Advanced Pathophysiology Essay

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Joan Riley, age 56, came to her nurse practitioner with fatigue, pallor, dyspnea on exertion, and palpitations. Her laboratory report indicates that her hematocrit, hemoglobin, and reticulocyte count are low, that her MCV is high, and that her MCH and MCHC are normal. Her diagnosis is pernicious anemia.Advanced Pathophysiology Essay

Answer the following questions regarding Ms. Riley’s anemia.

1. Why should Joan’s nurse practitioner ask her about paresthesias and ataxia?

2. Why did her nurse practitioner prescribe vitamin B12 by intramuscular injection rather than orally?

3. What causes pernicious anemia?

Inflammatory bowel disease (IBD) is a chronic disease that refers to both the Crohn’s disease and ulcerative colitis. These two conditions are variants of IBD that often share some pathophysiological similarities and differences. The incidence of Crohn’s disease and ulcerative colitis may be influenced by familial or hereditary predisposition (Brant, 2007) that may be relevant in the case of the 38-year old male patient suffering from ulcerative colitis and whose aunt was previously diagnosed with a Crohn’s disease. According to Baumgart (2012), a heritability studies of IBD revealed a prominent genetic component. This hereditary disposition is about 75 to 80 percent likely to occur in families having the same IBD type.
The gastrointestinal (GI) system consists of the mouth and then extends to the esophagus, stomach, small intestine, large intestine, and the anus. Both conditions affect the digestive tract, however ulcerative colitis mainly affects the colon and the rectum while the Crohn’s disease extends to involve the anus and the mouth. The anatomical involvement of the GI system in Crohn’s disease and ulcerative colitis is different. In ulcerative colitis, the inflammatory process only affects the inner lining of the intestinal walls. Advanced Pathophysiology Essay In Crohn’s disease, the inflammation appears in patches that can make the inner lining of the intestine inflamed, swollen and painful (Potter, 2004). The extent of damage in Crohn’s disease is more seirous as compared to ulcerative colitis because the injury to the tissues may extend across layers of the interstinal tissue and can lead to scarring, ulcerations and other complications. The scarring may also result in the thickening of the interstinal walls that makes it difficult to pass the bowel. The inflammatory response in Crohn’s disease may involve the esophagus and down to the large interstine. Healthy tissues may also be mixed along the inflamed tissues. Between ulcerative colitis and Crohn’s disease, the latter produces more serious health consequences and complications.
In the pathophysiology of ulcerative colitis, the inflammation begins along the mucosal layer of the large intestine. It is a chronic inflammatory process that may lead to ulcerations and sores along the intestinal walls and it can cause continuous edema, hemorrhage, and exudation. The extent of the lesion is usually confined only to the interstinal mucosa. Rectal discharges consisting of blood, pus and mucus occurs when the rectum is involved. Complications of ulcerative colitis may involve intraintestinal complications like a perforated intestine, colon cancer, toxic megacolon and sores or ulcerations. Extraintestinal complications like liver disease, kidney stone, bile duct inflammation, joint problems and osteoporosis are also common. Crohn’s disease and ulcerative colitis also share the same complications like episcleritis, colic arthritis, uveitis, ankylosing spondylosis, renal failure, colitis, gastrointestinal ulcers.Advanced Pathophysiology Essay
While the extent of the affected tissues of the GI system is limited to the small intestine and the rectum in ulcerative colitis, Crohn’s disease has a more expansive effect in GI injury. About 50% of patients with Crohn’s disease primarily suffer from the involvement of the distal ileum and the large intestine (Nagelhout and Plaus, 2010), and in some cases it can involve the upper GI system like the esophagus. Deeper layers of the mucosal wall are involved as compared to ulcerative colitis. Only in rare cases that the stomach becomes involved. Crohn’s disease usually appears as patches of inflamed tissues, thus this intermittent inflammatory response may mix with the other healthy tissues in the colon.Advanced Pathophysiology Essay
The treatment options for ulcerative colitis and Crohn’s disease is multifaceted and it is mainly focused on strengthening the immune system and addressing the manifestations of the symptoms. The cure for both conditions remain unclear, however, there is significant improvements in terms of making an early diagnosis of the conditions and treatment of the injuries to the gastrointestinal tract (Baumgart, 2009). Drug medication is a classic form of treatment given for both ulcerative colitis and Crohn’s disease. The main objective of pharmacological intervention is to treat the inflammation in the affected area of the gastrointestinal tract and to help prevent potential complications arising from both conditions. Symptoms of diarrhea, pain and bleeding are also managed with medications. Drug intervention in the long term are administered to maintain the suppression of the symptoms in the form of steroids,antibiotics, immunomodulators and biological therapy (Bayless and Hanaueur, 2011). However, in the presence of severe conditions and complications, conservative drug therapy will not suffice in the management of the conditions. Treatment may include surgery in this case. Surgical treatment has different outcomes in both diseases. The colon is surgically removed through the procedure called colectomy in ulcerative colitis and the condition may no longer recur. In Crohn’s disease, however, recurrence is possible, even after surgery. It can be noted that surgical procedure is rarely required in mild to moderate ulcerative colitis. The treatment of drug therapy in most cases will suffice because the location of the gastrointestinal tract is more localized and easier to treat with less severe complications. In Crohn’s disease, about two third of the patients will require surgical intervention and the remission is longer in ulcerative colitis than in Crohn’s disease where the rate of recurrence is high even after surgery.Advanced Pathophysiology Essay
It can be concluded, therefore, that between the two forms of inflammatory bowel disease, Crohn’s disease has more serious complications and a poor recovery rate. It affects any part of the gastrointestinal tract, unlike ulcerative colitis that has only a localized injury to the gastrointestinal tract confined mostly to the large intestines and in some cases to the rectum. The key to an effective maagement for ulcerative colitis and Crohn’s disease is early diagnosis and treatment to prevent further complications and better recovery from the conditions.

