Elderly Patient Care and Gastroesophageal Reflux Disease

The provided assignment revolves around the care of an elderly patient, John, who is experiencing symptoms of gastroesophageal reflux disease (GERD). The case study delves into the potential medication interaction between clopidogrel and zantac, which may exacerbate or alleviate his condition. Furthermore, it highlights John's increased risk of cardiac arrest and falls due to his age, emphasizing the importance of close monitoring and follow-up care. The assignment draws from various medical sources, including textbooks, journal articles, and online resources, providing a comprehensive understanding of the patient's condition and necessary interventions.

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Running Head: CLINICAL CASE STUDY
Clinical case study
Author’s name:
Submission date:

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CLINICAL CASE STUDY
Contents
Introduction.................................................................................................................... 2
First clinical review..................................................................................................... 3
Nursing intervention................................................................................................ 5
Second clinical review................................................................................................ 6
Nursing interventions.............................................................................................. 7
Third clinical review.................................................................................................... 7
Nursing interventions.............................................................................................. 9
Conclusion.................................................................................................................. 9
Bibliography............................................................................................................. 11

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CLINICAL CASE STUDY
Introduction
This is a case study analyzing the condition of our client John who is an 81 year
old retired farmer. John is married to Jean and together they live a happy life. They are involved
in the community and they are fit both physically and socially. John has a history of transient
ischemic attack and gastro esophageal reflux. He takes clopidigrel for the transient ischemic
attack and zantac for the gastro esophageal reflux (Kletzl, 2015). John wears reading glasses
and he is a non-smoker. He goes for regular medical check-ups and he weighs 104 kilograms
with a height of 180 centimeters. On calculating his basal mass index our client John has a basal
mass index of 57.7 which indicates that he is obese.
At the scene of the accident John was given morphine 2miligrams stat for the
sharp pain he was experiencing on the left upper thigh into and into the hip region, and on route
he was given a repeat dose of 2milligrams morphine, he was also given 250 milliliters of normal
saline stat before arrival to the emergency department (Hadzic, 2017). On arrival to the

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CLINICAL CASE STUDY
emergency department John was started on oxygen(fraction of inspired oxygen at 6litres per
minute) and he was hydrated with normal saline at 200mililitres per hour in the right cubital
fossa.
This case study focuses on the day John was found unconscious in his farm. He had
abrasions on his chest, extensive bruising to the left hip, he was unable to bear weight and his
legs were not shortening (Stenhagen, 2014). John reported sharp pain on the upper thigh and
left hip region, he also reported chest discomfort. He was taken to the hospital in a fairly stable
condition with a Glasgow coma scale of 15 an elevated heart rate of 94 and a slightly elevated
respiratory rate of 28 breaths per min. His condition later deteriorated to an extent he was
resuscitated. John responded to the resuscitation which involved the use of adrenaline and
defibrillation.
In this case study I will analyze the care provided to John and the events which
might have led to the deterioration of his condition. I will analyze the factors that may have
predisposed john to the complications he acquired while in the hospital and the drug interaction
between zantac and clopidigrel (Naidoo, 2016).
First clinical review
On arrival to the emergency department the patient was fairly stable and he was started
on oxygen therapy and hydration with normal saline. On the first nursing assessment that was
conducted John had a shallow breathing with a symmetrical rise and fall of the chest. He could
speak in small sentences. On auscultation the breath sounds were heard and they normal but his
chest was tender to touch, which could have resulted from the abrasions on the chest. There was

