Analysis of Diabetic Patient Presented to the Emergency Department - Case Study Example

Running Head: Case Study Analysis (Diabetic Patient Presented To The Emergency Department) Name: Course: College: Tutor: Date: Introduction According to the World Health Organization, diabetes mellitus is a metabolic disorder characterized by chronic hyperglycaemia whereby the body produces insufficient insulin. The deficiency causes reduced metabolism of carbohydrates, fats and proteins. The symptoms of marked hyperglycaemia results into the following conditions; a. Polyuria (where hyperglycemia acts as osmotic diuretic), b. Polydipsia (thirst as a result of polyuria dehydration), c. Weight loss (due to break down of fat and protein by the body to restore energy source), d. Polyphagia (hunger and the patient eats more since cell cannot utilize glucose), e. Glycosuria (renal threshold for glucose: 180 mg/dL), f. Malaise and fatigue (due to decrease in energy), and finally g. Blurred vision (the swelling of lenses because of osmotic effects) Although extreme diabetic cases have resulted in complications and eventual death prematurely, measures have been made available for diabetic patients to reduce the level of complications by controlling the disease. Although diabetes has been severally classified into four categories, the diseases are different but together share the blood glucose complications and resulting symptomatic signs. The four types are: Type 1 diabetes, Type 2 diabetes, Gestational Diabetes and other specific types of diabetes (Argyll & Clyde Health Board, 2000 pp 4 - 6). Type 1 diabetes mellitus, also called insulin-dependent diabetes mellitus (IDDM), occurs in young people. Physiologically, it results when hormone insulin generation fails due to the disintegrated pancreatic beta cells. As a result, the regulation of the blood glucose levels is hampered due to insulin absence. At this point, the disease strikes abruptly unknown to the victim due to ketoacidosis. Certain factors associated with this Type 1 form of diabetes include genetic, autoimmune and environmental. Type 2 diabetes mellitus, also referred non-insulin-dependent diabetes mellitus (NIDDM), usually begins as a result of the cells failing to use insulin properly (metabolic syndrome). Type 2 diabetes mellitus is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity. Gestational diabetes is a glucose intolerance, which develops during pregnancy. In order to avoid complications in the infant during pregnancy, there is need for early treatment of gestational diabetes in an effort to normalize levels of blood glucose in the mother. Finally, the other specific types of diabetes are associated with specific genetic defects such as complications of pancreatitis and endocrinopathies. Additional non-genetic defects include surgical procedures, drugs administered, malnutrition, infections, and other illnesses (Argyll & Clyde Health Board, 2000 pp 4- 10). Case Study Analysis (of a Diabetic Woman) Nursing Health History (a) Socio Demographic Data Name: Mrs. Cassandra Possingham Age: 48 years old Sex: Female Civil status: Married Name of Spouse: Mr. Possingham No. of children: 3 Profession: Accountant Address: (b) Initial Data Date of admission: Time of admission: Attending physician: Admitting diagnosis: On Admission on Emergency department, Mrs.Possingham was suffering from Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS), also called Hyperosmolar nonketotic Coma (HONK), as a consequences Diabetes type 2. She was experiencing increasing confusion and irritability, increased thirst and needing to void frequently (Figure 1).Her husband stated that her Blood Glucose Level (BGL) was 20 mmol/L but no ketones were found when she tested her urine 2 hrs previously. Figure 1: Symptoms for diabetes Type 2 (c)History of Present Illness According to Cassandra’s her diabetes was diagnosed 3 years ago and is managed with Avandamet 4mg/500mg BD after food. Cassandra also had a week off work whilst experiencing a serious bout of food poisoning 2 week ago. Cassandra works as an accountant and has business lunches/dinners several days a week, which makes it difficult for her to avoid excessive intake of food an alcohol. Her BMI is presently 26. She also smokes 10 cigarettes per day and has 2-3 glasses of red wine with the evening meal. She does not enjoy exercise but usually 4 times a week takes the family dog around the block for the dog’s exercise. She has three children the eldest currently doing year 12 and she does most of the housework and cooking herself. Mr Possingham states that he feels his wife has been extremely stressed over the last month as her firm has moved to new premises. She has also been complaining of cramps and restless legs at night. Mrs Possingham explained that she has small area near her left ankle that she injured during the move of her business from one building to another she is concerned that it