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Case Study
Title: The PEG tube leakage of patient who is cerebral palsy, and the administration of sodium valproate for seizure protection.
Summary of Medical History and presenting problem:
Mr S (pseudonym) was an 21-year-old Korean young man, who admitted to the emergency care centre (ECC) with percutaneous endoscopic gastronomy (PEG) tube ? leakage, which was inserted last year for ongoing dysphasia and weight loss. He was a cerebral palsy with spastic quadriplegia, epilepsy, mental retardation, previously spinal surgery for scoliosis. His allergies or adverse reactions are phenobarbitone which was evidence for his agitation and insomnia, and metoclopramide which showed dystonic reaction. His regular medications were domperidone (PEG), omeperazole (PEG), sodium valproate liquid (PEG), and diazepam (PR, PRN). He admitted to ECC in the afternoon.
I was happy to see them because we are the same ethnic group. When I assessed the patient, he was afebrile. His observation was stable except he was bit tachycardic, and he looked dehydrated. I can hear his crackles when he was breathing. His father stated that last three days he showed increase of vomiting to 4 episodes daily, reduced urine output, also some upper airway noise with breathing at times, but no cough or dyspnoea. He had constipation last 3 weeks ago then developed loose bowel motion following laxatives, which settled 3 days ago. He had a couple seizure episodes ten days ago. “My boy’s PEG tube is leaking here” He showed me his son’s PEG tube with a soaked area on the top of his nappy. His father said, “According to the surgeon saying, when the PEG tube is leaking, my boy will be in danger.” His father was a bit anxious.
Assessment Summary including tools used:
The patient was sitting in the electric chair in the sided-room in acute area. He is cerebral palsy which is a group of non-progressive, non-contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement (NINDS, 2010). Cerebral refers to the cerebrum, which is the affected area of the brain, and palsy refers to disorder of movement (NINDS, 2010). Cerebral palsy is caused by damage to the motor control centers of the developing brain (NINDS, 2010).
The patient has PEG tube, which is the most common method of placement of long-term feeding access and is used where patients cannot maintain adequate nutrition with oral intake (Farrell, 2005). The external retention device is applied and the tube fixed in position with a gap of 3 mm between the device and the skin (Farrell, 2005). I had a look at the PEG tube site, but there were no signs of infections, such as bleeding, swelling, redness and warmth. However, I saw the top of his nappy was soaked but the odour was not offensive.
The patient had episodes of seizure 10 days ago. A seizure is the physical findings or changes in behaviour that occur after an episode of abnormal electrical activity in the brain (Medline, 2010). Many types of seizures cause loss of awareness and some cause twitching or shaking of the body (Medline, 2010).
Summary of nursing problems identified:
Risk for deficient fluid volume related dehydration
The parent’s anxiety related to the possibility of seizures and leakage of PEG tube
The right medication management due to prevent seizure
Providing tube care and prevention infection
PEG tube’s surgical treatment and ongoing care
Summary of nursing problems identified:
Risk for deficient fluid volume related dehydration
When I assessed the patient, his father stated that last three days he showed increase of vomiting to 4 episodes daily, reduced urine output. He had constipation last 3 weeks ago then developed loose bowel motion following laxatives, settled past 3 days ago. He looked dehydrated. Therefore, I thought he needed IV leur for intravenous fluid. However, he has a slim arm. I thought it was not easy for me to insert Intravenous leur in his arm. I did not try to insert IV leur to avoid unnecessary pain. I contacted one of ED doctors and explained the patient’s condition. Finally, the doctor assessed the patient and inserted IV leur and took blood samples. I administrated the IV fluid for the patient to prevent dehydration.
The parent’s anxiety related to the possibility of seizures and leakage
of PEG tube
After the IV fluid administration, I talked to the father to wait for medical doctor’s review. After a couple of hours he kept moving the corridor with his son who was sitting in the electric chair. The father said, “My boy got stressed now”. He warned me the possibility of his boy’s seizure. “Does any doctor come to see him? How long do I need to stay?” I explained to the father, “ED doctor will come to see your boy, but I cannot tell you the exact time because of doctor’s priority”. He was not happy because he thought ECC environment made his son worse. The father kept complaining of his son’s stress level.
