Health

A patient came into the hospital looking very pale

Introduction

A patient came into the hospital looking very pale. The patient was suffering from abdominal cramps, vomiting and a severe case of diarrhea. The patient believes that the reason of such symptoms is the result of eating a probably undercooked chicken at a BBQ the previous night. To diagnose the patient, there are many important possibilities to take into considerations. For instance, the bacteria that caused the disease, the source of infection in the body and the reason for infection.

The previously mentioned symptoms are caused by more than one kind of bacteria. Escherichia coli, Salmonella, Shigella and Staphylococcus aureus usually cause such symptoms. The infection may be established in a particular site of the body, typically in the gastrointestinal tract considering the patient’s symptoms. A sample of the poultry consumed by the patient must also be tested to determine if it was carrying the same bacteria that caused the disease. This will prevent other people from the same infection. To do this, there are multiple experiments and techniques to identify the type and find the source of bacteria causing the symptoms. In addition, after identification of the bacteria the best course of treatment must be prescribed to the patient.

Gram staining is a classical and typical method used to identify the kinds of bacteria. Simply the samples of bacteria obtained from the patient will be stained by different solutions. E. coli, Shigella and Salmonella are enterobacteriaceae, therefore should stain pink because of the presence of a lipid bilayer around their cell walls. S. aureus, however, should stain purple due to its thick cell wall. Bacteria that stain pink are referred to as gram negative bacteria. On the other hand, bacteria that stain purple are referred to as gram positive bacteria.

As the patient has reported symptoms generated from a gastrointestinal disease, a coliform analysis of the food consumed must be undertaken. This test will aid the prevention of further infection. Moreover, it will help in determining the reason of the disease if the bacteria match the ones obtained from the patient’s samples. The quantity of the bacteria tested is an important variable as they wouldn’t cause the disease if their number was low. The test involves several diluted samples aspirated on corresponding numbers of petrifilm plates. After the bacterial colonies form, enumeration will be possible. However, if the colonies exceed 250 then it will be considered too numerous to count.

Isolating the normal flora from the disease-causing bacteria in the patient’s sample is necessary. Isolation is achieved by a four-quadrant streak in which each streak will result in weaker growth of bacterial colonies. It starts from a streak of a highly concentrated bacterial samples obtained from swabbing the patient’s skin and throat. The fourth streak will show single colonies leading to a clear distinction between bacteria. Normal flora are basically commensal, non-pathogenic bacteria living in animals, including humans. They benefit from the host’s nutrients while the host benefits from the normal flora’s protection from pathogenic bacteria. They protect the host by occupying sites and releasing anti-bacterial substances and metabolic byproducts. The isolation in the patient’s sample will help to distinguish and identify the pathogenic bacteria.

Bacteria differ in biochemical composition. Thus, biochemical identification of bacteria is also a useful method needed for diagnosis. In this case, a stool sample is needed from the patient. Bacteria colonizing the intestines are usually enteric bacteria, which means they are gram negative bacilli that are facultative anaerobic and form no spores. This technique is composed of two parts. One part involves the use of a Triple Sugar Iron (TSI) agar test and the other part is the Analytical Profile Index (API) Bacterial Identification. TSI contains iron which will allow iron metabolizing bacteria to produce H2S as a byproduct. In addition, it consists of lactose, glucose, sucrose and a colour pH indicator. The media is poured in small glass bottle and set at an angel to give the surface a slant. API is a standardized system to identify the family Enterobacteriaceae. It is composed of 20 test micro-tubes carrying dehydrated substrates. Samples of bacteria are added into each micro-tube and allow 3 hours of incubation to perform metabolic activities. Each species of bacteria has specific metabolic functions that will produce colour changes. A 7-digit numerical profile is determined after the reactions are observed and read. The 7-digit profile is inserted into a software to identify the samples.

Agar plates are very useful for identifying bacteria. They contain nutrients that allow bacteria to thrive and form colonies. In this case, Xylose Lysine Deoxycholate (XLD) and MacConkey (MAC) agar plates are used. XLD medium is specialized for the differentiation of pathogenic enterobacteriaceae, particularly Shigella, Salmonella and E. coli. It contains the pH indicator phenol red. When xylose is fermented by E. coli, the pH lowers which generates a yellow media. Deoxycholate is a bile salt that inhibits non-enteric bacteria. Furthermore, XLD contains thiosulphate and iron (III) salt which turn into a black iron sulphide after being metabolized by Salmonella. The MAC plate contains lactose and a neutral red pH indicator. When E. coli ferments lactose, it produces pink or purple colonies. Salmonella does not ferment lactose, so it produces colourless colonies.

