Engagement With Clinical Reasoning Cycle And Management Of A Type 1 Diabetic Patient

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

Temp: 37.9 degrees.

Sp02: 94%

RR: 20

BP: 90/50

HR: 120 beats per minute

GCS 13 (confused)

BGL 24

Poor skin turgor.

Frequent urination

Urinalysis positive for glycosuria

coarse air entry, moist productive cough.

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).

· The two most abnormal findings of the patient is the incidence of frequent urination. Furthermore the BGL was found to be 24 which were quite high in this context. Frequent urination also known as Polyuria is also known as the classical symptoms of diabetes. Polyuria is caused in diabetes because in diabetes the blood sugar level is too high and hence all the sugar in the blood stream cannot be absorbed and the excess glucose ends up in the urine drawing up more water (Atkinson et al.2014).

· It is revealed form the scenario that Nancy has been suffering from type 1 diabetes and generally manages her diabetes well by adhering to the medications and maintaining controlled life style, but her concern for not being able to complete her thesis on time caused excessive stress and she probably forgot to take her regular insulin shots for the last few days which is evident from her diabetes log book. According to Atkinson et al.(2014),One of the key element in the management of diabetes is adherence to the insulin uptake as in type 1 diabetes the body does not have the capacity to produce enough insulin for enabling the cells to take up glucose from the blood (Ozougwu et al., 2013). Diabetes and stress are directly proportional as the stress hormones like adrenaline and cortisol (Gan et al. 2012). Normally these hormones help the body to cope up with the stress by prompting the liver for secreting more glucose for the additional energy. But low blood sugar cause rapid release of the epinephrine leading to a slower release of the cortisol and the growth hormone (Nedeltcheva and Scheer, 2014).

This might have been the reason why Nancy was more irritated and agitated. It can be seen that Nancy had to remain awake at night for completing her thesis for which she had to take resort to soft drinks and caffeine. Sweetened beverages are digested fast and thus have high glycemic index (Jiang et al. 2014). According to Ducat  et al.(2014), too high levels of diabetes can lead to diabetic seizures, that can lead to confusion in the patient. Experimental studies have shown that a threshold concentration of glucose is required for supporting the synaptic transmission (Zochodne 2016). The GCS scale showing confusion might have been due to the diabetic seizures.

Predict:

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

If Nancy is left untreated then life threatening condition like diabetic coma can occur. People lapsing in to a diabetic coma might not awake or respond to any stimulation such as sounds or sights. Diabetes is also associated with high heart rate, kidney damage and cardiovascular risks. High blood glucose levels may contribute to the deposition of the fats in the coronary arteries leading to stroke (Goldstein and Müller-Wieland,  2016). Furthermore diabetic ketoacidosis can occur in Nancy, due to which the fat reserves of the body are broken down to ketone bodies that can be found in the urine of patients with type 1 diabetes.

Identify the Problem/s

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

The three key nursing problems related to this case study are:-

· Risk for unstable blood glucose level.

· Risk for disturbed sensory perfection.

· Risk for impaired skin integrity.

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).

Evaluation of the nursing care would be evident from the nursing outcomes and the feedback shared by the Nancy and her husband. The better outcomes should include the glucose level less than   180 mg/dL, the patient would display a normal cognitive status.  The stress level will be decreased with no signs of irritation or confusion. The nursing interventions should also contain the self management strategies for diabetes, regarding the insulin uptake and maintenance of proper records (Haas et al. 2012).

My encounter with this patient would be helpful in my future practice as I believe that it has helped me to enhance my decision making skills by applying my critical thinking skills. My eagerness for understanding the underlying pathophysiology has helped me to apply evidence based practice in my nursing research, as I have brainstormed through several nursing articles to understand the pathophysiology and is connected to the symptoms.  I have been successful in evaluating the patient outcome, which I feel is an integral part of the nursing professional standards.