Free Nursing Essays - A case study: Mr Taylor, a patient with gastro-oesophageal reflux, an essay on the evaluation of the treatment and care that he was given
Introduction
In this essay we are asked to consider the case on a Mr Taylor who has presented in the Gastro-enterology Clinic with gastro-oesophageal reflux. We shall present the elements of his case and describe his general condition. We will focus in on two of his major symptom complexes (pain and vomiting) and review them in some detail, considering the mechanisms that are relevant and that underlie the problem.
Gastro-oesophageal reflux is a major problem in the UK population. The disease process currently affects about 25 – 40% of the population (depending on either your inclusion criteria or the particular study that you quote) (Jones 1995 ).
(Graham et al. 1998)
It is a major strain on the NHS Purse, as it is currently carries the largest prescribing cost burden of any of single symptom complex (OHE 1996). The actual treatment (as we shall discuss in this particular case) is not without controversy, as there is still considerable discussion regarding the role of Helicobacter pylori. Some studies are reporting that the organism may actually help to protect against the disease process of gastro-oesophageal reflux. (Richter 1998)
The clinical picture
Mr James Taylor is a 48 yr. old married man who has had symptoms of gastro-oesophageal reflux for the past 8 years. For the first 6 of these years, the symptoms were intermittent and not particularly severe. He self-medicated with antacids and was able to keep the symptoms under reasonable control. He first sought medical intervention 2 yrs. ago. He was initially given Gaviscon, life-style modification advice and told to lose weight. (Kroes et al. 1999)
He defaulted from follow up because he felt that he could not change his life-style and actually put on more weight.
He currently has a BMI of 31. He is a heavy smoker ( 40 per day) and does no exercise. His diet is sporadic and has a high fat component. He works in a foundry as a manager, and his job is very stressful. He is known to be hypertensive and his last blood pressure measurement was 175/100. He denies excessive drinking but the General Practitioner has voiced his suspicions about his excessive drinking habits in the referral letter
He returned to see his General Practitioner about eight months ago and he was referred for endoscopy. His CLO test was found to be positive. The endoscopy showed him to have severe GORD, but no evidence of any other pathology. He has currently been admitted to the ward because of an episode of haematemesis after a bout of drinking.
Initial interview with the patient
Mr Taylor was clearly not at ease in hospital. He was fidgeting in the bed and could not lie still. Initial impressions were of a large (clinically obese) man with a ruddy complexion. He rapidly got out of breath with exertion. He frequently found excuses to go outside, where he could be seen smoking. He was clearly in some distress with his symptoms, which he described as central chest pain. He would hold his chest and grimace when describing it.
When eating, he would rush his food and then appear to be in considerable discomfort for some time after the meal. He could not lie flat as the symptoms of pain, abdominal discomfort and vomiting would come on, and he constantly asked for more pillows to keep himself propped up.
He vomited after virtually every meal and this caused a considerable increase in his pain. Blood was seen in at least one specimen of vomit.
Patient assessment.
It is generally good practice, when assessing a patient, to follow a plan or model. There are many to chose from. Most are completely rational and they all have their strengths and weaknesses. (Watson 1996)
In this essay we shall adopt the Roper, Logan, Tierney model. In general terms this model requires the nurse to establish just what the patient can and cannot do in each of the activities of living, bearing in mind the physical, socio-cultural, physiological, environmental and politico-economic factors that have a bearing or influence upon that person.
Ideally, both the patient and the nurse (or healthcare professional) will discuss each of the activities in turn, to both identify potential, or actual problems and to also decide upon a strategy to overcome the particular problems identified and to achieve any particular goals set. (Patton et al. 1998)
Pathophysiology
GORD (Gastro-oesophageal reflux disorder) is a poorly defined entity which covers a wide range of clinical presentations. (DeVault et al. 1999)
It is usually considered to be part of a wider spectrum of hyperacidity disorders which can range, on the one extreme, from a minor episode of heartburn, to the other extreme with full blown ulceration, pain, dysphagia, nausea and vomiting.
(Malfertheiner et al 2002)
The basic major pathophysiology is an excess production of hydrochloric acid in the stomach. This can be associated with gastric and/or duodenal ulceration. It can also be associated with gastro-oesophageal reflux. (De Koster et al 2000). It is this latter condition which is of particular significance in the case of Mr Taylor. We shall therefore consider it in greater detail.
From an anatomical viewpoint, food passes down the oesophagus with the aid of peristaltic waves. As the wave approaches the distal oesophagus, the cardiac sphincter relaxes and the bolus of food passes through into the stomach. In normal physiological conditions, the cardiac sphincter is kept tightly shut by its own intrinsic muscular action. It is supported externally in the healthy adult, by the two crura of the diaphragm which provide functional mechanical support. (Dent et al. 2001)
In the pathological state, the cardiac sphincter becomes functionally incompetent. This can be due to distortion (because of scarring, or ulceration) or, more commonly because it slides out of its anatomical position (to give an hiatus hernia). This has the effect of allowing the gastric contents to spill back up the oesophagus – or reflux. This allows the acidic gastric contents to produce a chemical burn in the mucosa of the oesophagus, and gives the symptoms of heartburn, central chest pain nausea or vomiting.
