Medical Surgical Nursing - Task 1

The first assessment that should be made by the nurse is the cardiovascular assessment. In this, the nurse should look for the patient's blood pressure and the heart rate. Blood pressure should be monitored so as to detect abnormalities that could lead to severe complications in the health of the person. If a person would be having hypertension than she could have risk towards developing atherosclerotic cardiovascular diseases (ASCVD) in addition to microvascular complication and heart failure. Whereas, if a person is suffering from hypotension then she may feel tired and experience fatigue and dizziness. This could also lead to depression in the diseased individual (De Boer et al., 2017). Measuring heart rate is necessary because it is a major determinant in the finding of cardiovascular complications such as cardiac, death, myocardial infarction and strokes in patients who are living with diabetes (Bulum, Blaslov&Duvnjak, 2013). If the assessment is not completed accurately than the correct diagnosis about her condition could not be made. She could also have a cardiac attack or multiple other complications like tiredness, myocardial infarction and so on. The chart that could be used for assisting the assessment is the WHO/ISH cardiovascular risk prediction charts. It could help to estimate the cardiovascular risk so as to motivate patient and bring behaviour change in them (World Health Organization, 2020).

The second assessment which should be made is of blood glucose level. Blood glucose level helps in diagnosing the patient condition who is suffering from diabetes. It helps in determining whether the level of glucose is less or more in the body and whether a person should adjust their diet or do exercise to control it. Therefore, it helps in the self-management of glucose in the blood. If the blood glucose level is not tested than people could suffer from various complications such as organ damage or they could not be able to control their glycemia. They would also not be able to achieve their glycemic target (Kahanovitz, Sluss& Russell, 2017). The chart which could be used to measure the blood glucose level in a person is a blood glucose chart which is formulated by the American Diabetes Association. It could help in measuring the glucose level in people with diabetes and also in people without diabetes (American Diabetes Association, 2020).

The third assessment which could be made is of the mental health of the patient. In the case study, it is mentioned that she is refusing to eat anything and is also feeling sad. Diabetes is a serious disorder which causes a physical, mental and social impact. Mental problems could negatively affect the social life of the diseased individual and could also impact her well-being. Mental or psychological problems could develop into depressive disorders which could lead to poor self-management of the disease and poor metabolic outcomes. If the assessment is not completed then the patient may also suffer from a limitation in functionality and increased cost which is related to health care. The patient might also not feel productive. The test which could be used is the general psychosocial test, which helps in the screening of mental health problems in the children who are in between 4 to 16 years of age (Kalra, Jena &Yeravdekar et al., 2018).

Medical Surgical Nursing - Task 2

Nursing Care Plan: Mrs Lily Orange

Nursing problem: Risk of fluid volume deficit

Related to: Electrolyte disorder in diabetes ketoacidosis patients especially deficiency of sodium, magnesium, phosphate and potassium.

Goal of care

Nursing interventions

Rationale

Maintain the level of the electrolyte in Lily

· Fluid therapy could be used in children with diabetic ketoacidosis (Jayashree, Williams &Iyer, 2019).

· Intravenous bicarbonate therapy could also be used in children withdiabetic ketoacidosis

· This therapy can be used for the restoration of interstitial, intercellular and intravascular components. It could also help in reducing hyperglycemia by lowering the hormones in counter-regulation and by enhancing renal glucose clearance (Jayashree, Williams &Iyer, 2019). 

· Bicarbonate therapy is used to balance the acidosis resolution in the starting few hours of the therapy. It also reduces the danger of hyperchloremic acidosis (Chua, Schneider &Bellomo, 2011).

Nursing problem: Nutritional Imbalance

Related to: While the person is starving, there is an increase in the level of glucagon hormones because of which glucose production is increased. This is a state of catabolism which happens when nutrition is not available.

Goal of care

Nursing interventions

Rationale

Maintains Lily’s nutritional balance

· Nutrition counselling could be done (Vasiloglou, Fletcher &Poulia, 2019).

· The dietary program could be altered and could involve more easily digestible diet which mostly fluid (Gosmanov, A. R., Gosmanova, E. O., & Dillard-Cannon et al., 2014).

· This technique is used because it affects the process of digestion and food absorption and thus reduces the burden on healthcare. With diabetes ketoacidosis, it is also used for cancer, chronic kidney disease and many more diseases. It helps in managing malnutrition in individuals and it is a two-way process in which a healthcare professional identifies the patient problem and provide monitoring (Vasiloglou, Fletcher &Poulia, 2019).

· This could help the patient to undertake important components such as electrolytes and carbohydrates and many other significant nutrients (Gosmanov, A. R., Gosmanova, E. O., & Dillard-Cannon et al., 2014).

Nursing problem: Risk of unstable blood glucose level

Related to: Unstable blood glucose level can occur in diabetes ketoacidosis patients because there is a high number of ketone bodies in the blood. This is related to less insulin secretion and glucose incapability to enter the cells.

