Medical Surgical Nursing - Task 1

The most paramount action needs to follow on the admission of the patient is to carry out the entire preliminary rapid evaluation of the patient. The ABC framework (airway, breathing and circulation) is widely deployed for the preliminary assessment of the trauma patient; further, this assessment allows the health care workers to identify life-threatening issues associated with patient's condition. Rapid identification of the life-threatening situation allows the timely appropriate treatment to put to prevent the death risk or any disability due to threatening issue (Skinner & Driscoll, 2013). In the present case, Mrs Lily Orange was admitted to the emergency department due to Diabetic Ketoacidosis (DKA). She was very fatigued, feverish and unwell. She was able to respond verbally to medical staff, therefore indicating that her airway was patent and had sufficient circulation, though she complained of difficulty in breathing.

In accord to National Institute for Health and Clinical Excellence clinical guidance (NICE); respiratory rate, heart rate, blood pressure, temperature, oxygen saturation and consciousness level must be recorder at the initial evaluation and followed by every 12 hourly on regular basis (Timmis & Roobottom, 2017). Modified Early Warning Score (MEWS) can be deployed in the present case for the detection of the deteriorating condition of Mrs Lily. Alam et al., (2014) presented that the score can be calculated based on vital sign and can be deployed in association with the clinical judgment. In the present case, irregular vital sign including high respiratory rate, increased heart rate and low blood pressure are indicative of acidaemia, ketonuria/ketonaemia and hyperglycemia (Dhatariya et al., 2013). In the present case, it is paramount to conduct a testy to evaluate the ketone and blood glucose levels, by finger prick test. Glucose levels greater than 11mmols/L and ketones levels 3mmols/L or more are indicative of DKA. If ketone meter is not available then ketone bodies can be estimated through patient’s urine by conducting dipstick test; value more than 2+ or more is indicative of DKA. Failure in the proper evaluation of blood glucose levels and ketones can be mortal therefore, it is mandatory to follow the blood glucose and ketone evaluation in the present case (Savage et al, 2011).

Additionally, a venous blood sample should be taken in the present case for the evaluation of the acidaemia as a venous blood sample is reliable and less invasive. If the value will be less than 7.3 or the levels of bicarbonates will be less than 15mmol/L then it will indicate that patient have DKA. Bedside monitoring of ketones and serum glucose levels must be repeated very hourly for the initial six hours (Savage, 2011). A venous blood gas will aid in the evaluation of some other values, for instance, electrolytes levels. Moreover, further blood test of Mrs Lily must send for evaluation of full blood count, electrolytes, and urea and for culture, to allow more extensive evaluation, as well as for identification of the infection. Additional investigations required are chest x-ray and Electrocardiogram for further evaluation of the patient’s condition (Noble-Bell& Cox, 2014).

Medical Surgical Nursing - Task 2

Nursing Care Plan: Mrs Lily Orange

Three priorities are as follow:

  • Treating Diabetic ketoacidosis.
  • Address Hyperglycemia.
  • Prevent ketones production.

Nursing Problem 1: Diabetic ketoacidosis

Related To: Patient is already suffering from Type I diabetes mellitus and presented with diabetic ketoacidosis.

Decreased volume can lead to a decreased conscious level.

Goal of care

Nursing Interventions

Rationale

Evaluation

-Treatment of DKA and reduce the mortality risk associated with this condition.

-Restore Blood pressure

-Administration of intravenous fluids: 0.9% of the sodium chloride solution.

- The blood pressure of Mrs Lily was 95/65 mm/Hg. Therefore, 500mls of fluid must be rendered with in the 15 minutes of the admission, followed by normal administration of 1000mls of fluid over the first initial hour.

-Regime must be delivered at a slow rate as high rate of infusion may lead to respiratory distress syndrome.

-Insertion of an indwelling urinary catheter.

-To reestablish circulatory volume: as the patient presented with DKA may have a fluid deficiency (approximately 6 litres) (Pasquel et al., 2020)

-Maintain electrolytes.

