Anxiety experiences different in everyone in different times, it’s a normal response to actual danger, promoting the body through stimulating of sympathetic and parasympathetic nervous system will be helpful action. (Springhouse, 2007). Anxiety affects our whole being. It affects how we feel, how e behave and has very real physical symptoms. It feels a bit like fear but whereas we know what we are frightened of, we often don’t know what we are anxious about. Mild anxiety is vague and unsetting-severe anxiety can be extremely debilitating (Medical News Today, 2010). Acute pain it is not good sign about tissue damage, (Gulanick et al., 2010).

1- How can you manage Evert’s pain?

As a nurse, the following can be done to manage Evert’s pain:

Anticipate need for pain relief: early analgesic intervention helps to decrease pain.

We have to respond to pain complain as soon as possible: early respond to patient’s complaining of pain its help to decrease anxiety and on other side its help to make a trust relationship.

Trying to eliminate the addition of stressor or comfort as we can: help patient to tolerate the pain either these elements from environment, intrapersonal, or intrapschic factors.

Make an good atmosphere of comfort, relaxation, and sleep: we have to help patient to be in good atmosphere to take a rest and sleep comfortably because some patient’s experiences of pain may will put them in fatigue condition, so we have to put him in darkroom and disconnected his phone (Gulanick et al., 2010).

2- What can you do to alleviate Evert’s anxiety?

The following interventions can be done to alleviate Evert’s anxiety:

Anticipate need for pain relief: early analgesic intervention helps to decrease pain.

We have to respond to pain complain as soon as possible: early respond to patient’s complaining of pain its help to decrease anxiety and on other side its help to make a trust relationship.

Some of cognitive behavioral strategies as follows:

Images: if patient use his mental images its help to distract stress and pain with using all his five senses.

Distraction techniques: heighten one’s concentration upon nonpainful stimuli to decrease one’s awareness and experiences of pain and reduce stress such as nerve stimulation and breathing modifications.

Use the relaxation exercises: it’s important for patient to decrease attention and pain.

Use breathing exercises.

Using Music Therapy in treatment: the music therapy works well on patients. Its apart of treatment team (Mount& Munro, 1978).

3- Why was Evert’s wife so worried the Evert did not eat? Should you treat with IV nourishment?

Evert’s wife was worried because Evert might suffer from dehydration and malnutrition, and this will cause electrolyte imbalances and his condition will be aggravated by this, his health will deteriorate more rapidly. As a nurse the treatment plans for Evert to restoring fluid and correcting any electrolyte imbalances. Early treatment intervention its help to prevent any potentially life threatening such as hypovolemic shock (Gulanick et al., 2010).

4- Make a nursing care plan for Evert. Explain and motivate you suggested nursing intervention in according with the four key areas listed in the introduction?

A. Assessment: defining characterized: Evert verbalizes pain, especially in connection with moving, narrowed focus such as withdrawal from social and physical contact, relief or distraction behavior( seeking out staff to do activities), restless, anxiety manifested, expression of helplessness, and inability to procure fluid and food.

B. Nursing Diagnosis: actual diagnosis: acute pain related to severe anxiety.

Nursing outcome: Evert will be enable adequate relief of pain when moving or ability to deal with the pain are not fully satisfied. Evert is able to recognize signs of anxiety.

Risk diagnosis: risk for fluid volume deficit related to inability to procure fluid and food.

Nursing outcome: sufficient fluids volume and electrolyte balance as evidence by urine output grater than 30ml/hr, consistency of weight, and normal skin turgor (Gulanick et al., 2010).

C. Nursing Intervention:

1. Assess pain characteristics: Quality as example sharp, burning, and shooting. If we want to measure the level of severity from 1 to 10, with 10 level it is more sever to patient. Location according to anatomical description, onset if it’s gradual or sudden. Duration for how long is it intermittent or continuous (Gulanick et al., 2010).

2. Administer parenteral fluids as ordered: the nurse must give patient IV fluids as needed and as ordered, challenge with intermediate infusion of fluids for Evert who is unable to procure fluid and food (Gulanick et al., 2010).

