable for easy healing of the affected tissues.
  
  

Conclusion

In conclusion clinical deterioration is caused by bad habits such as smoking and other underlying conditions that cause the drop in factors like temperature, heart rate, pulse rate and blood pressure.

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