To prescribe the best treatment for the patient, a bacterial antibiotic sensitivity test is performed. When it comes to curing a patient suffering from a bacterial infection, antibiotics are the best treatment. Antibiotics alter the function and structure of bacteria that are different from human cells. This allows the antibiotics to discriminate between the two and cause no harm to human cells. For example, Penicillin prevents a bacterium from forming a cell wall. However, different bacterium species are resistant to certain kinds of antibiotics while susceptible to others; thus, an antibiotic sensitivity test is needed. Basically, a ring with different antibiotics attached its edge is placed on an agar plate that has been covered in bacteria. This is done by using a swab to transfer the bacteria from a bacterial suspension sample to an agar plate. By using a swab a bacterial lawn is created. The bacteria are allowed to grow after placing the ring. The greater the bacteria free diameter around a specific antibiotic the more suitable it is for prescription.

Yet another way of identifying the pathogenic bacteria is by bacterial staining. This technique involves the staining of the structures of bacteria, namely, flagella, capsules and endospores. Flagella is found on many bacterium species. Usually in moist areas as flagella is used for locomotion. Since not all bacteria are flagellated then this way can be used as an identification method. Capsules are slimy layers produced by bacteria. Some bacteria have no capsules present; therefore, it also can be used to distinguish between bacterium species. Endospores are resistant structures that aid the bacteria producing them to survive in harsh environments. They vary in shape, size and location. All in all, these mentioned methods are used for classification of bacterial infections.

Discussion

The coliform analysis revealed staggering numbers of salmonella colonies that were impossible to estimate. The colonies were only possible to calculate after observing the 10-7 and 10-8 dilution of the sample. Regardless, Salmonella was still found in very high concentrations. Thus, the chicken consumed by the patient is the reason for infection.

When normal flora was isolated and grown in blood agar plates, some colony morphologies looked quite similar but slightly different from Salmonella. The difference was mostly between the colours of the colonies. One quadrant grown from the sample of the throat closely resembles Salmonella colonies; whereas, two quadrants resembling that of Salmonella are found from the skin. Perhaps due to the contact of the patient with the chicken while eating it. Finding some Salmonella in the throat is also rational as a consequence of swallowing the chicken.

For the TSI test, the small bottle had an orange-red and pink colour, indicating that glucose was fermented in some sites while in other sites there was no fermentation at all. This may be due to the unique biochemistry of Salmonella or a contaminated sample. The stab was showed a black colour and the presence of bubbles was visible, indicating the production of Hydrogen Sulphate.

The biochemical tests demonstrates that the unknown bacteria from the stool sample has a circular, convex and entire morphology in both the XLD and MAC agars. The colonies’ colour is black in XLD but colourless in MAC, and both colonies are gram negative. The oxidase test is also negative which all identifies the unknown sample as Salmonella. The software used for the API test found that 89% of the total bacteria found in the stool sample is composed of Salmonella.

Finally, the Antibiotic test shows that Salmonella is resistant to Penicillin and sulphatriad. However, it is mostly susceptible to Ampicillin and Tetracycline, since their diameters are the largest compared to the rest.

In conclusion, Salmonella is the cause of the disease. It was found in considerable amounts in the chicken sample and in the stool sample. The reason for infection is the consumption of contaminated poultry. The source of infection is most likely from the GI tract, as there are more found from the stool sample than form the throat and skin. Salmonella established itself in the stomach, proliferated and migrated to the intestines to occupy more space. Considering how bacteria cause disease, Salmonella bacteria absorbed nutrients from the patient, released toxins and enzymes leading to alterations in the patient’s metabolic processes and caused harm to the tissues. Therefore, Antibiotics are needed for treatment to cure the patient from Salmonella. Ampicillin and Tetracycline are more appropriate for treatment than other antibiotics, since both generated the largest diameters and are of similar size. Perhaps the combination of both will be more effective in the treatment.

