This essay aims to critically reflect on the experience of an encounter with a patient suffering from severe dehydration and vomiting. To structure the work, I will use the Gibbs reflective cycle as I believe it offers a thorough breakdown of the experience and a chance to fully interpret my actions and lead my future practice (Gibbs, 1988).
Description
A female patient, who we will refer to as Mrs Y to protect her identity, aged 79 was admitted to the ward after being diagnosed with severe dehydration and vomiting. The patient lives in a facilitated care home and has mild dementia. No other confounding conditions were reported. Upon admission the patient’s blood pressure was abnormally low, 104/49mmHg, so hypotensive. Pulse rate was high at 118 and tachycardic. Serum sodium levels and blood urea nitrogen were 145 mEq/L and 25 mg/dL respectively with serum creatinine below 3 mg/dL. The patient was visibly pallid and seemed to be suffering from mild dysphasia. This could be due to the dementia diagnosis but was highlighted as a symptom upon admission. Mrs Y was able to confirm her name upon request but was not able to recall her birthday or where she lived. She was slightly distressed and not compliant when consent was asked to insert a cannula to start the re-hydration process. Mrs Y also refused to drink any water as she was concerned about inducing further instances of vomiting. As the trainee nurse charged with caring for Mrs Y, I spent a period of 25 minutes talking with her to try and alleviate her concerns and encourage her to let us insert the cannula. After being unsuccessful in my attempts to encourage her to let us proceed, and due to the urgency of her deteriorating condition, I made the decision to contact Mrs Y’s next of kin, her daughter, to ask her to come down to the hospital and encourage the patient to allow us to treat her. Untreated severe dehydration can lead to hypovolemic shock and cause irreparable kidney damage and even death. Fortunately, the daughter arrived very quickly and after only 10 minutes of contact with her daughter we were able to begin treatment. Cannulation did prove difficult due to the dehydration, as lack of circulating fluids causes the veins to close and shrink. After unsuccessful attempts of insertion at the basilic and cephalic veins in the antecubital fossa, successful cannulation was found at the saphenous vein near her ankle. Mrs Y was admitted for a period of 2 days, where upon she was administered cyclizine to stop episodes of vomiting and 20 mL/kg of an isotonic crystalloid fluids. This was successful in bringing Mrs Y’s blood pressure back up to a more suitable level and reducing her pulse rate. Early indications show there is no lasting damage to her kidneys and she was discharged back into the care of the facilitated care home.
Feelings
Throughout out my involvement in the care of Mrs Y, I found myself feeling very worried and concerned for her health. When caught early enough, and treatment started quickly, severe dehydration can be reversed. But due to Mrs Y’s refusal to consent to the treatment needed it proved very difficult to start treatment. I was worried about her going into shock and causing irreversible damage to her kidneys, or worse her death. I do understand the need for consent to be given before health care providers complete any procedures on a patient, but sometimes I believe the need for treatment out ways the need for consent. Due to Mrs Y’s age and diagnosis of dementia, surely health care workers must be able to make the decisions that best suit the patient. Because Mrs Y had only recently been diagnosed with dementia, and it being classified as mild, she had not yet lost the right to autonomy, so still fully retained the right to refuse any procedures she wanted to.
Evaluation
Optimal bodily functions are controlled by a balance of water and electrolytes. When healthy, this balance is controlled by renal, metabolic, and neurological functions (Suhayda and Walton, 2002). Elderly people are more vulnerable to a disruption of this balance, and in the case of Mrs Y, she was not only elderly, in a care home, but also suffered from a vomiting bug. Dehydration affects a large number of elderly patients, especially those within care settings. It can exacerbate and contribute to already diagnosed medical conditions and cause confusion, disorientation and severely impair quality of life (Begum and Johnson, 2010). Mrs Y’s admission observations pointed to very severe dehydration, with possibility of hypovolemic shock. Low blood pressure points to a severe lack of fluids in the blood, causing the kidneys to try and retain as much fluid as possible to make up the volume in the blood, leading eventually to damage of the kidneys (Alkhatrash & Sreeharsha, 2020)
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