Patient Case Study Assessment

This patient case study assessment provides information about the procedures involved in the lab, patient symptoms and pathophysiology, GI diagnostic tests, nurses' roles, nursing diagnosis, sedation recovery, and nurses' reflection. It discusses the key observations and assessments undertaken for the patient, patient symptoms of persistent epigastric pain and GER, dysphagia and dyspnea pathophysiology, GI diagnostic tests like fiberoptic endoscopic evaluation of swallowing and rectal retroflexion tests, nursing diagnosis of impaired swallowing and aspirations/reflux of gastric contents, sedation recovery levels, and nurses' reflection on the assessment process.

Patient Case study assessment
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University
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Date

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Patient information
Question 1; Procedures involved in the lab
The key observations and assessments undertaken for the patient entailed weight
assessment to measure the patient weight status and allergies were performed to assess drug
intake management. This is often referred to as medical allergy which could be defined by the
adverse reaction which the patient could face. This is key for the patient so as to manage
patient medication management, electrocardium is essential for the patient is essential EKG,
pulse, blood pressure, oxygen oximetry, standard upper respiratory, and retroflection
performed on the gastric body assessments are crucial.
Question 2; Patient symptoms and path physiologic
The patient is experiencing persistent epigastric pain symptoms and GER symptoms
depicted by a burning sensation, chest pains, a sensation of the throat and regurgitation.
Assessments ordered entail screening colonoscopy, stool assessment, and blood hematocrit
blood levels. Assessments conclusion reflects the presentation of dyspenia and dysphagia
(Vakil et al., 2017).
Dysphagia entails swallowing problems which could lead to coughing and choking.
The pathophysiological assessment of the condition is a common function impairment related
to acute stroke affecting stroke patients. It is linked to medical complication condition leading
to difficulty in the intake of food. Swallowing of food is a voluntary and reflexive action
(Cecconi & Di Piero, 2012).
Dyspnea state reflects the state of shortness of breath linked to the uncomfortable
sensation of breathing. Dyspenia pathophysiology depicts complex activation of association
of various pathways which lead to increased breathing rates and simulation of receptors. The
clinical assessment and management of the disease state entail understanding the clinical
presentation of the disease and the underlying cause (Coccia et al., 2016).
Question 3; GI diagnostic test
Fiberoptic endoscopic evaluation of swallowing is a useful procedure in the assessment
of food intake. During the process, assessment of ear, nose, and throat is carried out using a

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thin flexible instrument. This offers an assessment of the throat during the swallowing
process.
Nurse’s roles entail patient assessment through various assessments such as blood
pressure and pulse. Safety assessment takes center stage. A key focus is to ensure
minimization of infection, bleeding, intestine perforations, medication complications, and
organ damage is undertaken. Finally, the nurse’s role is enhanced sedation of the patient and
helps the patient in the overall procedure (Ruiz-Rebollo, 2015).
Rectal retroflexion tests are performed to assess forward view of the rectum and at the
end of colonoscopy. In essence, it entails bending of a section of colonoscopy in order to
facilitate viewing of the back to allow viewing of the rectal canal (Chandran et al., 2015).
Nurses role for the patient entail undertaking various key assessments and facilitating
communication with the patient and provider, further, administration of medication which
include intravenous administration to facilitate patient preparation. Further, procure supplies
need to be availed for the patient. Facilitating the endoscopists is key in ensuring the patient
undergoes complete assessment procedure. Ensuring the patient received the need care post
surgery is curial in ensuring that the patient recovers adequately.
Question 4; Nurses diagnosis
Key nursing diagnosis entails impaired swallowing. This occurrence takes place due to
the inability of the food to be swallowed from the mouth to the stomach. Further, aspiration
of food can occur through structural problem and interruption through the dysfunctional
neural pathways and decreased strength level due to mastication (Ware, 2017).
Further another key nursing diagnosis is an assessment of aspirations or reflux of
gastric contents. The occurrence is due to obstructed GI pathway which could release to
reflux of gastric juice found in the stomach.
Finally, another key nursing intervention is oral phase impairment. This is caused by
the impairment of the swallowing, food falls from the mouth, lack of chewing and long meals
with little consumption, this is further exacerbated by the body’s GI tract from clearing food
from the oral cavity, thus management of these key factors is crucial in the post-recovery
phase of the patient (Yung et al., 2017).