The father has still waiting for medical doctor for the review of his boy. After 30 minutes he approached me, and complained of the lateness of doctor’s review. I answered ECC’s busy situation, apologised him, and felt sorry. In an effort to control seizure, factors that may precipitate them are emotional disturbances and new environmental stressors (Greenberg, 2001).
When I focused on other patient while the patient’s waiting for medical doctor’s review, a gynaecological patient who was a new admission occupied the room for Pelvic bleeding. The other staff nurse said, “The patient is not staying in his room and keep moving on the corridor. I don’t think that he needs the room” as a consequence, the patient can stay in cubicle area. I thought the father did not trust our staff any more. He was quite upset and talked to me a bit aggressively. At that time the patient can stay in side room due to other patient’s transferring to the ward.
The right medication management to prevent seizure
After 20 minutes he rang call bell and asked some medications for his boy, such as muscle relaxation, sedation, and pain relief. The father said, “If he gets stressed for any environment stimulation, he will get seizure” He urgently told me, “Bring me those medications”. I understood his feeling but I felt like explaining to him to understand this ECC situation as well. I answered the patient’s father, “Dr can only prescribe medications for the patient. I will contact to the doctor and relay your message and concern. It will take time to do that.”
I power paged to contact the Dr, and finally explained about the father’s concerns. His medications and food could not go through his PEG tube because his PEG tube was suspicious of leaking. The patient could not take medication per oral and per PEG tube. As a result, the patient’s medications had to be administrated by IV route until his PEG’s tube was fixed. The doctor had a look at the concerto, and read his medical summary to find his right medications. The doctor charted sodium valproate (Epilim) and IV route after reviewing the MINS. Cooperation of the patient and family and their trust is essential for control of seizures (Schachter, 2001).
I couldn’t find the IV medication in ECC department, powerpaged the clinical duty manager to get the medication, and also had to wait the medication until the medication was delivered.
I also reported to the father what I had so far done for his boy. For example, according to Dr’s saying, it is safe for him to take Epilim as he may have had a seizure episode while in hospital. We have to give the medication intravenously due to the PEG’s tube leakage suspicion. Any patient given an incorrect medication may suffer adverse effects, and patient with epilepsy are at risk for status epileptic from having their medication regime interrupted (Vemarec, 2001). The father understood the situation but still anxious because of the delay of administrating medication.
Finally I could get the medication. However, I was not really sure of administering dilution of the right dosage of the medication. I phoned the CCN, explained the situation, and wanted her to support me. The CCN encouraged me to do, and talked to senior ED. He rang to
Everything was organized at that time, such as the right medication, the right route, the right dosage, including the right person, etc. I handed over the patient’s medical condition to the evening staff.
The next day I asked the other staff nurse about the patient’s condition. One of staffs administered the IV Epilim after I left the department.
Providing tube care and prevention infection
According to Dr’s note, subsequently there was an episode of spike temp and sinus tachycardia, IV Augmentin started for aspiration pneumonia. PEG reviewed later by Gastro nurse specialist, impression leaky PEG secondary to evaporated balloon content which was reinflated to create a seal for its continued use. PEG feeding regime reviewed by dietician and appeared satisfactory. Tachycardia gradually settled to 100/min at discharge. The patient showed some ongoing upper airway noise but improved cough.
Surgical treatment and ongoing care
Medical doctor’s discharge summary (2010) stated that it has been recently planned for a PEJ placement rather than PEG, to circumvent the possible SMA-syndrome (superior mesenteric artery syndrome) type of partial obstruction previously noted on CT. According to Merrill (2010), SMA syndrome is well recognized clinical entity characterized by compression of the third, or transverse, portion of the duodenum between the aorta and the superior mesenteric artery, which results in chronic, intermittent, or acute complete or partial duodenal obstruction.
The patient received input from the gastro team who re-introduced the idea of a PEG tube to circumvent vomiting and pooling of feeds secondary to probable SMA syndrome. Family meeting was held with interpreter to discuss this, and had a PEG tube extension inserted via gastroscopy. Procedure was performed with successful placement of PEJ tube.
According to district nurses Specialist (2010), a new 20 French PEG was placed and a 9 French jejuna feeding tube extension was inserted into the new PEG feeding tube. Teaching was given to Mr Kim as sole caregiver now of his son to ensure that there was adequate flushing with this smaller feeding tube. The patient should still be sat up while feeding to prevent any aspiration of his saliva with the ongoing dysphagia he has.
