Wednesday, August 14, 2019

Case Study of Kathleen Johnson Samples

The report reviews the case study of Kathleen Johnson, a 45 year old woman with obesity and Type 2 diabetes. Due to the problem of overweight and challenges in managing appearance, she was admitted to the hospital for sleeve gastrectomy surgery. The report discusses about the etiology and pathophysiology of patient’s presenting condition (obesity) and then reviews her observation after 2 hours in post-anesthetic recovery room (PARU) to detect deterioration and the pathophysiology behind the deteriorating symptoms. Based on this justification, appropriate nursing management and role of interdisciplinary health care team to manage patient’s condition is provided. Since Kathleen has been admitted to the hospital for sleeve gastrectomy surgery, it is evident that obesity is main presenting condition in patient. Her BMI is 40kg/m 2 and due to weight gain and appearance issue, she had to undergo sleeve gastrectomy surgery. Obesity is a clinical condition leading to excessive deposition of fat or adipose tissue in the body of a person. Any person having a BMI of over 30 kg/m 2 is regarded as obese (Cummings & Cohen, 2016). The etiology of obesity involved multiple factors. For instance, metabolic factors, diet, genetic factor and physical activity level play a role in regulation of body weight. Although genetic factor also plays a role in risk of obesity, however behavioral, environmental, physiological and socio-cultural factors also increase energy balance and contribute to obesity. The most common behavioral and environmental risk factor obesity includes sedentary lifestyle, excess energy intake and poor physical activity (Saunders, Chaput & Tremblay, 2014). Social link to increase in weight includes impact of parent lifestyle and food habits on health behavior of children and youths Increase in weight is associated with other comorbidities such as insulin resistance, type 2 diabetes and cardiovascular disease (Bray 2014). Kathleen is a patient with type 2 diabetes and struggling to control her diet and blood sugar level. To prevent risk of other complication, weight loss surgery was important for her. From the etiology of obesity, it is understood that genetic as well behavioral factors increase the risk of excess fat deposit in patient. The adipocyte is the main cellular basis for obesity and increased in size or number of these cells contributes to obesity. Although in normal condition, fat is stored in the body for survival during starved state. However, when a person takes high energy food in large amount, it results in excessive storage of fat and the end result for which is obesity (Goossens & Blaak, 2015). Hence, the cause begin obesity is high calorie food and the cellular basis for obesity is the adipocyte. In case of Kathleen, her obesity was untreated before the surgery. Although she was gaining weight, she had not taken any preventive steps to control the condition. For this reason, opting for sleeve gastrectomy was a necessary option for her to manage her condition. Obesity mainly contributes to metabolic dysfunction and damages the function of cardiac, liver, endocri ne and intestinal gland if it left untreated (Saltiel & Olefsky, 2017). Hence, bariatric surgery is the best option for obesity management. Evidence has shown that bariatric surgery leads to weight loss and contributes to improvement in metabolic disorders like diabetes too (Reges et al., 2018). Sleeve gastrectomy is also one of the bariatric surgeries that promotes weight loss and improved gyclemic control in patient (Fuchs et al., 2017).   Therefore, by opting for surgical option, Kathleen can improve her symptoms related to diabetes too. Pathophysiology of patient’s post-operative deterioration Kathleen observation after two hours in the PARU revealed several deteriorating signs and symptoms. For instance, Kathleen respiratory rate was 28 breaths per minute whereas pulse rate was 130 beats per minute. By comparing these vitals signs with normal parameters, it can be said that respiratory rate of patient is abnormally high as normal respiratory rate is 12-20 breaths/min. His pulse rate is also an area of concern as it is above the normal value of 60-100 beats/min. Such abnormalities in Kathleen’s respiratory and pulse rate might have occurred due to the effect of obesity, smoking and alcohol consumption in patient. Obesity is highly associated with respiratory complication in obese patient. Obese patients tend to have higher respiratory rate because of the impact on lung function (Pepin et al, 2016). Abdominal obesity and lung dysnfunction affects systemic inflammation thus leading to respiratory disorder in patient (Oppenheimer et al., 2014). The review of Kathleenâ €™s history revealed that he was heavy smoker and consumed four bottles bear every night. Cigarette smoking is one factor that has an impact on pulse rate, breathing rate and oxygen consumption of an individual. This occurs because the chemical found in cigarette aggravates the cilia, leads to the deposition of tar and narrows the air passage. Such change in the lung is reason for abnormal respiratory rate in patient (Papathanasio et al., 2013). Hence, patient’s presenting condition exacerbated his vital signs post operation. The review of other vital signs in patient included blood pressure of 190/100 min. This clearly indicates that Kathleen was hypertensive. The likelihood of hypertension might have increased in patient due to the effect of surgery as well