is very slow to heal. (d) Admission Examination T38.8 Pulse 132; BP 164/70; RR 24; SaO2 96% room air; BGL 38mmol/L; Urine: 15mL/hr, dark amber, pH of 5; Glucose +++. Neurovascular obs: peripheral pulses decreased (L) leg which is shiny and hairless to mid calf and a relatively painless 1.5cm round oozing wound on left lateral mallelous was noted – Area around the mallelous red and hot to touch. The R leg pulses palpable, CWMS good, skin not shiny and plenty of hair. Calf on this leg also looks swollen in comparison to the other leg. From the above information, we can conclude that Mrs.Possingham was suffering from Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS), also called Hyperosmolar nonketotic Coma (HONK), resulting to Type 2 Diabetes mellitus. According to Venkatraman & Singhi (2006), Hyperglycemic Nonketotic Syndrome (HHNS) is a complication resulting from uncontrolled type 2 diabetes mellitus. HHNS in most cases is characterized by increased serum osmolality and dehydration without accumulation of ketone bodies, and severe hyperglycemia. Extended osmotic diuresis results to dehydration and hence a term referred to hypertonic dehydration. The rationale for Type 2 diabetes is seen from literature whereby, suggested risk factors for type 2 diabetes is in accord with Mrs. Possingham’s background. According to American Diabetes Association (2004), Type 2 diabetes is associated with the following risk factors (Figure 2). Overweight (Body Mass Index ≥25 kg/m2), Age 45 years and older, Physical inactivity, History of Impaired Glucose Tolerance (IGT) or Impaired Fasting Glucose (IFG), Presence of coronary artery disease and/or hypertension (blood pressure ≥140/90 mm Hg), SaO2 96% and Presence of other vascular complications. Furthermore, the medical history and Laboratory test results confirmed this scenario. For instance, on Admission on Emergency department Mrs.Possingham was suffering Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) as a consequences Diabetes type 2. Her level Glucose indicated +++, BGL 38 mmol/L, SaO2 96 %, pH of 5 and Urine: 15 mL/hr. According to Cassandra’s her diabetes was diagnosed 3 years ago and is managed with Avandamet 4mg/500mg BD after food. According to Cassandra’s her diabetes was diagnosed 3 years ago and is managed with Avandamet 4mg/500mg BD after food. Figure 2: Type 2 Risk factors Table 1: Diagnoses/ needs/ problems on admission Nursing Problems Identified Cues Rationale Altered Nutrition more than body requirements related to excess intake, which strains metabolic demands as manifested by verbalized dietary concern. 1.verbalized dietary concern 2.weight over normal 3.poor muscle tone Insulin sensitivity in overweight individuals is interfered with therefore; it heightens the likelihood of developing the disease without prior knowledge of the victim. This is evidenced by research that has established that exercise allows blood sugar control (American Diabetes Association, 2005; Argyll & Clyde Health Board, 2000 pp. 10 - 20). With poor wound healing, the risk of infection is increased especially due to foot injury. Poor wound healing Clients with diabetes are susceptible to infections of many types, making it difficult to treat an infection once it has occurred. Due to its chronic nature, the medical practitioners are enlightening the victim and their families on the required daily management of the condition. This efforts will help them assess the complications that may arise thereof instead of contacting a physician when its too late (Elliot et al., 1996; Stevens et al., 1997). Knowledge deficit regarding disease process related to development of preventable complications is seen from her habits; such as smoking cigarettes, excess intake of alcohol, poor food eating habits, in adequate physical exercises. 1.Lack of exposure 2.Unfamiliarity of information resources 3.Cognitive limitation This is a state where an individual lacks specific information necessary to make choices regarding condition/therapies/treatment (Revised Kit Bethesda, 2005) (e) Medications prescribed prior to admission Medication Dose Ventolin puffer PRN Aspirin 100mg daily Avandamet BD with meals Atenolol 50mg daily Atorvastatin 80mg mane Table 2: Medications prescribed (f) Plan • Review by medical registrar for admission to endocrine ward. • Commence IVT 4% & 1/5 Saline 125mL/Hr • Insulin infusion (50units Actrapid in 49mLs N/Saline) with sliding scale dose range • Complete blood review notify MO about K result. • Swab from L) malelous wound to be taken. • Consult with Wound management nurse to be organised from the ward. • Request Doppler both lower legs. • Discuss Doppler result with medical team and assess the need for a vascular consult • Commence IV antibiotics as ordered. • IDC to be inserted hourly measures • ECG • CXR Management of Diabetes Hyperglycemic Nonketotic Syndrome is treated by restoring the intravascular volume and correcting the