If available lab results, I would like to see the resulted complete blood count with differential and complete metabolic profile. Possibly supplying the patient with supplemental oxygen if deemed so by her oximetry and perfusion status review. As such the following would be the initial assessment and treatment:

Obtain vital signs: blood pressure, temperature, pulse, respiratory rate with auscultation, as well as pain scale rating Note her capillary refill time and skin color and turgor, especially around lips for color and for turgor Seeing if she has sunken eyes or dry mucous membranes indicative of dehydration. Place a pulse oximeter on her finger for oxygenation levels. Place EKG monitor for heart rate and rhythm analysis.Advanced Pathophysiology Essay

Place IV for obtaining blood works and order stat CBC, CMP, PT/INR/PTT, ABG, CXR, cardiac and liver enzyme profiles. Perform blood glucose monitoring
with glucometer for immediate assessment of her diabetic state, is she hypo or hyperglycemic. Review airway for any obstruction as she is dyspneic.

While conscious review pain level, duration and site of pain and medical history-hopeful to review current medications, with attention to evaluate current mental status such as orientation to person, time and place. Note that she is in acute distress with disorientation that is progressing to unresponsiveness (Gerontological nursing, 2010).Advanced Pathophysiology Essay

If unresponsive at the time of arrival, the nurse needs to be vigil in looking for clues to how she is experiencing pain by looking for signs such as moaning, agitation, restlessness and facial grimacing. Assess skin is intact with no abscesses or open wounds or sores. Consider value of inserting a urinary catheter.

Tools that will be utilized in the assessment of Mrs. Baker may include: Stethoscope- will be used for listening to heart beat to ascertain dysrhythmia above 90 beats/minutes would be indicative of concern and comparing radial/peripheral pulses with baseline of heart apex rate to ascertain if variance exists , auscultation of lungs for clearness of lung fields and respiratory rate should be 16 per minute if she is over 20 breaths/ minute concern for hyperventilation and oxygen delivery and consumption would arise . Tachypnea and dyspnea are noted, oxygen would be applied.Advanced Pathophysiology Essay

blood pressure cuff (sphygmomanometer)- The blood pressure cuff will determine if she is normotensive or hypo-hypertensive, expected range is 120/80 mmHg if below 90 mm hg systolic or 70mm hg diastolic is cause for concern. Glucometer-ascertain rapidly, serum blood glucose level range expected 70 – 130 (mg/dL) before meals, and less than 180 mg/dL after meals (as measured by a blood glucose monitor).