3. Assess patients and help them to recognize the sign and symptoms of anxiety: it is important for patients to be able to know and recognize the sign and symptoms of anxiety, which will help Evert to be able to solve his sign and symptoms when anxiety level is low (Gulanick et al., 2010).

4. Relieving factors. Monitor the patient signs and symptoms with pain: Like Heart Rate, Temperature, Blood Pressure, skin color, restlessness, and patient inability to focus. Some patient’s ignoring sign and symptoms of pain when occur. The patient’s must inform the nurse about these sign and symptoms because it well helps the nurses in evaluation (Gulanick et al., 2010).

5. Assessing the main causes of pain: it is important for doctors and nurses to look to the causes of pain because the different causes having different treatments (Gulanick et al., 2010).

6. Assess the patient knowledge regarding pain relief strategies: a lot of patient’s may not realize how effective non drug method on them either with or without pain killing medication. So, we have to explain to them this point carefully (Gulanick et al., 2010).

7. Evaluate patient’s regarding response to pain medications or therapeutics: it is important to give patient’s chance to tell nurse about his expression regarding pain medication, and also let him to talk about effect of medication on him (Gulanick et al., 2010).

8. Assess patients from cultural, intrapersonal, intrapsychic, and environmental degree factors which are share to relief pain: these factors will affect patient’s expression on experiences, for example some cultural you have complete freedom to express how you fell (Gulanick et al., 2010).

9. Evaluate what is the meaning of pain to individuals: it is important to all patients’ to know the meaning of pain because if he doesn’t know it will affect him to response (Gulanick et al., 2010).

10. Assess patient’s regarding expectation of pain relief: it is important for nurses to know patients expectations regarding pain relief either the pain decreased or pain disappeared. Because these patient expectation will help the nurse to know either the pain relief or need to participate in another treatment (Gulanick et al., 2010).

11. Assess patients if they would like to explore some other techniques to control pain: it is important to patient to know that there is many ways of pain relief (Gulanick et al., 2010).

D. Evaluation: Evert manifests adequate relief of pain, recognizes sings of anxiety, and demonstrates positive coping mechanism. Evert’s urine output greater than 30ml/hr, weight is consistent and with normal skin turgor (Gulanick et al., 2010).

FOUR MAJOR AREAS:

Symptoms Control: A palliative approach, involving attention to symptoms control and the psychological, social and spiritual wellbeing of the patient and their family is relevant at all stages of the disease, and it has been argued that attention to these aspects combined with understanding of the patient’s feelings and concerns all contribute to improving quality of life of the person with acute pain (Montazeri et al., 1998). The principles of symptom control, which are used as standard by clinicians include: assessment of the symptom, understanding the meaning ascribed to it by the patient, explanation of the likely cause, investigation should only be undertaken if they will change the course of action to be followed, institution of treatment based on known or likely etiology, available options for treatment, and wishes of the patient, monitoring of the response to treatment and modification as necessary ( Steinhauser et al., 2000).

Communication: make a good relationship between nurse and patient which well make patient comfortable in communication. Trying to orient the patient to the environment and help him to take experiences from people as needed, and also when the patient is aware and oriented very well it will help him to be comfort and may will decrease anxiety. Help the patient to express anxious felling if the patient has ability to describe them. (Gulanick, 2010).

Teamwork: during assessment pain in patient, contributions from the multidisciplinary team is very important to evaluate the following: a detailed history of each pain, full examination, and psychosocial assessment, a history of analgesics already used and the response to them, investigations to confirm the diagnosis, depending on the stage of disease and the treatment options (Ripamonte et al., 1997). Perception of pain will be influenced by the meaning of pain for the patient. Open discussion among team members, family and patient, allowing fears to be discussed, providing explanation of the symptoms and reassurance of continued support is important (Twycross, R. G, 1993).

Family: the nurse must teach patient and his/her family about intervention regarding inadequate intake, and explain to him the importance of intake such as drinking fluids and eating food. Explanation of the importance of the rationale and intended effect of treatment program to alleviate pain, diminish anxieties (Gulanick et al., 2010).

