Nursing case study approaches and clinical applications

Nursing Case Study

Managing a possible Case of Gastroenteritis: A Nursing Case Study

The effective delivery of optimal nursing care requires a comprehensive treatment plan that addresses both the patient's symptoms and the security of the immediate environment. This report presents a case study of appropriate evidence-based nursing practices in treating an elderly female patient presenting with abdominal discomfort in a residential care setting.

The client presents with new onset faecal incontinence, diarrhoea and increasing abdominal discomfort and cramps. These symptoms suggest a possible gastrointestinal disturbance (Crisp & Taylor, 2009) and present a number of possible diagnoses. While the client's nursing care plan indicates that she is normally continent, her confidential disclosure to the nurse suggests that her symptoms may be more prolonged. Another relevant client characteristic is her advanced age of 85 years.

The client's proximity to the dirty utility room in the aged care facility and the report of similar symptoms from a patient in the adjoining dementia unit suggests a diagnosis of gastroenteritis. Possible causes for this may be the result of cross contamination via the oral-faecal route of transmission, or through consuming contaminated foods and water (Kirk, Hall, Veitch, Becker, 2010). The physical location of the dirty utility room proximal to the eating and food preparation areas appears inappropriate and may be the source of a possible viral infection through food contamination. This health risk presented by the design of the facility should be reviewed by the appropriate agency (Department of Health and Ageing, 2007). The most often cited causes of gastroenteritis are salmonella infections and clostridium difficile (Andrew & Simor, 2010).

While the symptoms are very evident, they are broad and may apply to other diagnoses that must be considered as part of the nursing care assessment. Inflammatory bowel disease is especially common for clients over the age of 60 (del Val 2011) and even Crohn's Disease, while less likely, must be taken into consideration. Other potential causes of the symptoms may be simple dietary imbalance leading to constipation or adverse drug effects. A recent study conducted by Gurwitz et al. showed the high prevalence of adverse drug effects in long-term care facilities (2005).

Gastroenteritis cases do not generally deteriorate quickly but if left untreated could have potentially life-threatening consequences. Depending on the client's current health condition, which may be compromised due to her advanced age, the client may experience dehydration, abdominal pain, fevers, vomiting, diarrhoea and loss of appetite (Crisp & Taylor, 2009). Extreme dehydration from excessive fluid loss through vomiting and diarrhoea may lead to delirium and psychological distress (Thomas et al., 2008). If the virus remains untreated, the infection may spread to other organs and produce a whole-body inflammation or sepsis (Halvorson, Cedfeldt & Hunter, 2010).

The combination of hypoglycemia due to vomiting and loss of appetite, hypovolemia and immune compromise could trigger a cardiac arrest in the client (Vanden Hoek et al., 2010). Irrespective of the specific progression of the gastroenteritis symptoms, studies have shown that the elderly are at a relatively high risk of adverse outcomes from gastroenteritis. Van Asten and colleagues recently documented significant increases in morbidity, hospitalizations and deaths during gastroenteritis outbreaks among the elderly (2011). While residents of long-term facilities such as nursing homes account for less than one percent of the U.S. population, 17% of all deaths attributable to gastroenteritis of unknown etiology can be traced to that population. According to Frenzen, nursing home residents are more than four times more likely to die from gastroenteritis than other elderly (2003). Clearly, the potential consequences for the client in question are severe.

Of immediate concern to the patient are fluid resuscitations measures to replenish fluid and electrolyte loss. This will help to reestablish haemodynamic stability, adequate nutrition, fluid balance, and stable vital signs. Patient goals are to implement nursing interventions to care for the two residents who are already elderly and immunocompromised. These interventions include ensuring comfort, (Department of Health and Ageing, 2007) and addressing the abdominal pain with medication to prevent potential patient falls. (Crisp & Taylor, 2009) After addressing the immediate concerns, the nursing care should focus on preventing other patients from becoming infected with the gastrointestinal pathogen. This involves identification of the pathogen through a tissue biopsy. Only few cases of gastroenteritis are caused by bacterial infection but confirmation remains necessary to preclude antibiotic therapy (Crisp & Taylor, 2009).

Measurable outcomes for these goals include the following: 1. No further outbreaks of gastroenteritis in the unit, 2. Symptom control and improved health status in the affected residents 3. Identified possible causes of the gastroenteritis, 4. Review of the unit's infection control practices (Garibaldi, 1999).

A single case of gastroenteritis in an elderly resident in an aged care facility may signal the beginning of an outbreak. (Kirk, Roberts, & Horvath, 2008)

Immediate nursing actions to manage the suspected infected resident include collecting a faecal specimen to confirm infection (Crisp & Taylor, 2009). In terms of the physical assessment, the nurse should palpate, auscultate and percuss the affected abdominal area to isolate the source of the pain. Often, gastroenteritis can be diagnosed by a simple physical assessment. In performing this physical, the nurse should take special hygienic care to prevent infection. Especially in performing the rectal examination to inspect for bloody stool or leakage.

Approximately fifty percent of gastroenteritis cases are caused by the norovirus (Centers for Disease Control and Prevention, 2011). There is substantial evidence that document the challenges to controlling the spread of the virus (Dolin, 2007). The effected patients should therefore be isolated to reduce the risk of the infection spreading to other residents and staff (Kirk, Roberts & Horvath, 2008). Increased hygiene measures should be implemented that address bed-making procedures (Xue, 2010) to eliminate the contagions from the patient's room. The nurse should implement a long-term management plan that monitors the patient's nutrition, fluid intake, and skin care (Crisp & Taylor, 2009). Additional personnel should be recruited to provide psychological comfort for the patient in her quarantine.

Evidence-based studies that address diagnostic and treatment options for acute gastroenteritis are extensive. A majority of studies focus on the epidemiology of the illness and the molecular basis of its source -- the norovirus. However, a number of relevant guidelines have been published in recent years that directly address care planning.

The primary risk of gastroenteritis, especially in an aged care facility, is the spread and infection of other patients. This requires a bifocal care plan that treats the individual patient's symptoms while simultaneously isolating the patient and sterilizing the contaminated site to prevent spread of the virus to other patients. After the condition has been stabilized and fluid resuscitation has been administered to the affected patients, a review of the facility's infectious control practices should be made to determine the source of the original outbreak. In developing a care plan in an aged care facility, nurses must always prioritize care to focus on the safety of all patients in the facility.

References:

1. Crisp J, Taylor C. (2010). Potter & Perry's fundaments of nursing (3rd ed.). Chatswood, N.S.W.: Elsevier, Australia.