Consider the patient situation

Ms Nancy Huang is a 29 year old university student undertaking her honours year in physics.  Nancy was diagnosed as a type 1 diabetic three years ago.  She normally manages her diabetes reasonably well since making a number of lifestyle changes combined with regular insulin.   Nancy has been very stressed, as she has not been able to finish her thesis on time due to having to recently return to China unexpectedly to attend a family funeral.  Since returning a few days ago, she has seen her GP, as she was unwell, and was diagnosed with a viral chest infection that was managed conservatively. She subsequently fell further behind in her studies.  Nancy decided to pull a few ‘all-nighters’ to get her thesis finished and decided to  consume excessive amounts of coffee and soft drinks in order to stay awake to finish her thesis. 

The next day her husband noticed Nancy was particularly irritable and becoming emotional as she could not concentrate on finishing her thesis.  Nancy was insisting on being driven to the university to speak to her lecturer.  On the drive in, they had to stop 4 times for Nancy to use the bathroom.  She became even more irritable and her husband decided to call an ambulance once they arrived at the university, who then transported her to hospital. The time is now 1400 and Nancy has just been admitted into the emergency bay.  You are the first RN to assess her.  She is awaiting medical review.

Collect Cues

Review:

See available patient information via MyLO.  Little documentation available at this point as newly admitted.

Gather new information (patient assessment):

Upon undertaking a further assessment of Ms Huang you obtain the following new information:Log book

Her husband provides you with a logbook that was provided to Nancy by her endocrinologist. It shows that Nancy has been diligently recording her BGL levels and insulin regime for some months.  You note there are no entries for the last few days. 

Vital signs

BP: 90/50

HR: 120 beats per minute

Sp02: 94%

RR: 20, coarse air entry, moist productive cough.

Temp: 37.9 degrees. 

Other information

Patient irritable and agitated.  Speaking in a confused mixture of English and Mandarin. Husband in attendance.

GCS 13 (confused)

BGL 24

Poor skin turgor.

Frequent urination

Urinalysis positive for glycosuria, specific gravity 1.030. No ketones present.

Soft abdomen, no rebound tenderness. Bowel sounds present.

Recall:

Recall and apply your existing knowledge to the above situation to ensure you have a broad understanding of what is/may be occurring before proceeding with the rest of the cycle (self-directed)

Process Information

Interpret:

List the data that you consider to be normal/abnormal below (not included in word count)

Normal

Abnormal

Hyperglycemia (diabetes mellitus)

Dehydration

Hypotension (low blood pressure)

Relate& Infer:

·         Relate the two most significant abnormal findings to the underlying physiology/pathophysiology to justify why it is considered abnormal in this context.

·          Based on your interpretation of all the information/cues presented, form an overall opinion on what may be happening and justify your answer (400 words).

Nearly all variables are abnormal in Ms. Nancy’s body. Her body temperature is 37.9 degrees Celsius whereas the average body temperature is 37 degrees (Celsius Wei et al., 2017). She has reduced blood pressure. Her readings are 92/50 mm/ Hg whereas the average blood pressure ranges from 120/80 mmHg to 140/90 mmHg (Chen et al., 2015).  The average heart rate is 60 to 100 beats per minutes while her rate is 120 beats per minute (Meijden et al., 2015). Her oxy meter levels are lower than the normal. She records 94% while the normal range is 95-100% (Deschamps et al., 2016). Her respiratory rate is 20 beats per minute. The normal range is 12-20 beats per minute (O’Leary, Hayen, Lockie, and Peat, 2015).

Pathophysiology of Diabetes mellitus (hyperglycaemia)

Diabetes causes the blood pressure to be lower than the usual (Zaccardi, Webb, Yates, and Davies, 2015). As indicated in the case study, Ms. Nancy has a blood pressure of 92/50mmHg when the normal range is from 120/80-140/90 mmHg. The second abnormal reading is the heart rate. Her readings indicate 120 beats per minute while the standard rate is from 60 to 100 beats per minute. During the onset of Diabetes type one; an individual has increased blood sugar levels (Tiwari et al., 2017). Therefore, the sole energy source which is glucose is in the bloodstream and is not reaching the cardiovascular muscles. The two most abnormal conditions in the case study are hyperglycaemia (diabetes) and dehydration.

The heart muscles require glucose in the presence of oxygen to produce energy in the process of metabolism. Due to the inadequacy in the amount of glucose, the muscles cannot synthesize energy. Thus, they are weak and cannot pump the blood either at the average or abnormal rates. The weak pumping of blood leads to a reduced blood pressure below the normal. Diabetes increases the heart rates (Tiwari et al., 2017. The inadequacy of glucose to metabolize energy overworks the heart since all the organs require blood for the delivery of oxygen and other essential nutrients. The center is unable to pump blood at the standard rate hence increases its work rate. The low blood pressure is known as hypotension.

Hypotension leads to a state of confusion and emotional stress. When blood sugar is trapped in the bloodstream, the brain cannot form energy (Tiwari et al., 2017. Moreover, the central nervous system fails to perform its coordination duties leading to confusion. Ms. Nancy temporarily stops taking her insulin dosage and checking the glucose levels. Her reluctant actions compound her diabetic problems. Her urine contains glucose (glycosuria).