-To obtain accurate urinary measurements (Freudenthal et a., 2013).

-Regular check of vitals and blood pressure.

-The patient will remain normovolemic can be evaluated through urinary output rate-must be greater than 30ml per hour.

-Normal skin turgor.

-Good capillary refill.

-Patient will not feel excessive thirst.

-Monitor serum ketones, potassium, sodium, and blood creatinine.

 

Nursing Problem 2: Uncontrolled blood glucose level

Related To: Patient is already suffering from Type I diabetes mellitus and presented with diabetic ketoacidosis.

Goal of care

Nursing Interventions

Rationale

Evaluation

Address hyperglycemia.

Reduce the risk of infection.

-Administration of Insulin.

-50mls of quick-acting insulin with 0,9% of saline with administration rate 1unit/kg/hour.

-Obtain blood sample for sensitivity and culture.

-To reduce the blood glucose level by 3mmoll/L/Hr.

-Identifies fungus/bacteria that lead to an infection that aids in rendering appropriate drug for the same (Danne et al., 2019).

-Blood glucose test.

-Blood culture.

 

Nursing Problem 3: Ketone production

Related To: Can lead to acidosis and significant weight loss.

Further, can cause coma or even death.

Goal of care

Nursing Interventions

Rationale

Evaluation

To prevent the production of ketones bodies.

-Replacement of potassium.

-Reduction of elevated serum glucose levels this can lead to a decrease in the blood ketones levels by approximately 0.5mmols/L/hr and upsurge the bicarbonate levels by 3mmol/L/hr.

-Insulin infusion based on ketones level and blood glucose level.

-Due to infusion of insulin, blood glucose level will decrease faster than ketone bodies, therefore, regularly check for the blood glucose level and if it is lower than 14mmols/L then commence 10% dextrose at 125mls/her rate.

-To reverse the acidosis.

-Potassium levels may reduce during ketoacidosis.

-Clear the serum of ketones (Ghimire & Dhamoon, 2019).

-Blood glucose evaluation by a blood test.

-Ketone evaluation by a ketone test kit.

-Estimation of levels of Bicarbonate.

Monitor potassium level continuously.

-Ketone bodies evaluation in the urine sample of the patient through dipstick test if ketone kit is not available.

.

Task 3: Patient Education

It is recommended that following the admission of the patient with diabetic ketoacidosis, the diabetic specialist team must be contacted as early as possible. Further, timely communication ensures to reduce the risk associated with hyperglycemia and ketone bodies. Additionally, it is recommended that the patient must receive strict follow up upon hospital release, must include proper reviewing of the patient's condition, medication and assessment of the risk of DKA reoccurring that enables to formulate customized interventions to reduce the associated risks (Cooper et al., 2016). Additionally, the main aim is to render possible education to Mrs Lily within three months of her discharge to improve her understanding, to reduce the risk of further admittance with ketoacidosis (Bradford et al., 2017).

 As refer to earlier points, deprived insulin control is one of the leading causes of DKA and most associated with the frequent admission of the patient with DKA. The above-stated point is directly correlating with the current scenario of the patient Mrs Lily. It is evident from the piece of literature that adherence to prescribed medication is lower in certain health issue, for instance, diabetes mellitus (Giugliano et al., 2019). Therefore, it is paramount to fetch the reason why the patient is not following the prescribed medication. For instance, Mrs Lily was also non-adherent to her prescribed insulin regime. In such a case, communication is a vital tool to render essential knowledge to the patient and proven essential for motivating patient for following the regime properly (Moore, 2018).

Proper communication with Mrs Lily throughout her assessment and treatment help her to understand her disease and the current situation more efficiently, despite her previous admission due to diabetic ketoacidosis. It is essential to motivate the patient for two way communication and make her ask a question about tests and results of the test. Two-way communication can be an effective way to render proper knowledge to the patients and helps in improving patient's compliance and associated results. In the present case, discussing Mrs Lily condition and intervention during her hospital stay and follow up can be beneficial in improving her adherence to the regime and potentially preventing further admissions with DKA (Delamater et al., 2018). It has been evident that basic techniques like giving written advice, talking in simple language and speaking with normal pace, while communicating with patients can increase patient's understanding of their health issue. 