The reflux of the gastric contents – and for that matter the hiatus hernia itself - is often the result of physical pressure in the abdomen. This can be secondary to simple obesity or mechanical factors such as bending down. If the sphincter is simply incompetent, then even lying flat will allow the gastric contents to reflux under the force of gravity. If the abdominal pressure increases for any reason, then vomiting can occur. This may further damage the mucosal lining of the oesophagus and be responsible for the haematemesis.
Initial treatment plan – discussion
A comprehensive treatment plan is, by its very nature, multidisciplinary. It will require the co-ordinated efforts of a great many healthcare professionals to provide and effect a rational care plan for Mr Taylor.
We will discuss the basic elements of the plan.
After his admission he will need a full assessment by the medical team and the nursing team. Because he is overweight, he would benefit from the expertise of a dietician. Because he is a smoker he may well benefit from the attentions of the support team to help quit smoking. He is clearly reticent about admitting his drinking habits. He may well therefore also benefit from an interview with a psychologist and possibly the alcohol support team. His hypertension is not under control and therefore the physicians may well be asked to advise.
Mr Taylor clearly does not handle stress well. The psychologist may well have a role to play here and relaxation techniques may have some value for him.
Mr Taylor will clearly need endoscopy. As such he will need the expertise of a gastro-enterologist, possibly an anaesthetist. Several nurses and technicians will be required to prepare him and assist in his recovery.
The pharmacist will need to prepare his medication and may need to be consulted about any possible interactions between the medication regime that is being considered.
The assigned ward nurse often has a major role to play in co-ordinating the dissemination of information throughout the various members of the team. They may also have a major role to play in the acquisition of information. Patients may well perceive that nurses have more time to discuss peripheral issues than the medical staff. (Lynn 2001). It is therefore quite conceivable that the nursing staff may well be in a better position to make some inroads into areas which he clearly finds difficult to discuss, such as his drinking. This may give a very valuable insight into Mr Taylor’s state of mind and the best way to approach his problems.
Assessment of two major symptoms. (Pain & Vomiting)
At endoscopy, Mr Taylor was found to have a large sliding type of hiatus hernia, marked secondary oesophageal oedema and ulceration from the resultant reflux, but no other significant pathology. The endoscopist was able to visualise both the stomach and the duodenum and was able to say that there was no evidence of ulceration or other pathology. He has been found to test positive to Helicobacter pylori.
This presented a therapeutic problem. There is a considerable body of evidence to suggest that Helicobacter pylori plays a significant role in the aetiology of gastro-oesophageal reflux (Raghunath et al 2003). It is fair to say that there is no common consensus as to the mode of action. There is also a divergence of opinion as to the actual significance of the infection. (Schenk et al 1999)
There are actually some meta-analyses that suggest that Helicobacter pylori may even exert a protective effect on the oesophageal mucosa. (Richter et al 1998)
In Mr Taylor’s case, the decision was made to offer eradication therapy and this was prescribed to be taken after his discharge from hospital.
In trying to approach this problem from a holistic viewpoint, it is clear that neither of Mr Taylor’s prime symptoms can be viewed in isolation. They are part of the whole spectrum that goes to make up his overall health status.
From a physical point of view, it follows that both of his major symptoms can be improved by alterations in his physical status. Loss of weight and subsequent reduction of his abdominal girth will reduce many of the factors that will aggravate the increase in intra-abdominal pressure.
The socio-cultural factors related to his stressful occupation and his inability to handle stress clearly need to be tackled in order to try to reduce his smoking and drinking levels.
Physiological factors such as his blood pressure need to be confronted and tackled.
Environmental factors also impinge on his work, but perhaps more importantly on his diet and his eating habits as, perhaps do politico-economic factors. His diet may actually be dictated by the fact that he cannot easily buy (or afford) more healthy food.
Mr Taylor was also given some omeprazole to reduce the acid production in the stomach and was told that it was likely that he would have to stay on that (or similar) medication for a considerable time. (Kuipers et al 2004)
Reflection
Reflection is a vital part of the therapeutic process. (Gibbs 1998). We can consider the whole process from presentation, through investigation and up to the point of discharge and reflect on the consideration that we have done the best for this particular patient.
It may be that there was not enough time to really help to get to the bottom of Mr Taylor’s drinking. As empowerment and education is a vital part of therapy, did we spend enough time in explaining the role of smoking in Mr Taylor’s symptomatology?
(Kuhse et al 2001). Did we spend too much time pontificating rather than explaining our treatment plan? - counting on compliance rather than concordance with the treatment regime. (Marinker M.1997)
We will not actually know the answers to these questions until Mr Taylor returns for a follow up assessment. If we have been successful, then we could hope that his symptoms will have significantly improved. If they have not improved, then clearly we will not have been.
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