Predict:

What may happen to your patient if you take NO action and why? (100 words)

Prediction

Ms. Nancy has to resume her insulin dosage and to check her blood sugar levels on a regular basis. If she fails to do that, she is likely to get be dehydrated due to the frequent urination. The brain controls all body functions (Tiwari et al., 2017. Therefore, the brain requires glucose to function properly. If she doesn’t take insulin dosage, then chances of stroke are high. Low energy levels lead to body weaknesses and dizziness.  An elevated blood sugar level reduces the blood pressure below the normal (Tiwari et al., 2017. If she does not control her condition, must body functions cannot happen. Therefore, she can experience coma and even death.

Identify the Problem/s

List in order of priority at least three key nursing problems (not included in word count)

Nursing problems in managing diabetes

No relevance resource in diabetes management

Lack of confidence and limited autonomy

Lack of support from hospital managers

Establish Goals & Take Action

From the above (identify problems), use the top 2 nursing problems identified and for each of these establish one goal and thenlist related actions you would undertake, including detailing any relevant nursing considerations (350 words)

Evaluate outcomes& Reflect on new learning

Briefly describe how you would evaluate the effectiveness of the care provided (i.e. what do you want to happen?) and reflect on how this encounter has informed your nursing practice if you were to encounter a similar situation in the future (150 words).

The patients should encourage Nancy to take her insulin dosage regularly. Additionally, she should periodically check her blood sugar levels. If she does the two actions, her levels of blood sugar levels go down (Hem, Pedersen, Norvoll, and Molewijk, 2015). The hospital should employ a language translator in the future to avoid language barriers among the nurses and the patients. The government should equip hospitals with modern equipment for measuring the variables of a diabetic patient (Hem et al., 2015). It is essential for the nurse to look at the medical history of the patient before the commencement of treatment. The management of diabetes is through lifestyle changes and regular injection with insulin dosage.  A point of note is that diabetes lowers the blood pressure.

In dealing with future diabetes patients, I will ask for their past medical records. Additionally, I will advise them to check their blood sugar levels. The patients should regularly take a dosage of insulin (Hem et al., 2015). The first variable to measure when dealing with such patient is the blood pressure. The readings should be lower than the normal range.

References

Chen, S., Cao, P., Dong, N., Peng, J., Zhang, C., Wang, H., Zhou, T., Yang, J., Zhang, Y., Martelli, E.E. and Prasad, S.V.N., 2015. PCSK6-mediated Corin activation is essential for healthy blood pressure. Nature medicine, 21(9), p.1048.

Deschamps, A., Hall, R., Grocott, H., Mazer, C.D., Choi, P.T., Turgeon, A.F., de Medicis, E., Bussières, J.S., Hudson, C., Syed, S. and Seal, D., 2016. Cerebral Oximetry Monitoring to Maintain Normal Cerebral Oxygen Saturation during High-risk Cardiac SurgeryA Randomized Controlled Feasibility Trial. Anesthesiology: The Journal of the American Society of Anesthesiologists, 124(4), pp.826-836.

Hem, M.H., Pedersen, R., Norvoll, R. and Molewijk, B., 2015. Evaluating clinical ethics support in mental health care: a systematic literature review. Nursing Ethics, 22(4), pp.452-466.

Lewis, S.L., Bucher, L., Heitkemper, M.M., Harding, M.M., Kwong, J. and Roberts, D., 2016. Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems, Single Volume. Elsevier Health Sciences.

Meijden, W.P., Fronczek, R., Reijntjes, R.H., Corssmit, E.P., Biermasz, N.R., Lammers, G.J., Dijk, J.G. and Thijs, R.D., 2015. Time?and state?dependent analysis of autonomic control in narcolepsy: higher heart rate with normal heart rate variability independent of sleep fragmentation. Journal of sleep research, 24(2), pp.206-214.

O’Leary, F., Hayden, A., Lockie, F. and Peat, J., 2015. Defining normal ranges and centiles for heart and respiratory rates in infants and children: a cross-sectional study of patients attending an Australian tertiary hospital pediatric emergency department. Archives of disease in childhood, pp.archdischild-2014.

Tiwari, J., Gupta, G., Sharma, R., Pabreja, K., Matta, Y., Arora, N., Mishra, A. and Dua, K., 2017. Role of microRNAs (miRNAs) in the pathophysiology of diabetes mellitus. Panminerva Medica.

Wei, Q., Lee, J.H., Wang, H., Bongmba, O.Y., Wu, C.S., Pradhan, G., Sun, Z., Chew, L., Bajaj, M., Chan, L. and Chapkin, R.S., 2017. Adiponectin is required for maintaining normal body temperature in a cold environment. BMC Physiology, 17(1), p.8.

Zaccardi, F., Webb, D.R., Yates, T., and Davies, M.J., 2015. Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgraduate medical journal, pp.postgradmedj-2015.