Treatment of Acute Cholecystitis

In this paper, I am going to talk about a patient I had the chance to assess in the clinical area. I spent one day with this patient where I gave him some of his medications and did a head to toe assessment on him. In this paper, I am going to illustrate briefly his demographics, his chief complaint, his past health history, and I am going to focus on the medication he is taking.

GG is a 49-year-old High school teacher of Mexican descent.  He has been admitted to the hospital because of his acute pain in his abdomen and back. When discussing his health history, patient states that he has hypertension and gout. The patient reported no having any prior episodes of pain in his abdomen and his posterior right side. He reported having sudden sharp pain in those areas and cramping. Patient stated he quit smoking two years ago, denies the use of recreational smoke and drinks occasionally, specifically two beers on weekends. He is 5 feet 8 inches tall and weighs 205 pounds; his oral temperature is 99.8, pulse 72, respirations 18, blood pressure 150/82; On physical examination, his abdomen was tender to palpation.

Furthermore, he presented redness, swelling, and tenderness in the metatarsophalangeal joint of the first toe of the right foot. He had a fever has demonstrated by his high temperature, and his labs were abnormal; specifically, his white blood cell count was above average, specifically 12000 units. After this finding, the provider ordered a computed tomography (CT) scan of his abdomen, and the results showed acute cholecystitis. Therefore, the provider ordered two antibiotics to eliminate the infection and pain medications to reduce the patient’s pain.

The patient is currently receiving the following medications: Rocephin (Ceftriaxone) 2 grams intravenous every 24 hours combined with Flagyl (Metronidazole) 500 mg intravenous every 8 hours to get rid of the infection. Tylenol (Acetaminophen) 1000mg orally as needed every 6 hours for his pain combined with Motrin (Ibuprofen) 600mg orally as needed every 6 hours for his pain. On top of this medication’s patient can receive Oxycodone 5 mg orally every 4 hours for his pain if Tylenol and Motrin do not work. The patient had the following home medications, Zyloprim (Allopurinol) 100 mg orally every 12 hours to treat the patient’s gout and Micardis (Telmisartan) 80 mg orally once a day to treat his hypertension.

One of the medications I am going to focus on is an antibiotic GG is currently taking. Specifically, metronidazole. This antibiotic is in the nitroimidazoles family and is used in the treatment of anaerobic infections, in this case for intra-abdominal infections, and it is usually used in conjunction with a cephalosporin, in this case, in fact, it is used together with Ceftriaxone. Its action is to disrupt DNA and protein synthesis in a susceptible organism, and its effect is to kill bacteria. This antibiotic is absorbed about 80% after oral administration and 100% via intravenous. As far as distribution, it is widely distributed into most tissues and fluids. It crosses the placenta and enters fetal circulation rapidly and enters breast milk in concentrations equal to plasma levels. Metrodinazodole is partially metabolized by the liver, partly excreted through urine and a minimal part in the feces (McCuistion, Yeager, Winton, & DiMaggio, 2018, pg.371).

Metronidazole side effects regarding the central nervous system are dizziness, headaches, and with intravenous administration encephalopathy and aseptic meningitis. For the gastrointestinal tract, the most common side effects are abdominal pain, nausea, dry mouth, and vomiting. Regarding the skin, it can cause rashes, urticaria, and skin irritation in general. Three adverse effects that need to be monitored for this drug are seizures, Stevens-Johnson syndrome, and superinfection. Some contraindications for this medicine are hypersensitivity and first-trimester pregnancy, on top of that, it should be used with caution when breastfeeding. Some precautions to have when using this drug are in cases of severe hepatic impairment, history of blood dycriasis, and when receiving corticosteroids. As far as interactions, this drug should not me took at the same time with cimetidine because it could decrease metabolism. Not to be taken with rifampin, which could increase metabolism and reduce effectiveness. Avoid taking it together with warfarin or lithium due to its increased effects of these medications. Furthermore, avoid taking with alcohol this could cause confusion and psychosis ((Vallerand & Sanoski, 2018, p.850).

The administration of this medication can be oral, topical, vaginal, and intravenous like in our case.  The maximum dose to be given intravenous is 4 grams in one day for adults, GG is currently taking 500 mg three times a day. Therefore, his dose is within the safe dose. There are no accu- checks with this medication. As far as labs in order to assess the efficacy of the antibiotics we would check his blood results to see if the white blood cells are going down meaning that the infection is diminishing, also we want to check renal and liver function since this specific antibiotic since it can cause liver and renal problems (Vallerand & Sanoski, 2018, p.850).