Goal of care

Nursing interventions

Rationale

Lily’s blood glucose level will normalize

· Intravenous insulin infusion could be given to the patients who have altered blood glucose level (Hörber et al., 2018).

· Insulin in the blood will signal the cells of the body to absorb glucose from the blood and thus use it in energy production. This would help in the management of glucose in the patient body and thus reduce the symptoms of diabetes ketoacidosis (Hörber et al., 2018).

Medical Surgical Nursing - Task 3

Discharge planning of Lily included nurse giving her information about the insulin regimen and self-management of the disease. By knowing about these two interventions, Lily could control her disease and can better adapt herself to her situation.

The nurse needs to educate Lily on the intake of insulin and how to control her blood glucose level with the use of it. With that, it is also important that the nurse would brief her about the use of insulin in the case of infection or fever. Insulin intake is necessary for the patient suffering from diabetes ketoacidosis because it enhances and promotes the utilization of glucose by peripheral tissues. It also promotes the diminishing of glucogenesis and glycogenolysis. The nurse also needs to tell Lily about the amount of insulin which she should take as an infusion of insulin can worsen the condition of dehydration. In addition to that, the nurse also needs to tell about the food and insulin intake time period. The food should be taken just after the intravenous injection of the insulin so that the blood glucose level could be maintained in the patient body (Gosmanov, A. R., Gosmanova, E. O., & Dillard-Cannon et al., 2014). One strategy that could help Lily in taking the insulin would be the use of an insulin pump. The insulin pump can help the patient of Type-1 diabetes mellitus and diabetes ketoacidosis by managing the insulin volume and subcutaneously delivering of insulin in the patient’s body. The pump supplies insulin in the patient's blood time to time and thus substitutes for long-acting insulin. Because of use of this device, patients did not have to insert multiple insulin injections in themselves every day and it will thus improve the level of glucose in their blood (Tran et al., 2017).

The nurse also needs to inform Lily about the self-management of type- 1 diabetes mellitus and diabetic ketoacidosis. For that, the nurse needs to give her educational coaching and tell her about the skills for self-management of the disease. The nurse should tell the patient about the complications which happen if the disease is not managed. The nurse needs to tell Lily about the impact of the day to day decision which she makes on the management of her disease. The nurse needs to highlight the importance of checking of blood glucose level regularly so that any alteration in them can be detected and treated. With that, the nurse should also mention about the importance of daily exercising and the correct nutritional intake by the patient. Self-management of the disease would help in managing the level of glucose in the patient’s body and improving the life quality which will ultimately help in the reduction of complications which are associated to glucose (Diriba, Bekuma&Bobo, 2020). Therefore, for self-management of Lily's condition, it is beneficial that she checks her blood glucose level regularly. She could do that by urine tasting to colourimetric strips of blood glucose. Other than this, she could also make use of glucometers. Glucometers are actually auto-calibrated biosensors which could estimate the level of glucose in the blood by just a single drop of the blood (Khadilkar et al., 2013).

Medical Surgical Nursing - Task 4

In the case of Lily, she was provided by intravenous compound sodium lactate (CSL) and intravenous sodium chloride so that electrolytes in her body could be maintained. For that, CSL was provided to her in the quantity of 250mls per hour and sodium chloride was given in the quantity of 125mls per hour. This was calculated by taking the whole amount and dividing it by the time taken to provide the whole quantity to the patient.

The first intravenous fluid which was provided to the patient was sodium chloride. Sodium chloride is provided to the patient in 0.9% in the case of diabetes. It is given to the patient by an intravenous route so that it distributes in the body regularly. Maintenance of sodium happens outside the cell of the body with the use of the ATPase pump. Excess amount of sodium chloride is also execrated out from the body via urine. It is given to the patient so that her electrolyte levels balance out as there is the fluid deficiency in her body. By maintaining the fluid level, Lily would not feel dehydrated and lethargic. Thus, it is beneficial for her that she is being provided with sodium chloride (Van Zyl, Rheeder&Delport, 2012). ). Disruption of sodium concentration in the body can cause multiple side effects such as hypernatremia and hyponatremia. Hemodynamic instability can also occur in patient and thus can cause complications in diabetic complication (Diaz-Fuentes, G., Bajantri, B., &Venkatram, 2018).

The other medication which was provided to Lily was Insulin glargine, which was long-acting insulin and is used for managing the type-1 and type-2 of diabetes mellitus. They generally have a very wide duration of action which extends from 18 to 36 hours. It takes about 2 to 3 days in reaching a steady state in the body. Insulin glargine is taken by the patient 1 to 2 times a day. They usually have a flat profile of action and normally referred to as peakless. Insulin is required in the body for controlling the levels of glucose. Thus, this long-acting glucose will also help in glycemic control (Stubbs, Levy &Dhatariya, 2017). The side effects of glargin are that people can suffer from hypoglycaemia which can further cause headache, weakness, tremors, concentration troubles, fast heartbeat, seizures, hunger, sweating, irritability and rapid breathing. It can also cause redness, itching, pain and thickening of the skin (Gandhi et al., 2018). 