Client-Centred therapy communication model

The Client-Centred therapy has three key qualities for the therapist to be maintained which are unconditional positive regard, genuineness and empathetic understanding (Eyssen et al. 2014). As mentioned by Wilkins (2015), the key goals to be accomplished by using Client-Centred therapy are personal growth and health development, increasing patient’s self-esteem, enhance the patient’s understanding of them and mitigation of distress faced by the patient. Thus, using this model can be effective to bring in positive health benefit for Mr Lawrence as it guides the nurse regarding the way they can gradually meet his communication and health needs. According to the model, the initiation of Client-Centred therapy is executed by forming a psychological contact with the client by the therapist (Whalley, 2015). This aspect is to be used by the nurse in meeting the communication need of Mr Lawrence so that he feels positive to initiate sharing his exact needs and the reason behind his discomfort to the nurse. As mentioned by Fransen et al. (2015), effective psychological relationship between the patient and the nurses helps the patient to develop trust over them as they can relate with one another. Thus, by using this aspect of the model while initiating the two-way communication need for Mr Lawrence the nurse require to develop trustful relation with him. This, in turn, is going to help the nurse in understanding the key needs of Mr Lawrence such as he is suffering osteoporosis and has taken picolax which has made him more anxious to be unable to go alone to the toilet.

The second aspect of Client-Centred therapy is that nurses need to understand the patients are emotionally upset due to their health issues and are in a state of incongruence (McCorquodale and Kinsella, 2015). Therefore, the anxious behaviour and repetitive asking for assistance to go to the toilet and when to be reviewed by the doctor by Mr Lawrence is required to be effectively attained by nurse. This is because he is doing so as a result of being emotionally upset by his diseased state and therefore needs assistance to get relived from the situation. As per Rogers (2012), in Client-Centred therapy, the counsellor requires being genuine and aware of patient’s own feelings. Therefore, this aspect of the model is to be used by the nurse in taking action to manage Mr Lawrence by making him feel okay to not control his toilet even if some points badly about him in the doctor’s chamber. This would make him feel comfortable and relaxed apart from being anxious and shameful of the act which avoids him to take help or see the doctor out of shame. The other nurse who shared incidence about bowel cancer to Mr Lawrence need to refrain doing such act because the patient is already in a state of anxiousness due to his health issue.

The other aspect of Client-Centred therapy model informs that the counsellor requires having unconditional positive regard for the client (Cameron and McColl, 2015). As mentioned by Bertilsson et al. (2016), the unconditional positive regard means whatever the patient does is to be accepted by the therapist without any constraint and be supported in any condition. As seen in the case study, the nurse was getting irritated with the repetitive behaviour of Mr Lawrence for asking where the toilet is and he could not go there alone. Thus, this aspect of the model is to be used by the nurse in managing Mr Lawrence by providing him effective support and assistance without getting irritated of his repetitive behaviour of asking for help and assistance to go to the toilet. Moreover, the nurse who made Mr Lawrence fear about facing bowel cancer should not do so and require making him feel that whatever his health situation is would be resolved to effectively support him.

The Client-centred therapy model informs that the counsellor requires acting empathically in understanding the needs of the client and requires informing this understanding to the client (Rogers, 2012). This is because it forms the basis for positive therapeutic relationship as the client feel that he is personally taken care of by the counsellor. As per Njelesani et al. (2015), positive therapeutic relationship is required to make the client feel satisfied with the healthcare services, in turn, improving their health. Thus, this aspect of the model is to be used by the nurse in managing Mr Lawrence by giving him assistance to go to the toilet as he is not able to move properly due to his diseased state of osteoporosis. The assistance would make him feel that he is empathetically understood regarding his inability to go to the toilet alone. The empathetic understanding is going to make the client recognise that the counsellor has unconditional positive regard for them, in turn, creating successful client-centred therapy (Rogers, 2012). Therefore, the assistance for Mr Lawrence is vital as per the aspect of the model because it forms the basis for him to recognise that the nurse has unconditional positive regard for him. Thus, the nurse requires personally taking effective approach is assisting Mr Lawrence to go the toilet and make him feel relaxed that he would be cared in time by the doctor.