as due to obesity. Overweight and obese patients are more likely to suffer from hypertension. Such association between obesity and hypertension is seen due to the impact of obesity on metabolic functions. Other mechanisms linking obesity to hypertension includes endothelial and vascular impairment, neuro-endocrine imbalance, maladaptive immune response and dietary factors (DeMarco, Aroor & Sowers, 2014). This explanation confirms that obesity is the reason for deteriorating post-operative sign for Kathleen. Other factors that might have contributed to high blood pressure for patient includes smoking and diabetes. The link between diabetes and hypertension has been established because both have common pathways such as inflammation, oxidative stress an d insulin resistance. Low-grade inflammatory response and insulin resistant increased in type 2 diabetes patient thus contributing to hypertension (Lingam et al., 2018). As Kathleen had undergone sleeve gastrectomy surgery and effect of anesthesia and surgery might have also lead to hypertension in patient (Brethauer et al., 2015). Another sign of post operative deterioration found in Kathleen was low urine output and pain score in patient. Kathleen’s indwelling urinary catheter (IDC) volume was 5mls in the last hour, although the normal urine output per hour is 50-60 mL. Surgery is one of the reasons for low urine output. Surgical blood loss and dehydration in patient decreases urine output and lead to acute kidney injury on surgery patients. Poor renal perfusion and decreased urine output are common complication seen in the post anesthesia care unit (Canales & Hatch, 2014). Hence, the reason for such clinical deterioration in patient is clear. Another parameter that was affected for patient post operatively was her pain score. Kathleen’s pain score was 7/10 and the severity of the pain might also be the reason for presence of abnormal BP and respiratory rate. Blood pressure of Kathleen might have increased due to effect of pain. Pain promotes sympathetic activity thus leading to high blood press ure (Laquian et al., 2018).   Hence, while deciding treatment for patient, the effect of pain on other vital signs must be carefully examined. Based on analysis of post-operative deterioration in patient, the main care priorities for patient are management of abnormal vital signs of patient hypertension, pain score and respiratory rate and low urine output). Since Kathleen is obese and has diabetes, hence it is necessary to improve respiratory and vascular function as leaving these sign untreated may further complicate his condition (Mahajan, Lau & Sanders, 2015). The management of hypertension can be done by providing hypertensive medication to patient. After consultation with physician, the nurse can provide beta-blockers or angiotensive converting enzyme inhibitors to control his blood pressure (Wolf et al., 2016). To promote recovery in patient, the nurse also need to focus on dietary changes so that blood sugar level is maintained. Due to high pulse rate and respiratory rate, the patient may have ineffective breathing pattern. Hence, the care priority will be to assess respiratory rate and monitor ventilation status of Kathleen regularly. The rate and depth of respiration and need for oxygenation can also be examined. To provide comfort to patient, proper body alignment should be maintained too (Gordon, 2014). To address the issue of low urine output, there is a need to provide both fluid and drug therapy to prevent dehydration. During gastrectomy, some parts of her stomach were removed. Hence, it will be necessary to monitor wound healing and prevent signs of infection in patient. Apart from clinical intervention for management of vital signs, another care priority is to provide health education to patient so that Kathleen could be motivated to make changes in her lifestyle and eating habits. Since she is a smoker and consumer, making her quit both is necessary to maintain her health in the long term. Smoking has deleterious impact on obese patient and those with obesity (Lycett et al., 2015). Hence, the nurse needs to make Kathleen aware about the harmful effect of smoking on alcohol consumption on her metabolic and respiratory function. After this education, the patient can be supported to quit smoking by means of nicotine replacement therapy. Apart from nurses and medical team, the contribution of dietician is necessary to help Kathleen take low calorie foods and avoid food containing high amount of salt and sugar. Dietary intervention can reduce risk of diabetes related complication and prevent patient from gaining weight. Secondly, the involvement of physiotherapist is necessary as due to surgery, her mobility is affected. By collaborating with physiotherapist, Kathleen can learn to do exercise so that she can build her muscle strength. The role of a bariatric consultant is also necessary to educate Kathleen about her care needs and ways to manage her wound after discharged (Torti et al., 2017). The report discussed about the process of planning care for Kathleen by examining her medical history and discussing about the pathophysiology of obesity. The etiology and pathophysiology of obesity gives the insight that presence of various risk factors predisposed patient to obesity. The review of deterioration in vital signs and justifying them with the path physiology also helped to understand the mechanism by which Kathleen faced such clinical deterioration in patient. 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