Summary of client /family outcomes:
The patient was administrated IV fluid by staff nurse due to patient’s dehydration.
The patient got the right medication due to collaborate with health care professionals.
The patient was administrated IV antibiotics by staff nurse due to his aspirated pneumonia.
Initially the patient’s father had a tense situation due to ECC busy situation, but medical doctor made the patient’s plan for his PEG tube surgical treatment and ongoing care.
Reflection on nursing practice, outcomes and own learning from review
Controlling the anxiety
The patient’s father showed me as a tense emotional state. He had to wait for long time to review doctors and did not know the exact time of staying. The staff gave the patient’s room to the other patient. Therefore, he thought staff nurse could inappropriately respond to him. He was quite upset and talked to me a bit aggressively.
At that time I needed to listen actively and focus on the father’s personal feelings. Even though ECC was busy situation, I must be vigilant about the patient and the father who worries excessively. When the father asked me to bring the medications, I should understand his concerns firstly, and had to discuss the importance of safety and the patient’s overall sense of well-being. When the father asked me the medications of sedations and muscle relaxations, and pain relief analgesia, I thought he wanted to try to anything for his boy to bring down his stress level. Sometimes I found that the parents (not everybody), who has child with disability, such as Down syndrome, or cerebral palsy, diabetes with insulin dependent, showed high levels of sensitivity or anxiety.
For example, when I tried to take blood sample, or IV leur, some parents showed overreaction to me. I took some water from tap, which is drinkable, in order to administer the medications to the patient. However, the parent’s father was upset to me. At this time the CNN had to explain to the patient to persuade the patient’s parents. I believe that they need more support and I understand their physical, emotional, and mental stress when they were going through.
The right medication
It took some times to get the right medication, including the right dosage, the right route, and the right time. I collaborated with the doctors, clinical charge nurse, and duty nurse manager to administrate the right medication. Intermittently I reported to the father about the progress of medication but he was not happy due to worry his son’s medical condition. However, I tried to act as best as I could. I should explain all procedures, policies, medications, treatments, or protocols for patient’s care to understand the situation rationally.
Collaborate and communication with health professional and parents
I practice partnership in relation to empower my patient to be involved in his own medical procedures and nursing care. Due to his limited body functions, I became empathetic and understanding with my patient’s capabilities and family’s level of stress. I promptly notified the doctors, CCN, DNM and shift coordinator about the conditions of the patient, and their family’s concerning and the stage of progressiveness. I believed I developed nursing skills and gained more confidence by collaboratively working and communicating with staff. However, I felt I need to openly communicate with the family to reduce their stress level.
Knowledge extension
The patient medical condition was complicated. He has cerebral palsy and previous spinal surgery for scoliosis. Recurrent PEG leakage due to ongoing dysphagia and weight loss, re-inserted, recurrent vomiting ? SMA syndrome, which PEJ feeding tube placed in place of PEG. He has currently vomited and diarrhoea. I can understand the patient’s medical condition as a whole and father’s concerning after reading the summary of the patient’s note.
In this case I, as emergency nurse, should learn or extend my knowledge about the PEG, such as any leakages or balloon related feeding problems, etc, which can deal with the patient efficiently. Repositioning etc would not be able to be done by the nurse in an ED setting at that time. The gastro nurse would be helped and short cut the time of review if I refer to them directly.
I will make a difference on the patient or the family medically or emotionally in my small little ways through this experience in the future.
References
Drugs.com. (2000-2010). Diazepam. Retrieved from 29/10/10. http://www.drugs.com/diazepam.html
Farrell, M. (2005). Smeltzer & Bare’s textbook of medical-surgical nursing. (1st Australian and N.Z. ed.) NSW: Lippincott Williams & Wilkins.
Medline. (2010). Seizure. Retrieved from 30/10/10. http://www.nlm.nih.gov/medlineplus.
Merrill, K (2010). Superior mesenteric artery syndrome, Emedicine, Retrieved from 30/10/10 http://emedicine.medscape.com
National Institute of Neurological Disorders and Strokes (2010). Cerebral Palsy. National Institute of Health. Retrieved from 15/11/10. http://www.ninds.nih.gov/
Vernarec, E. (2001). Lamictal. Packaging gets makeover to reduce errors. RN, 64(10), 96.
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