In the case of GG, this medication is prescribed to cure the infection in his cholecystic. Since his cholecystic is infected, the provider orders this antibiotic to eradicate the bacteria and kill the infection.  The provider could have chosen a different class of antibiotics such as Aminopenicillins like amoxicillin, which is excreted unchanged in the bile. In patients with normal biliary function, the concentration of amoxicillin is three times higher in bile than in plasma.  For example, the biliary level of ceftriaxone is 28 to 45 times higher than the plasma concentration. The bile concentration remains high even in patients with obstruction of the gallbladder. The combination of ciprofloxacin with metronidazole may be an alternative to amoxicillin/clavulanic acid in patients with mild or moderate ACC and no risk factors for resistance. In this case, the provider preferred a combination of ciprofloxacin and metronidazole. In acute cholecystitis, metronidazole is prescribed in conjunction with other antibiotics; nitroimidazole derivatives are assigned in addition to the antibiotic base suspected mixed aerobic-anaerobic infection as we can see in this specific case metronidazole has been prescribed together with ceftriaxone to increase its action (Fucks, Cossé, & Régimbeau, 2003, para.11).

When giving metronidazole, we need to assess the patient for infections, by checking his vital signs, and appearance of wounds if any, sputum, urine, and stool for infection. Also, we need to check blood; specifically, the white blood cells count at the beginning and during the therapy. Then we need to monitor intake and output and daily weight, especially for patients on sodium restriction. Another essential thing to do is to check the patient periodically for rash due to the possibility of Steven-Johnson syndrome, which is an adverse effect of this medication. Potential nursing diagnoses with this medication can be a risk for infection and diarrhea. When giving this medication the patient needs to be taught to avoid intake of alcoholic beverages, inform patient that the medicine can cause an unpleasant metallic taste and that it can cause dizziness, therefore avoid tasks that require alertness and not be alarmed if urine turns dark. Very important is to notify the provider if a rash occurs.  Lastly, the desired outcomes of this medication are the resolution of signs and symptoms of infection (Vallerand & Sanoski, 2018, p.852).

As we already discussed, metronidazole is better to be avoided in the first trimester of pregnancy, Metronidazole crosses the placental barrier, and its effects on the human fetal are not known.  Safety and effectiveness in pediatric patients have not been established. In elderly geriatric patients, monitoring for metronidazole associated adverse events is recommended, especially for decreased liver function in geriatric patients can result in increased concentrations of metronidazole that may necessitate adjustment of metronidazole dosage (Vallerand & Sanoski, 2018, p.851).

The other medication I am going to focus on is an anti-inflammatory GG is currently taking. Specifically, Ibuprofen. This medication is a nonsteroidal antiinflammation agent (NSAID)and is used to decrease pain and inflammation. Its action is to inhibit prostaglandin synthesis. This antibiotic is absorbed about 80% after oral administration and 100% via intravenous. As far as distribution, it is widely distributed into most tissues and fluids; however, it does not enter breast milk in significative amounts. Ibuprofen is mostly metabolized by the liver and excreted through the kidneys in a small amount ((Vallerand & Sanoski, 2018, p.666).

Ibuprofen side effects regarding the central nervous system are Drowsiness, dizziness, headache, confusion, insomnia. For the gastrointestinal tract, the most common side effects are gastric distress, nausea, vomiting. It can also cause blurred vision, edema, and tinnitus. Some adverse effects that need to be monitored for this drug are myocardial infarctions, various types of dermatitis, Stevens-Johnson syndrome, and gastrointestinal bleeding. Some contraindications for this medicine are hypersensitivity, active gastrointestinal bleeding, and ulcers. Should be used cautiously with patients that have had a coronary heart bypass. Some precautions to have when using this drug are in cases of severe renal impairment since it can cause nephrotoxicity history and with cardiovascular diseases.  As far as interactions, this drug should be avoided when taking warfarin sound, it can Increase bleeding, and with some foods like garlic and herbal supplements such as ginger, gingko, and ginseng. Increased effects with phenytoin, sulfonamides, warfarin, cephalosporins, and decreased effect with aspirin (Vallerand & Sanoski, 2018, p.667).