References for 

American Diabetes Association. (2020). The big picture: Checking your blood glucose. Available at https://www.diabetes.org/diabetes/medication-management/blood-glucose-testing-and-control/checking-your-blood-glucose

Bulum, T., Blaslov, K., &Duvnjak, L. (2013). Resting heart rate is associated with nonproliferative retinopathy in normoalbuminuric type 1 diabetic patients. The Journal of Clinical Hypertension15(8), 579-583.https://doi.org/10.1111/jch.12130

Chua, H. R., Schneider, A., &Bellomo, R. (2011).Bicarbonate in diabetic ketoacidosis - a systematic review. Annals of Intensive Care1(1), 23. https://doi.org/10.1186/2110-5820-1-23

De Boer, I. H., Bangalore, S., Benetos, A., Davis, A. M., Michos, E. D., Muntner, P., ...&Bakris, G. (2017). Diabetes and hypertension: A position statement by the American Diabetes Association. Diabetes Care40(9), 1273-1284.https://doi.org/10.2337/dci17-0026

Diaz-Fuentes, G., Bajantri, B., &Venkatram, S. (2018). Fluids and sodium imbalance: Clinical implications. Fluid and Electrolyte Disorders.IntechOpen: United Kingdom

Diriba, D. C., Bekuma, T. T., &Bobo, F. T. (2020). Predictors of self-management practices among diabetic patients attending hospitals in western Oromia, Ethiopia. PloS One15(5), e0232524. https://doi.org/10.1371/journal.pone.0232524

Gandhi, H., Sarvaia, A., Malhotra, A., Acharya, H., Shah, K., &Rajavat, J. (2018). Effects of glargine insulin on glycemic control in patients with diabetes mellitus type II undergoing off-pump coronary artery bypass graft. Annals of Cardiac Anaesthesia21(2), 167–172. https://doi.org/10.4103/aca.ACA_128_17

Gosmanov, A. R., Gosmanova, E. O., & Dillard-Cannon, E. (2014).Management of adult diabetic ketoacidosis. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy7, 255–264. https://doi.org/10.2147/DMSO.S50516

Hörber, S., Hudak, S., Kächele, M., Overkamp, D., Fritsche, A., Häring, H. U., Peter, A., &Heni, M. (2018).Unusual high blood glucose in ketoacidosis as first presentation of type 1 diabetes mellitus. Endocrinology, Diabetes & Metabolism Case Reports2018, 18-0094. https://doi.org/10.1530/EDM-18-0094

Jayashree, M., Williams, V., &Iyer, R. (2019). Fluid therapy for pediatric patients with diabetic ketoacidosis: Current perspectives. Diabetes, Metabolic syndrome and Obesity: Targets and Therapy12, 2355–2361. https://doi.org/10.2147/DMSO.S194944

Kahanovitz, L., Sluss, P. M., & Russell, S. J. (2017).Type 1 diabetes - A clinical perspective. Point of Care16(1), 37–40. https://doi.org/10.1097/POC.0000000000000125

Kalra, S., Jena, B. N., &Yeravdekar, R. (2018).Emotional and psychological needs of people with diabetes. Indian Journal of Endocrinology and Metabolism22(5), 696–704. https://doi.org/10.4103/ijem.IJEM_579_17

Khadilkar, K. S., Bandgar, T., Shivane, V., Lila, A., & Shah, N. (2013).Current concepts in blood glucose monitoring. Indian Journal of Endocrinology and Metabolism17(Suppl 3), S643–S649. https://doi.org/10.4103/2230-8210.123556

Stubbs, D. J., Levy, N., &Dhatariya, K. (2017). Diabetes medication pharmacology. Bja Education, 17(6), 198-207. https://doi.org/10.1093/bjaed/mkw075

Tran, T., Pease, A., Wood, A. J., Zajac, J. D., Mårtensson, J., Bellomo, R., &Ekinci, E. (2017). Review of evidence for adult diabetic ketoacidosis management protocols. Frontiers in Endocrinology8, 106. https://doi.org/10.3389/fendo.2017.00106

Van Zyl, D. G., Rheeder, P., &Delport, E. (2012). Fluid management in diabetic-acidosis—Ringer's lactate versus normal saline: A randomized controlled trial. QJM: An International Journal of Medicine105(4), 337-343.

Vasiloglou, M. F., Fletcher, J., &Poulia, K. A. (2019). Challenges and perspectives in nutritional counselling and nursing: A narrative review. Journal of Clinical Medicine8(9), 1489. https://doi.org/10.3390/jcm8091489

World Health Organization.(2020). Cardiovascular disease. Available at https://www.who.int/cardiovascular_diseases/guidelines/Chart_predictions/en/#:~:text=WHO%2FISH%20risk%20prediction%20charts,diabetes%20mellitus%20for%2014%20WHO

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