The second concern is to motivate Mrs Lily to maintain her blood glucose level, though above-stated concern and blood glucose level concern, both are interlinked and associated with a non-adherent attitude of Mrs Lily. For the same, her family members must be included while planning intervention and setting her further health goals. Keeping patients and family members/ caretakers fully informed throughout the process (investigation and intervention process) enables them to feel that they are in control of their situation and this help in the improvement of psychological wellbeing of the patient. Lastly, Mrs Lily was sad about her condition. With due course of time, she may get anxious and depressed due to her physical condition. Therefore, it is essential to counsel her for the same and enhance her psychological well-being (Davies et al., 2018, Delamater et al., 2018). It can be concluded that the two important points need to point about during discharge planning are the non-adherent attitude of the patient and increase glucose level because these two issues make the frequent admission of the patient and can make the patient anxious in real life. Further two-way communication and involvement of the patient and her family members will be a helpful technique.

Task 4: Medication

As per the medication chart, it is evident that the patient had been on IV fluid, including sodium lactate 500mls over 2 hours and Intravenous sodium chloride 1000mls every 8 hourly.

The hourly rate of the above-stated infusions can be calculated through the formula as below:

Hourly rate= volume (ml)/ Time (hrs) = mL per hour.

The hourly rate can be calculated by dividing volume(ml) by time (hrs). For instance, in the present case, 500mls of sodium lactate is giving over 2 hours then the hourly rate is 250 ml per hour. The calculation for the same is as below:

Hourly rate of sodium lactate=500mls/2 hrs = 250ml per hour.

Additionally, 1000mls of sodium chloride is given every 8 hours. So, the hourly rate is 125ml per hour. The calculation is as follow:

Hourly rate of sodium chloride= 1000mls/8hrs = 125ml per hour.

On further evaluation of the medication chart, it is clear that Mrs Lily is on Actrapid insulin. Human insulin is the active substance in the Actrapid. This medicine is for the treatment of diabetes. In the present case, the blood glucose level of the patient is high and presented with DKA, therefore, Actrapid is included in her medication chart to maintain the blood glucose level within normal limits by replacing the insulin that is similar to insulin formulated by the pancreases. The onset of action of the drug is a half-hour and reaches its maximum effect within 1.5 to 4 hours and the entire action duration is 7 to 8 hours. The most common risk associated with Actrapid is hypoglycemia and the patient might develop an allergic reaction, like redness, pain, swelling, itching, bruising and hives and can hamper vision temporally (Bell et al., 2020). Secondly, on the evaluation of IV fluid orders, it is evident that the patient is on sodium lactate. On initial hours of hospital admission patient with DKA are treated by Hartmann's solution/ sodium lactate to reestablish the circulatory volume and maintain the blood pressure of the patient within the normal clinical values. The lactate present in the sodium lactate solution can be metabolized by gluconeogenesis and/or by oxidation, mainly in the liver and lead to the production of bicarbonate over approximately 1 to 2 hours. The side effects of sodium lactate include overhydration, blood electrolyte dilution and pulmonary edema (Aramendi et al., 2020)

References for Management of Hyperglycaemia

Alam, N., Hobbelink, E. L., van Tienhoven, A. J., van de Ven, P. M., Jansma, E. P., & Nanayakkara, P. W. (2014). The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Resuscitation85(5), 587-594.

Aramendi, I., Stolovas, A., Mendaña, S., Barindelli, A., Manzanares, W., & Biestro, A. (2020). Effect of half-molar sodium lactate infusion on biochemical parameters in critically ill patients. Medicina Intensiva (English Edition).