BOE model of communication

The other communication model that could be used by the nurse in assisting Mr Lawrence is BOE communication model. As per Crawford et al. (2014), BOE communication model assists the nurse to take immediate action in providing better healthcare services to patients. The BOE model stands for brief, ordinary and effectiveness. According to Silverman et al. (2016), Brief in BOE communication model involves the time spent in communicating with the patient in understanding their needs of care and assistance. Thus, according to this aspect of the model, the nurse needs to develop effective communication as well as understand the requirements of the patients by utilising time spots such as eye contact, body posture, small talk and others. Therefore, the nurse in the given scenario requires identifying brief regarding Mr Lawrence that he is inefficient to properly move from the body language that he is using a stick to walk. Moreover, Mr Lawrence anxious asking of going to the toilet and when to be reviewed by the doctor requires the nurse to identify in brief that he is not feeling well and needs to be assisted in going to the toilet. Moreover, the nurse, who later attended Mr Lawrence, does not require sharing her mother's consequence of bowel cancer by understanding the anxious behaviour of the patient that he is already feeling vulnerable.

The brief regarding the patient’s condition is required to be identified properly so that the nurse can understand the immediate requirements of care to be given to the patient (Amutio-Kareaga et al. 2017). This, in turn, avoids issues with the patient that he is not properly taken care of by the nurse. Further, according to the model nurse during brief communication with Mr Lawrence need to maintain a positive body language so that the patient does not feel offended and refrain from sharing details of requirement of care assistance. As mentioned by Robinson et al. (2016), ordinary is the aspect of BOE model where it is referred that healthcare setting of the patient is required to be made homely. Thus, the nurse communicating with Mr Lawrence requires making him feel homely by using generic and pragmatic communication. Therefore, the nurse who informed about her mother with similar symptoms like Mr Lawrence of having bowel cancer to the patient should not do so because it would make him feel anxious. The nurse require to act pragmatically by provide assistance to Mr Lawrence that he would be healthy in no time and the colonoscopy is not going to hurt him anyway. This is because it would make Mr Lawrence feel relaxed and homely due to mental support from the nurse.

The Effectiveness in BOE model refers the importance of interaction on clinical outcomes and informs that the model is driven by promotion of patient satisfaction, evidence-based practise and effective steps taken by the practitioners and organisations (Crawford et al. 2014). Therefore, based on this aspect to accomplish the effectiveness part of the model the core skills to be performed by the nurse according to BOE model are suggested. According to the initial core skill, the nurses require making them available for care and assistance to the patients in all condition (Biglino et al. 2017). Therefore, the nurse communicated by Mr Lawrence need to show a personal urge to make him feel that the nurse is available for asking any form of assistance by him. As mentioned by Crawford et al. (2014), one of core skill according to BOE model is that the nurses require being friendly in nature and empower patients by encouraging their self-determination. In the given case scenario, the nurse is seen to communicate with Mr Lawrence in a professional manner. Moreover, the other nurse was seen to share unfamiliar incidences of bowel cancer to Mr Lawrence. Thus, both the nurses require keeping informed about this skill and developing friendly and empowering conversation with Mr Lawrence to make him feel relaxed and ask for assistance without hesitation.

The communication ended by the nurse with Mr Lawrence was seen to mutually unsatisfying as the patient was seen to go home without executing colonoscopy due to shame and anxiousness. This is because the first nurse showed irritating and frustrating behaviour at the end of the conversation which is disrespectful for the patient while other made him fear of bowel cancer. As per Expósito et al. (2018), core skill mentioned in BOE model is that nurses require executing and ending conversation with the patients in a mutually respectful and satisfying manner. Thus, the nurse while executing and ending communicating with Mr Lawrence require sharing positive information and develop respectful manner of talking. As asserted by Barker and Williams (2018), the BOE model refers that nurses require being able to build sustaining rapport with the patients by using warmth, genuineness and positive body language as core skills. This is required to be abided by the nurse while communicating with Mr Lawrence so that he can be made to feel familiar in the surrounding. Moreover, it is required to avoid him to think that he is vulnerable to experience a grave disease and would not be helped or relived from the disease thus assuring him protection and satisfactory healthcare services.

Conclusion

The above discussion shows that the initial need of Mr Lawrence was to successfully establish two-way communication so that he can communicate his needs and demands of service to the nurse. The Client-Centred Therapy model is seen to inform that the nurse communicating with Mr Lawrence need to be empathetic, genuine and have unconditional positive regard for providing effective healthcare services to him. According to the BOE communication model, the nurse requires developing a brief regarding Mr Lawrence through effective communication. Later, the nurse needs to form familiar and ordinariness to provide services to Mr Lawrence for effectively assisting him in resolving his service demands of assistance for going to the toilet.

References

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