fluid and electrolytes (Na+, K+, Ca++, Mg++, PO4++) deficits. Correction is also done on serum hyperosmolarity and hyperglycemia. Treatment is done by using the 0.9% saline until hemodynamic stabilization is attained, and then followed by 0.45% saline with insulin infusion at the rate of 0.1 units/kg/hour. About 5% of dextrose is added in fluids. Insulin infusion is reduced once the blood glucose reads 250 to 300 mg/dl (Venkatraman & Singhi, 2006 p 55-60) . Measurement of blood pressure, weight, urinalysis and Doppler measurement of ABPI has to be recorded on first presentation. Blood pressure is taken to monitor cardiovascular disease, weight is measured at baseline to monitor weight loss if the patient is obese, and urinalysis is undertaken to diagnose diabetes mellitus. Microorganisms usually colonize chronic leg ulcers, but how these affect healing is unclear (Trengove et al., 1996). The influence of bacteria on ulcer healing has been examined in a number of studies (Trengove et al., 1996; Skene et al., 1992 pp. 1119 – 1121) and most studies in humans with chronic wounds have not demonstrated an association between bacteria and impaired healing. There is no evidence that aspirin increases the healing of venous leg ulcer (Layton et al., 1994). Specialist assessment is essential as Doppler measurement of ankle: brachial pressure index (ABPI) may be unreliable in this group of patients. This is because Patient with Diabetes may have deceptively high-pressure reading of ABPI (Skene et al., 1992 pp. 1120 – 1121). Therapeutically the options available for the treatment of Type 2 Diabetes are: • Biguanides- Increase insulin sensitivity • Thiazolidinediones- Increase insulin sensitivity • Sulfonylureas- Increase insulin release • Meglitinides- Increase insulin release • Alpha-glucosidase inhibitors- aid carbohydrates absorption • Insulins- Replace insulin For optimum control, the above drugs are commonly prescribed together. However, at the initial stages of the disease, a prescription of low dozes could be adopted as it efficiently lowers the side effects and improves the therapy (Revised Kit Bethesda, 2005 and Diabetes Guidelines Task Force, 1995). For an individual suffering the first or second leg ulcer, a clinical examination, lab tests and physical examination should be conducted on him. In addition to the examination, haemodynamic and therapy should be continued thereafter. In the process, the immediate cause will be discovered in addition to the associated diseases. With the analysis the predictions, management and further referral decisions will be objectively made. However, the option available for the physician includes making reference to a professionally trained practitioner. In many communities, cases of ineffective and inappropriate treatments have resulted due to unprofessional clinical and physical examination limb ulcerations patients (Elliot et al., 1996; Stevens et al., 1997). Patient Education and Discharge Planning The discharge plan of Mrs.Possingham is achieved by carefully monitoring of glucose levels and ensuring adequate hydration done. This has to be done to decrease further risk of HHNS while she is still receiving medications that might interfere with the effectiveness of insulin. Screening programmes has to be continued which detect type 2 diabetes mellitus, as this will help identify risk for HHNS (Venkatraman & Singhi, 2006). The most appropriate treatment for diabetes mellitus during the initial stages of the disease includes physical exercise and weight management. These options once adopted ought to be maintained throughout the duration of the disease. The advantage associated with physical exercise and weight management is the reduction glucose response to diverse diseases (Diabetes Guidelines Task Force, 1995). Mrs Cassandra Possingham needs to be empowered on the need to take physical exercise very serious, its importance and implication to her health prior discharge. She has to choose an enjoyable activity that suits her lifestyle. Starting with low-level exercise and building up. For instance: walking, cycling, jogging, golf, tennis, swimming, and gardening. Exercising with her husband (Figure 3) or joining a club, it will help keep her motivated. It is important for her to look out for other ways to increase her activity. For example, use the stairs, while throwing the remote to the TV away. Figure 3: Motivation from her husband during exercise With time she has to increase her physical fitness to engage in doing aerobic exercise which include, mountain climbing, hiking, swimming or taking a water-aerobics class, playing basketball, volleyball, or other sports, then progressing in doing exercises with hand weights, elastic bands, or weight machines three times a week builds muscle (Figure 4). According to Argyll & Clyde Health Board (2000, pp 4- 12) more muscle and less fat is required for any victim. This is because the muscle allows