The administration of this medication can be oral as in our case and intravenous. The maximum dose to be given orally to adults is 3 grams, GG is currently taking 600 mg three times a day. Therefore, his dose is within the safe dose. There are no accu- checks with this medication. Regarding labs, it is critical to check blood urea nitrogen (BUN), creatinine, complete blood count (CBC), and liver function (Vallerand & Sanoski, 2018, p.668).

In the case of GG, this medication is given to decrease the patient’s pain due to his infection. Ibuprofen is a non-steroidal anti-inflammatory drug with anti-inflammatory, analgesic, and antipyretic activity. More in detail, ibuprofen can perform these activities by inhibiting cyclooxygenase (COX). Ibuprofen works by inhibiting COX-2 consequentially preventing the synthesis of prostaglandins responsible for fever, inflammation, and pain. However, it is crucial to point out that ibuprofen is not selective for COX-2; therefore, it is also able to inhibit COX-1. This latter inhibition is at the origin of some of the side effects typical of all non-selective NSAIDs such as gastrointestinal side effects (McCuistion, Yeager, Winton, & DiMaggio, 2018, pg. 311).

Before giving this ibuprofen, we need to obtain a drug and herbal history and report any possible drug-drug or herb-drug interactions. After we have given the medication, we need to assess for GI distress and peripheral edema, which are common side effects of NSAIDs. Report to the provider immediately if the patient has GI discomfort since this is one of the adverse effects of this medication. We need to access for asthma and urticaria as well. Observe the patient for bleeding gums, petechiae, ecchymoses, or black tarry stools. When giving this medication, we need to check labs, specifically, if BUN is elevated, creatine levels and urine output. Since this is a pain medication, we have to re-assess the pain prior and 1-2 hours following noting the type, location, and intensity. When teaching the patient about the medication, we will advise the patient to avoid alcohol when taking NSAIDs.  Moreover, we would recommend the patient to consult the doctor if visual disturbances, tinnitus, or rashes appear. Potential nursing diagnoses with this medication can be acute pain. Lastly, the desired outcomes of this medication are decreased in the severity of pain (Vallerand & Sanoski, 2018, p.669).

Ibuprofen is better to be avoided after 30 weeks’ gestation because it may cause premature closure of fetal ductus arteriosis.  We need to be careful when using it with our older population since it can increase the risk of adverse reactions secondary to age-related and drug interactions, also need to be closely monitored for decreases in renal and liver function. As far as infant’s safety has not been established for infants under six months (McCuistion, Yeager, Winton, & DiMaggio, 2018, pg. 314).

We looked at the patient’s problem and the treatment he had to cure his acute cholecystitis. We talked about his medications, in particular about antibiotic metronidazole and pain medication, ibuprofen. We discussed in depth the mechanism of action, nursing assessment and lifespan considerations of this medication and the rationale that the provider used to prescribe this medication which helped the patient get better and get discharged from the hospital.

References

• Electronic Health Record
• Fuks, D., Cossé, C., & Régimbeau, J.-M. (2013). Antibiotic therapy in acute calculous cholecystitis. Journal of Visceral Surgery, 150(1), 3–8. https://doi-org.dax.lib.unf.edu/10.1016/j.jviscsurg.2013.01.004
• McCuistion, L.E., Yeager, J.J., Winton, M.B., & DiMaggio, K.  (2018).
  
  Pharmacology: A patient-centered nursing process approach
  
  (9
  
  ^th
  
  ed.). Philadelphia, PA: Saunders.
• Vallerand, A.H., & Sanoski, C.A. (2018).
  
  Davis’s drug guide for nurses
  
  (16
  
  ^th
  
  ed.). Philadelphia, PA: Davis.

Appendix A

Pharmacology Patient Profile

Demographic Data

Patient Health History

Past or family History of problems in the Following Categories:

Current Medications

Physical Assessment

Appendix B

Medication Worksheet