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Question 5; Sedation recovery
Analgesia medication is used to enhance and achieve analgesia or relief pain. It uses
sedation and analgesia works in a manner to relieve pain. Administration procedure depends
on the level of sedation. Most patients wake up after the procedure undertaken is finalised
and medications stopped. Possible side effects entail drowses and nausea and few effects
from the general anesthesia. Analgesia and sedation are offered at times offered with other
types of pain control. This can be offered through injections or numbness on a small area of
the body.
Levels of sedation often depend on the patient and other various factors of the patient.
Level of sedation affects the recovery phase. The three main levels of sedation include
minimal. They help the body relax and no sleeping as you will be answering questions.
Moderate level entails a feeling of drowsiness and chances of falling asleep with memory
being affected. Deep sedation entails being unconscious. Throughout the procedure, the
patient will sleep and no memory will be remembered (Toktas et al., 2016).
Question 6; Nurses reflection
My nursing reflection RN during the overall assessment is key towards enhancing my
career and building my core competencies. Understanding the overall process of assessing the
patient is essential for understanding endoscopy tests. The importance of understanding the
nursing roles and skills in ensuring that the patient is sedated and GI assessment is key in
shaping my practical skills as a nurse. The key aspect of undertaking the relevant assessments
as a nurse is vital in enhancing overall patient care process. Nursing role plays a critical role
in ensuring that the patient status of the patient is well managed with post-operation health
care being enhanced and o allows smooth recovery of the patient. Thus as a nurse, it is
essential for understanding the relevance and key steps pertaining to the indicative procedures
of the patient to be managed and tracked down.

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References
Cecconi, E., & Di Piero, V. (2012). Dysphagia-pathophysiology, diagnosis and treatment. In
Manifestations of Stroke (Vol. 30, pp. 86-89). Karger Publishers.
Chandran, S., Parker, F., Vaughan, R., Mitchell, B., Fanning, S., Brown, G., ... & Efthymiou,
M. (2015). Right-sided adenoma detection with retroflexion versus forward-view
colonoscopy. Gastrointestinal endoscopy, 81(3), 608-613.
Coccia, C. B., Palkowski, G. H., Schweitzer, B., Motsohi, T., & Ntusi, N. A. B. (2016).
Dyspnoea: Pathophysiology and a clinical approach. SAMJ: South African Medical
Journal, 106(1), 32-36.
Gulabivala, K., & Ng, Y. L. (2014). Endodontics E-Book. Elsevier Health Sciences.
Ruiz-Rebollo, M. L. (2015). Should rectal retroflexion be included as a quality indicator for
colonoscopy?. Gastrointestinal endoscopy, 82(2), 421.
Toktaş, Z. O., Konakçı, M., Yılmaz, B., Ekşi, M. Ş., Aksoy, T., Yener, Y., ... & Konya, D.
(2016). Pain control following posterior spine fusion: patient-controlled continuous
epidural catheter infusion method yields better post-operative analgesia control
compared to intravenous patient controlled analgesia method. A retrospective case
series. European Spine Journal, 25(5), 1608-1613.
Vakil, N., Vieth, M., Wernersson, B., Wissmar, J., & Dent, J. (2017). Diagnosis of gastro‐
oesophageal reflux disease is enhanced by adding oesophageal histology and excluding
epigastric pain. Alimentary pharmacology & therapeutics, 45(10), 1350-1357.
Ware, D. (2017). The therapeutic relationship between nurse and patient in the endoscopy
setting: a literature review. Gastrointestinal Nursing, 15(10), 34-44.
Yung, D. E., Fernandez-Urien, I., Douglas, S., Plevris, J. N., Sidhu, R., McAlindon, M. E., ...
& Koulaouzidis, A. (2017). Systematic review and meta-analysis of the performance of
nurses in small bowel capsule endoscopy reading. United European gastroenterology
journal, 5(8), 1061-1072.

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