DIVERTICULITIS CASE STUDY Susan Kwan a 58

DIVERTICULITIS CASE STUDY Susan Kwan a 58 year old female is admitted to a general hospital with a history of abdominal pain and diarrhoea over the last 2 days. Accompanied by 12 hours of nausea and vomiting pre admission. Susan has a past medical history of type 1 diabetes, hypertension, peptic ulcer disease, haemorrhoids, mild osteoarthritis and deep vein thrombosis requiring ongoing anticoagulant therapy. A colonoscopy has been performed in the past confirming diverticular disease. Current medications include: Omeprazole 40 mg nocte oral Ramipril 10 mg mane oral Novomix insulin 12 units b.d. subcutaneous (s/c) Warfarin 2mg daily Allergies: Elastoplast Weight: 72kg Diet: Diabetic Your assessment reveals the following: Temperature: 38.7C Pulse: 120 b/min (regular) B.P. 105/55 mmHg Respirations: 20/min SaO2: 96% on room air Abdominal examination: mild distension with marked tenderness in the left lower quadrant pain 5 out of 10 at rest. Some mild lower back ache pain 2 out of 10. Susan also stated she had a single episode of rectal bleeding at home of bright red blood. Bowel sounds scant. An indwelling catheter (IDC) is ordered by the Dr and inserted by the clinical staff, Susan is placed on nil by mouth (NBM), a nasogastric tube (NGT) is ordered by the Dr and inserted by the clinical staff, a fluid balance chart (FBC) is commenced, frequent vital sign observations are commenced 1-2hrly and the RMO prescribes oxygen at 2 l/min via nasal prongs (NP). QID blood sugar level reading via glucometer. TED stockings and pedal pumps. Other general care. The medical officer orders the following investigations; urea and electrolytes, full blood count & Hb, APTT, INR, Platelet Count, cross match blood, blood cultures, catheter specimen urine (CSU) Blood results: Na: 137 K: 3.9 Urea: 7.0 mmol/L Creatinine: 0.10 mmol/L Hb: 118 WCC: 14,000 Platelets: 175 INR: 2.0 APTT: 30 seconds BSL: 8.0 Urinalysis: S.G: 1030 pH: 6.0 Ketones -ve Sugar + Protein + Chest X Ray (CXR) – was clear Abdominal X Ray (AXR) – left lower quadrant bowel oedema. The Medical Officer suspects Susan may have ruptured diverticula and is at risk of peritonitis. Medications Prescribed by the Dr are: Amoxil 1 G qid intravenous (IV) – (empirical antibiotic therapy) Gemtamicin 420mg IV single dose – (empirical antibiotic therapy) Metoclopramide 10 mg 8 hrly prn IV Stemetil 12.5mg TDS IM prn if metoclopramide is not effective Morphine 1-2 mg IV 6hrly prn Panadol 1 G IV 6 hrly prn Omeprazole 40 mg nocte IV Ramipril 10 mg mane oral – with held whilst NBM & review BP Actrapid insulin on sliding scale re QID BSL Warfarin 2mg daily – with held whilst NBM & risk of bleeding Intravenous (IV) therapy prescribed by the Dr includes: Normal Saline 1 litre 8/24 rate Normal Saline 1 litre 10/24 rate Normal Saline 1 litre 12/24 rate Susan is admitted to the ward for 24 hours and is prescribed intravenous (IV) hydration and intravenous antibiotics. The next day she has not responded to treatment and has a CT scan of her abdomen. The results indicate acute sigmoid diverticulitis. There are nil signs of bowel obstruction, bowel perforation, abscess or fistula. The catheter specimen urine (CSU) on microscopy, culture and sensitivity (MC&S) results indicate klebsiella bacteria which is sensitive to cefotaxime. The blood culture results on MC&S indicate Escherichia coli (e-coli) bacteria which is sensitive to metronidazole. Amoxil and Gentamicin are ceased and the following additional antibiotics are prescribed by the Dr: Metronidazole 500mg BD IV Cefotaxime 1G TDS IV On day three Susan’s vital signs are: Temperature 37.5 degrees Celsius Pulse 98/min regular Respiration 18/min Oxygen saturation 98% on 2 l/min via NP. Blood Pressure 125/70 Abdominal assessment: Left lower quadrant pain is 1-2 out of 10 on movement. Urine output is 50-60mls/hour. Susan is commenced on ice and sips of water and then progresses to light diet. When a special diet is resumed she is recommenced on her normal s/c. insulin regime. Susan stabilises and is discharged to home two days later for follow up by her G.P. regarding diet, lifestyle and medications. Susan is discharged to home on her normal medications and oral antibiotics. Questions 1) How does the aeitology and pathophysiology of the the case study relate to the clinical manifestation of the patient in case study. 2) Identify abnormalities in the case study. Describe and explain the reasons for abnormalities in sentences. Describe in full the specific focused nursing assessment that is related o the case study. 3) How does clinical manifestation relate to the therapeutic management strategies of the patient. The therapeutic management strategies include nursing assessments, and interventions, and the medical assessments and investigations.

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