for the body to burn more calories especially between exercise sessions. Consequently, strength training improves balance and coordination making easing the daily chores eventually improving bones’ health. Figure 4: Doing exercises with hand weights During exercise, it is important to put on cotton socks and comfortable, well-fitting shoes designed for the activity being done. After exercise, feet as to be checked for cuts, sores, bumps, or redness (Figure 5). Figure 5: Checking feet for any cut, sore or wound regularly. Mrs Cassandra Possingham has to educated and enlightened on importance of regularly checking for diabetic complications. This can be realized through diagnoses and early treatment before complication (Diabetes Guidelines Task Force, 1995 pp.149-151). Hence, it is important to have: Regular eye checks Regular foot care Regular blood pressure checks Blood tests for glucose Frequent blood and urine tests to diagnose the presence of damages likely to occur to the kidney During the course of Type 2 diabetes, the victim should strictly adhere to the dietary specifications and exercise to lower the blood sugar level. According to the medical practitioner, dietary specifications and nutrition therapy are primary to blood glucose control (Revised Kit Bethesda, 2005). Food is divided into six groups as stipulated by the Diabetes Food Pyramid (shown as sections on the pyramid, Figure 6). These groups vary in size. For instance, the largest group which constitute of beans, starchy vegetables, and grains is at bottom, which means that it is important to eat more servings of grains, starchy vegetables, and beans than any other foods in as shown in the pyramid. At the narrowest section of the pyramid is the smallest group—fats, sweets, and alcohol. Thus, we should eat very few servings from these food groups compared to the other two levels. Figure 6: The Diabetes Food Pyramid Adapted from Using the Diabetes Food Pyramid: http://www.diabetes.org/nutrition-and-recipes/nutrition/foodpyramid.jsp The emotional impact of diabetes and its effect on the family may require professional help. In diabetic cases, there are three specific points that send patients to a counselor: when the patients are newly diagnosed, when something about their diabetes care is going off track — there is frustration, depression, anxiety, it is not going smoothly — and thirdly, is when there is the onset of long-term complications of diabetes. The most common diagnosis is depression. According to the American Diabetes Association (2005), non-diabetics have a one out of four chances of being depressed compared to diabetic people. However, no research documents how it affects the rest of the family. While there may be a physical explanation for the increased rate of depression, it is clear the psychological cause is “a feeling of helplessness,” Bibliography American Diabetes Association 2005, Nephropathy in diabetes (Position Statement), Diabetes Care 27 (Suppl. 1), S79 –S83, 2004 American Diabetes Association 2004, Hyperglycemic crisis in diabetes (Position Statement), Diabetes Care 27 (Suppl. 1):S94 –S102, Argyll and Clyde Health Board 2000, Nursing Guidelines Care and Management of Diabetes in Registered Nursing Homes pp. 2-29 Awad N, Gagnon M, Messier C 2004, The Relationship Between Impaired Glucose Tolerance (Type 2 Diabetes) & Cognitive Function, Journal Clinical Exp Neuropsychol 26:1044 –1080, Diabetes Guidelines Task Force 1995, AACE Guidelines for the Management of Diabetes Mellitus, Endocr Pract; 1:149-157. Eastman RC 1995, Neuropathy in diabetes, In Diabetes in America, 2nd ed. National Diabetes Data Group, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (NIH publ no. 95-1468), p.339 –348 Layton AM, Davies JA, Ibbotson SH, et al., 1994, Randomised trial of oral aspirin for chronic venous leg ulcers, Lancet, 344 (8916), pp. 164 – 165. Revised Kit Bethesda, Md 2005, National Diabetes Education Program, Feet Can Last a Lifetime, National Diabetes Education Program, Skene AI, Smith JM, Dore CJ, Charlett A and Lewis JD 1992, Venous leg ulcers: a prognostic index to predict time to healing, British Medical Journal, 305 (6862), pp. 1119 – 1121 Trengove NJ, Stacey MC, McGechie DF and Mata S 1996, Qualitative bacteriology and leg ulcer healing, journal of wound care, 5 (6), pp. 277 – 280. Venkatraman R. and Singhi Sunit C., 2006, Hyperglycemic Hyperosmolar Nonketotic Syndrome: Indian Journal of Pediatrics; 73 (1): p 55-60 Appendices Table 3: Showing Nursing Care Plan Problem Cues Analysis Objectives/ goals Intervention Rationale Evaluation Table 4: Diabetes Management Flow Sheet: Check list for every Hospital visit Name: Date of Birth: Height Sex: M/ F Date: Target Body Weight Weight/ BMI Home monitoring results Blood glucose Blood Pressure Dietary advice Exercise advice Foot inspection Smoking/alcohol Symptoms Drugs Adherence with treatment Insulin treatment injection sites states Read More