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401010 Health Variations Questions  Eleanor Brown has been admitted to hospital with complications of ulcerative colitis. Eleanor, now 48 years old, was diagnosed with ulcerative colitis when she was 31 years old. Over the years, she has had numerous admissions to hospital for acute episodes of ulcerative colitis. Eleanor’s ulcerative colitis has been managed with a combination of diet, medication (infliximab) and medical monitoring. Eleanor has been experiencing an acute exacerbation of ulcerative colitis over the last two weeks. She has had up to fourteen episodes of diarrhoea with blood and pus per day and severe pain in her lower abdomen. She has been experiencing a sensation of abdominal bloating and cramping pain. Eleanor states she has been feeling too ill to eat and drink much and that she has lost nine kilograms in the last two weeks. She also states that she is feeling fatigued and has been unable to complete daily activities. A colonoscopy performed four years ago revealed that Eleanor had developed a large number of pseudopolyps in her descending and sigmoid colon. Due to her current exacerbation of ulcerative colitis, Eleanor’s gastroenterologist ordered an MRI scan of Eleanor’s abdomen as a colonoscopy posed a risk of perforation and haemorrhage. The MRI scan revealed that Eleanor had now developed pancolitis. The gastroenterological surgeon has recommended that Eleanor has a total colectomy and construction of an ileostomy.   On examination, Eleanor has a tender distended abdomen. Her skin is dry, pale and cool to touch with poor turgor. Eleanor’s capillary refill is slow and she has flat neck veins. She states she has had reduced urine output over recent weeks. Observations on admission Blood pressure: 90/50 mm/Hg Pulse rate: 112 beats/minute Weak peripheral pulses Respiratory rate: 23 breaths/minute Temperature: 38.4C Sa02: 97% in room air Weight: 54 kilograms Height: 165 cm   Urinalysis: specific gravity: 1039 dark coloured urine no other abnormalities noted Initial pathology results Haemoglobin: 86 g/L (117 – 157 g/L) Haematocrit: 52% (35 – 47%) WBC 16780/mm3 (3500 – 11000/mm3 ) Erythrocyte sedimentation rate (ESR): 31.3mm/hour (0 – 20 mm/hour) C-reactive protein (CRP): 33.6mg/dl (20 mg/dl) Albumin: 22.8g/L (35 – 50 g/L) The MO orders the following Morphine 15mg IMI QID PRN metoclopramide (Maxolon) 10mg IMI TDS 1000mL Hartman’s solution over 6 hours methylprednisolone 20mg IVI TDS nil by mouth 1. Prioritise the nursing responsibilities and associated rationales related to the administration of morphine to Eleanor. (Learning outcome 7; NMBA Registered nurse standards for practice 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 2.3, 2.5, 4.1, 4.2, 4.3, 5.1, 5.2, 5.3, 5.4, 6.1, 6.2, 6.5, 7.1, 7.2, 7.3)   2. Describe the structural and functional changes that occur in the pathogenesis of ulcerative colitis that led to Eleanor’s episodes of diarrhoea with blood and pus. (Learning outcome 5; NMBA Registered nurse standards for practice 1.1, 2.7, 3.3) 3. Explain the characteristics of the intravenous fluid that was ordered for Eleanor, and the rationale, related to Eleanor’s specific fluid balance status, for the administration of this intravenous fluid to Eleanor. (Learning outcome 1, 2; NMBA Registered nurse standards for practice 1.1, 2.7, 3.3, 4.1, 4.2, 4.3) Answers 1: Different types of morphine are mainly provided for relieving the patient form pain. In case of the patient, morphine is often prescribed by doctors to be given to patients undergoing severe pain associated with surgery preoperatively and postoperatively. The main rationale for the use of morphine is that it binds with opiate receptors in the central nervous system. By the process of this mechanism, the perception of the patient along with her response to pain stimuli will be modified. This will be altered in such a way so that a generalised CNS depression will take place and the patient will feel less or no pain at all. The nurse should be responsible enough to consider the contraindications like hypersensitivity and concurrent administration of MAOIs responsibly. She has to also take care whether any side effects like nausea, vomiting, flushing, itching, hallucinations, headache and others. The nurse should ensure that she is performing her interventions in safe way maintaining ethical and professional standards of nursing. She should be careful that over dosage does not happen as overdosage may inturn have negative impact on the morphine effect on the patient. She should clearly monitor the patient conditions like respiratory depression, pinpoint pupils, hypotension or others to ensure over dosage had occurred or not. She should be also ready to manage the over dosage like providing antidote, emptying the stomach and similar others to maintain safe practice. While fixing the dosage for the patient, she should also endure the weight of the patient and the age accordingly as morphine affects different cohorts in different ways. She should be also careful while assessing the result after administration mainly in pain assessment, over dosage chances and also in bowel function. She should be careful to administer it gradually as rapid administration may lead to complications. Fluid intake should be maintained in order to manage bowel movement and reduce constipation. 2: Colitis usually refers to that particular condition of the patient when he suffers from inflammation in the colon. By the term ulcerative colitis, it means that the patient has developed ulcers in the places of inflammation in the gut. The ulcer mainly occurs when the inner lining of the gut gets damaged thereby exposing the underlying tissue beneath the lining layer. This ulcer mainly looks like the small and red crater on the inside layer of the gut. In ulcerative colitis, ulcers are tending to bleed. These inflammations and the ulcers present in the regions of the large intestine mainly cause the diarrhoea along with which blood and pus is seen to come out. The inflammation that occur in the rectum and also in the lower part of the colon forces the colon to be empty and thereby increases the frequency of diarrhoea. The ulcers are usually formed in places where the inflammation has killed the cell that usually line the colon and that makes the ulcers to bleed and produce pus that comes out with that of the diarrhoea. As the patient is also showing symptoms that match with the above mentioned path physiology of ulcerative colitis, one can assure that similar occurrences have taken place in her making her suffer so much. Being a nurse, therefore it becomes important to critically analyse the background of the case and relate it with the knowledge of the diseases so that proper interventions can be provided after proper clinical reasoning steps. 3: Hartmanns IV Infusion contains sodium lactate – sodium chloride – potassium chloride – calcium. It is mainly used for replacement of body fluids and mineral salts which are lost from the body or when too much acid is produced in blood. Moreover it is also given to patients having low blood volume and low blood pressure. Since Eleanor had very low blood pressure and had reduced fluid output for few weeks, therefore Hartman was instructed as her intervention. It is given in form of intravenous infusion with the help of special equipment and should be done by a healthcare professional only.

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