Bell, K. J., Fio, C. Z., Twigg, S., Duke, S. A., Fulcher, G., Alexander, K., ... & Steil, G. M. (2020). Amount and type of dietary fat, postprandial glycemia, and insulin requirements in type 1 diabetes: a randomized within-subject trial. Diabetes care43(1), 59-66.

Bradford, A. L., Crider, C. C., Xu, X., & Naqvi, S. H. (2017). Predictors of recurrent hospital admission for patients presenting with diabetic ketoacidosis and hyperglycemic hyperosmolar state. Journal of clinical medicine research9(1), 35.

Cooper, H., Tekiteki, A., Khanolkar, M., & Braatvedt, G. (2016). Risk factors for recurrent admissions with diabetic ketoacidosis: a case–control observational study. Diabetic Medicine33(4), 523-528.

Danne, T., Garg, S., Peters, A. L., Buse, J. B., Mathieu, C., Pettus, J. H., ... & Cariou, B. (2019). International consensus on risk management of diabetic ketoacidosis in patients with type 1 diabetes treated with sodium–glucose cotransporter (SGLT) inhibitors. Diabetes Care42(6), 1147-1154.

Davies, M. J., D’Alessio, D. A., Fradkin, J., Kernan, W. N., Mathieu, C., Mingrone, G., ... & Buse, J. B. (2018). Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia61(12), 2461-2498.

Delamater, A. M., de Wit, M., McDarby, V., Malik, J. A., Hilliard, M. E., Northam, E., & Acerini, C. L. (2018). ISPAD Clinical Practice Consensus Guidelines 2018: Psychological care of children and adolescents with type 1 diabetes. Pediatric diabetes19, 237-249.

Dhatariya, K., Savage, M., Kelly, T., Sampson, M., Walden, E., & Walton, C. (2013). Joint British Diabetes Societies Inpatient Care Group. The management of diabetic ketoacidosis in adults [homepage on the Internet]. Joint British Diabetes Societies Inpatient Care Group.[cited 2014 Mar 18]. Available from: www. diabetologists-abcd. org. uk/JBDS/JBDS_IP_DKA_ Adults_Revised. pdf.

Freudenthal, R., Tufton, N., Podesta, C., Mulholland, R., & Rossi, M. (2013). Fluid management in diabetic ketoacidosis: are we adhering to recommended guidelines?. The British Journal of Diabetes & Vascular Disease13(3), 138-142.

Ghimire, P., & Dhamoon, A. S. (2019). Ketoacidosis. In StatPearls [Internet]. StatPearls Publishing.

Giugliano, D., Maiorino, M. I., Bellastella, G., & Esposito, K. (2019). Clinical inertia, reverse clinical inertia, and medication non-adherence in type 2 diabetes. Journal of endocrinological investigation42(5), 495-503.

Moore, M. D. (2018). Food as medicine: diet, diabetes management, and the patient in twentieth century Britain. Journal of the history of medicine and allied sciences73(2), 150-167.

Noble-Bell, G., & Cox, A. (2014). Management of diabetic ketoacidosis in adults. Nursing Times110(10), 14-17.

Pasquel, F. J., Tsegka, K., Wang, H., Cardona, S., Galindo, R. J., Fayfman, M., ... & Narayan, K. V. (2020). Clinical outcomes in patients with isolated or combined diabetic ketoacidosis and hyperosmolar hyperglycemic state: a retrospective, hospital-based cohort study. Diabetes Care43(2), 349-357.

Savage, M. W. (2011). Management of diabetic ketoacidosis. Clinical Medicine11(2), 154.

Savage, M. W., Dhatariya, K. K., Kilvert, A., Rayman, G., Rees, J. A., Courtney, C. H., ... & Joint, B. D. S. (2011). Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabetic medicine: a journal of the British Diabetic Association28(5), 508.

Skinner, D. V., & Driscoll, P. A. (Eds.). (2013). ABC of major trauma. John Wiley & Sons.

Timmis, A., & Roobottom, C. A. (2017). National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm. Heart103(13), 982-986.

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