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CLINICAL CASE STUDY
grazing over the left side of the chest and his capillary refill was less than 4 seconds. John had
pink extremities and they were cool to touch.
On pain assessment, John stated that he was in pain and ranked it at 3/10 during rest
and 10/10 during movement, john had normal sensation on all his limbs. He was still on oxygen
and his oxygen saturation was at 92%, his Glasgow coma scale was at 14 and his heart rate was
at 120 beats per minute which indicated sinus tachycardia with a reduced blood pressure of
96/50. His respiration rate was slightly elevated at 26 breaths per minute (Wijdicks, 2015).
John had a temperature of 35.9 Celsius which was markedly reduced in comparison to his
temperature during admission which was 36.4 degrees Celsius.
Our client condition is deteriorating as indicated by the vital signs. His blood
pressure is falling and his temperature is falling. He had an initial blood pressure of
122/54mmHg but on the nurses assessment in the clinical review his blood pressure had dropped
to 96/50mmHg. His temperature had dropped from an initial temperature of 36.4 degree Celsius
to 35.9 degree Celsius. His heart rate had also increased to 120 beats per minute. All of these
changes in his vital signs indicate a worsening condition that requires urgent attention to halt the
onset of complications.
According to John’s history he has been on zantac which is a histamine-2 blocker
and clopidigrel which is used in the prevention of a heart attack for patients who are predisposed
to heart attacks. John was predisposed to developing a heart attack because he had a history of
transient ischemic attack. His gastro esophageal reflux is attributed to his alcohol intake which is
3-5 times a week, which is why he is on Zantac histamine 2 antagonist medications (Gyawali,
2017).

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CLINICAL CASE STUDY
During the review a CT scan of the abdomen was requested and the surgical team
was consulted. An indwelling catheter was inserted and John was put on nil per oral. This meant
that he was not supposed to take any solid or liquid food through the mouth.
Nursing intervention
As a nurse I will:
Ensure that John receives all the prescribed medication at the right time in order to
prevent occurrence of complications and promote complete adherence to medication (Morton,
2017).
Provide warm blankets and a warm environment to prevent him from experiencing
hypothermia, which may result from his falling temperatures (Morton, 2017).
Provide fluids as prescribed in order to raise John’s blood pressure. The falling blood
pressure might result in a complication that is why John is on normal saline to help raise his
blood pressure (Morton, 2017).
Use aseptic technique while inserting the catheter and ensure that John has been taken
for the abdominal CT scan and all the preparations are made including contacting the surgical
team. This is to ensure that the entire tests prescribed are conducted and urinary output is
measured (Morton, 2017).
Ensure that John receives his oxygen and is on complete bed rest with minimal
interference to reduce the chances of complications (Morton, 2017).

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Second clinical review
John condition was assessed by the clinical team and strategies were formulated to
prevent any further decline in his health status. Preventive measures were taken to ensure that his
blood pressure was maintained at more than 100mmHg (Manning, 2015). Despite the
intervention John’s condition further deteriorated and the rapid response measures were initiated
(Harshman, 2017).
John’s vital signs continued to worsen, his blood pressure dropped to
92/54mmHg, his respiratory rate increased to 30 breaths per minute, and his heart rate increased
to 134 beats per minute. His oxygen saturation reduced to 88% despite being on artificial oxygen
at 6litres per minute (Chan, 2018). His Glasgow coma scale reduced to 11 and his capillary
refill was at 4 seconds.
These changes lead to the initiation of the rapid response. A central venous access
device was inserted which is used for measuring central venous pressure and is also used as a
quick access to the blood circulatory system during resuscitation. John was receiving fluids at
200mililitres per hour with an aim of raising the blood pressure (Ozekcin, 2015).
Due to John’s worsening condition a rapid response was initiated because he was not
in the intensive care unit. His condition was closely monitored for further complications. His
condition was tracked for possible complications which were associated with his past medical
history of experiencing a transient heart attack and gastro esophageal reflux. His past medical
history predisposed him to complications such as heart attacks and gastrointestinal bleeding
which would result from over-production of gastric acid (Ozekcin, 2015).

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CLINICAL CASE STUDY
Nursing interventions
The nurse should ensure:
The insertion of the central venous access device is done at the right time, by the
right person and strict aseptic technique is observed to prevent complication such as infections
which may arise from the procedure (Morton, 2017).
That the access site is not bleeding and administer pain medication to help manage
the discomfort associated with the insertion of the central venous access device (Morton,
2017).
That the clinical indicators which would detect any form of complications are
carefully monitored, because our client is in the rapid response phase (Morton, 2017).
The nurse should ensure the client receives his medications to promote drug adherence
(Morton, 2017).
Third clinical review
John’s condition continued to worsen. His vital signs further deteriorated which
called for resuscitation. His blood pressure significantly dropped to 52/25mmHg. This was the
only indicator to raise an alarm for quick action. A drop of systolic pressure from 92 -52 signifies
and worsening state of condition and the need for urgent attention to raise this blood pressure to
prevent further complications like death and total unconsciousness. His diastolic pressure
dropped from 50- 25mmHg and this was an additional indicator for resuscitation and his heart
rate significantly increased to 144 beats per minute from 120 beats per minute. The drop in
John’s blood pressure and the increase in his heart rate showed that John’s condition was