blood tubes with needle access for blood testing (vacutainers)-to conduct CBC- to monitor white blood cell, red blood cell and platelet counts, CMP- for fluid and electrolyte
imbalance, kidney and liver function, ABG-, analysis for acid/base imbalance liver and cardiac enzyme for indication of liver or cardiac impairment as well as blood coagulation profile such as PT/INR/PTT- for elevation in bleeding time . Blood cultures and antibiotic sensitivities for sepsis pulse oximeter-to rapidly measure the oxygenation of her hemoglobin saturation 95 to 99 percent expected.Advanced Pathophysiology Essay

continuous cardiac monitoring via electrocardiogram(EKG)-to examine rhythm and rate-expect normal sinus rhythm and rate 80-100 beats per minute. Thermometer-measure the core temperature which should be 37 c if above 38 c or below 36 c if hypothermic

bladder catheterization kit
chest x-ray- cardio pulmonary function

The benefits of using these tools, as time is critical for an older patient who has multiple

organ dysfunction syndrome(MODS), is to have precise and state-of-the-art information to

effectively treat the patient. Maintaining and monitoring tissue perfusion would be key goals in

her care and I would utilize these tools to evaluate blood pressure and respirations,

monitoring pulse and assessing for any cardiac arrhythmias. To evaluate for any underlying

respiratory disease, pneumonia, PE, or pulmonary edema a chest x-ray would be advantageous.Advanced Pathophysiology Essay

A bladder catheter would give accurate accounting of urinary output.

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The patient became unresponsive; her respirations became more labored, so breathing became the main priority while reading the scenario. The patient is unable to verbalize how she is feeling and with her dyspnea it is clear she is in respiratory distress. Evaluating the electrocardiogram would be done to ascertain if there are any dysrhythmias that could be causing the symptoms. I would review the vital signs, is the patient having hypo- hypertension?

Review the patient’s pain assessment, is the patient experiencing any pain? I would then review lab results, focusing on abnormal results. The prioritization was done with basis for basic needs first, that of breathing effectively to promote oxygenation then focus of vital sign monitoring that is compatible with sustaining life.

I would assess pain in a geriatric patient who is alert by questioning the patient directly, do they have any pain, asking them where the pain is, what is the duration of the pain and when was onset.Advanced Pathophysiology Essay

On a numeric pain scale 0 to 10 what is their level of pain. Are they taking any pain medication at home? In a geriatric patient who is not alert, I would need to assess the patient based on signs such as moaning, agitation, restlessness and facial grimacing. I would manage the pain in a geriatric patient experiencing multisystem failure and showing signs of pain but not alert with caution.

The elderly are susceptible to polypharmacy and often have impaired renal function that increases risk or potentiates the medication such as barbiturates. Knowing I have a standing order for acetaminophen and by judgment of the pain with a lot of moaning, restlessness and grimacing, I would elect to give the morphine 0.1mg/kg IM. She cannot take the acetaminophen by mouth as she not responsive, the 0.05 mg/kg Morphine IV will likely obtund the patient with the rapid absorption and likely decrease her blood pressure severely as she is dehydrated.

The patient’s pain level would need to be reevaluated approximately 20 minutes after administration for effectiveness and then again in one hour. It is likely with her being unconscious , I would assess by a presence or lack of grimacing, moaning or agitation. I found her to have been relieved of pain when reassessing her I have learned it is very important to recognize the fragility of the elderly related to polypharmacy, agedness of vital organs, key focus on concern of
cognitive ability and its role in assessment by nursing.Advanced Pathophysiology Essay

It is likely that the metformin (Glucophage) can have decreased effects when combined with Hydrochlorothiazide (diabetes forum, 2012). The patient recently added lisinopril to her regimen and this in the form of Zestoric has hctz in it as well. It is possible she has had too much hctz and the prescribing physician needs to be alerted. The recommendation for this possible interaction is to monitor blood sugar levels when taking all three of these medications.

This is especially important when starting, stopping or changing the dosage of your lisinopril/HCTZ. The collaborative team members pertinent to her care are the emergency room physician for immediate assessment, diagnosis and treatment recommendation, the medical physician involved in her current care, possibly an endocrinologist who is managing her diabetes, a pulmonologist or intensivist who is caring for her current state as a consultant and the radiologist and cardiologist who will review her lab, radiology and EKG results.

In the event where her status became unconscious the respiratory therapist and emergency room physician and ER code team responded to facilitate returning her to stable vital signs. It is likely she will need social work involvement and discharge care planning as she will be admitted until the current situation is diagnosed, treated and stabilized.Advanced Pathophysiology Essay