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worsening. The cardiac monitor raised and alarm because John was in ventricular tachycardia
and he needed to be resuscitated quickly to normalize the heart rhythm (Osborne, 2015).
Cardiopulmonary compressions were started and the advanced life support team
was called to assist in stabilizing John’s deteriorating condition. John was attached to an
automated external defibrillator, a rhythm of 200joules was administered but it did not cause any
effect on the ventricular tachycardia rhythm. John remained unresponsive and this state
prompted the team to administer adrenaline which was augmented with a second rhythm to
revert the abnormal rhythm to a normal heart rhythm (Osborne, 2015).
The second shock made John responsive and his vital signs improved. His blood
pressure rose to 72/48mmHg and the heart rate rose to 89 beats per minute, the cardiac monitor
indicated a sinus arrhythmia and two minutes later John vitals reverted back to almost normal
(Watkins, 2016). His blood pressure rose to 99/64mmHg, his heart rate rose to 82 beats per
minute, and his respiratory rate normalized at 14 breaths per minute and his oxygen saturation
remained at 88 %. John was put on a non-Rebreather mask with an increase in the Glasgow coma
scale to 14 from 11 (Teasdale, 2014).
After being put into the rapid response state, John’s condition worsened which lead
him to being resuscitated by use of cardiopulmonary compressions and defibrillation.
Resuscitation on the first attempt did not work, but on the second attempt with use of adrenaline
and electrical shock wave from an automated external defibrillator reversed John’s worsening
condition; therefore he was able to respond and his condition improved.

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CLINICAL CASE STUDY
Nursing interventions
The nurse should ensure that no harm comes to John and that the person offering the
resuscitation is highly skilled and qualified at resuscitation (Morton, 2017).
The nurse should ensure that John is well oriented to what happened to prevent psychotic
episodes that may be caused by fear and anxiety from being resuscitated (Morton, 2017).
The nurse should ensure that John’s vital signs are well documented and all the
procedures performed on him are documented for future reference (Morton, 2017).
Conclusion
According to the bio data availed John is and elderly man who is at risk of
developing cardiac arrest due to his experience with a transient ischemic attack. He is also on
medication for gastro esophageal reflux which may predispose him to abdominal pain and
bleeding due to ulcer formation as a result of increased secretion of gastric acid (Roman,
2017).
The complication experienced by John may be associated with his increasing age
which results to reduce physiologic process such as reduced gastric motility and reduced patency
of the blood vessels. John is also at risk of developing complications associated with obesity
because of his increased basal mass index. These complications may have led to further
complicating his current condition.
John uses clopidigrel a drug used to prevent the risk of developing cardiac arrest in
individuals at risk, thus drug increases the rate of bruising and it may explain why extensive
bruising to the left hip and chest had (Naidoo, 2016). The pain he was experiencing may have
been caused by his fall at his far. Risk for falls is highly increased in the elderly because of

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CLINICAL CASE STUDY
osteoporosis which worsens with old age (Horgas, 2017)s. John’s gastro esophageal reflex
may be worsened by clopidigrel; however this effect is counteracted by zantac.
Due to his increased risk of developing cardiac arrest and his age John should be
closely monitored and his health condition should be closely followed up.

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CLINICAL CASE STUDY
Bibliography
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Intradialytic Hypotension. Nephrology Nursing Journal,, 1(45), 53-61.
Gyawali, C. P. (2017). Classification of esophageal motor findings in gastro‐
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Hadzic, A. (2017). Textbook of regional anesthesia and acute pain management.
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Osborne, S. (2015). The primacy of vital signs–acute care nurses’ and midwives’ use
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