Diabetes Mellitus Management

Diabetes Mellitus Management Short answer response (600 words) Short answer response (600 words) Task description This question is based on the case study (Nick). In the management of Nick’s care, a nursing care plan has been developed by the Community Diabetes Nurse and sent to the ward to be implemented. You note that the care plan is for hyperglycaemia and Nick has experienced hypoglycaemia this admission. The Community Diabetes Nurse has asked you to adjust the care plan as needed for the individual and ensure that any intervention and education you provide is patient centred. Questions: Part 1 : Identify the lega l/ethical issue in relation to receiving the wrong care plan. Briefly identify the legal/ethical issue provided in the scenario above. Your response here should be brief (maximum of 50 words) . Part 2 : Provide a critical discussion on the education you woul d provide Nick. T he discussion should focus on two of the following aspects of diabetes mellitus management and include evidence based reasoning in relation to contemporary and emer ging research within the topics: • Diet and nutrition • Physical activities • Insulin management Structure and presentation : T he response should include a brief (one sentence) introduction , followed by the case analysis (one paragraph for each of your chosen topics) and a brief (one/two sentence/s) conclusion . Do not use dot points, headings or tables. Nick's health is suffering as he starts to live life in the 'fast lane' Nick begins university Nick at uni Nick, 18, has just begun his first semester in his first year of an engineering degree at University of Sydney. He was diagnosed with type 1 diabetes mellitus at age six and prior to his first semester at uni, Nick’s parents had helped Nick maintain strict control over his blood glucose levels, insulin administration, diet, exercise and overall health. He is currently prescribed Humulin R Twice a day. When Nick was in high school, several teachers on staff were very supportive of his condition and encouraged Nick to maintain regular eating schedules and inject insulin at regular intervals. For years, his diabetes was managed well. He is living away from his parents and siblings for the first time and lives in on-campus dormitory university accommodation. Over the past several months, Nick has been introduced to many stressors that he is challenged by. He is away from the support of his family, he is responsible for his own meals and insulin management, he is involved in a whole new social group, and he is struggling to keep up with the workload of his course. In addition, Nick is on the university’s rugby team and feels peer pressure from his teammates to engage in activities such as chasing girls, binge-drinking, late night fastfood runs, skipping class, pulling all-nighters before exams and extreme training schedules. Presentation to Emergency After a night of hard-core partying, friends found Nick looking unwell in the dorm’s common room and brought him to the hospital’s Emergency Department. Nick's friends reported that they found him shaking and sweating uncontrollably, and floating between being unconscious and irritable and uncooperative. They put him in their car and brought him straight to the Emergency Department. Observations on arrival Upon arrival, Nick’s observations were: • • • • • Blood pressure – 140/94 Pulse rate – 116bpm Respiratory rate – 26 breaths/min, shallow Temperature - 37.5oC O2 Sat - 93%. • • • Skin – diaphoretic, warm and pale Trembling Blood glucose level – 2.5mmol/L Medical diagnosis and treatment plan The doctor diagnoses Nick as having a hypoglycaemic episode. Nick’s immediate treatment includes the administration of SC 1mg glucagon and 50mL of 50% Glucose, IV over 2 hours. Nick in the medical ward On the ward It is now three days later and Nick’s condition is stable. You are the nurse assigned to Nick for the duration of your shift on the medical ward. Nick’s current vital signs are as follows: BP Pulse RR Temp O2 sats 128/78 60 beats/min 16 breaths/min 37.5oC 97% He is alert and oriented to person, place, and time with no subjective complaints of pain. He is neurologically intact. His blood glucose level has stabilized to his pre-university state of 7.8 mmol/L (non-fasting state). He is eating regularly and his fluid intake is equal to his fluid output. Where to from here? Nick does not want his parents to discover that he is in the hospital for the second time in seven months and has asked the team not to inform his parents. After his last admission in his first semester, his parents were threatening to pull him out of university and have him attend a local university so that he can return home. Nick is readmitted to hospital and transferred to the medical ward Nick becomes unwell again It is now at the end of the university year and Nick has represented to the local hospital. He presented to the Emergency Department late the previous evening very unwell, complaining of vomiting for the past two days and admitted to skipping several doses of insulin recently. He mentioned that he was feeling feverish at home and reported an occasional cough. He was transferred to the medical ward this evening from the Emergency Department and is assigned to your care. Whilst reading through Nick’s notes from his assessment in the Emergency Department, you find the following: pain throughout all abdominal quadrants with “cramping” reported in all four abdominal quadrants. He was extremely lethargic and difficult to rouse at times. He complained of severe thirst. His skin was extremely dry. Electrocardiogram (ECG) showed a sinus tachycardia at 120 bpm. Lungs were clear bilaterally, but respirations were deep and rapid. There was an acetone smell to Nick’s breath. He denied alcohol and illicit drug use and could recall no drug or food allergies. He did report that one of his aunts has type 1 diabetes mellitus. You are aware of Nick's social history as a university student. You notice Nick's last hospital admission was for hypoglycaemia resulting from his university life style. However, since Nick has presented with a different health issue related to his Type 1 Diabetes, you ask him about his current situation. Nick states, “I often struggle with the costs of university and rugby and sometimes my medication runs out or I forget to get my scripts filled”. During the past year, Nick has been admitted to the hospital with the diagnosis of hypoglycaemia once and diabetic ketoacidosis (DKA) once. In addition, he had failed to attend two of his follow up appointments, because he couldn’t take time off university to attend appointments. On arrival at the ED Observations On arrival at emergency, Nick’s observations were: • • • • BP 124/80 HR 122 bpm Respirations 32/min Temperature 35.8o C Urinalysis His initial urinalysis revealed: • • • • • • Specific gravity: 1.015 Ketones: 4+ Leukocytes: few Glucose: 4+ Nitrates: 0 RBCs: many Bloods His initial blood studies revealed: • • • • • • • • • • • Hgb: 14.5 g/dl Hct: 58% Ca+: 8.8 mmol/L Phosphate: 6.8 mg/dl Na+: 126 mmol/L K+: 5.3 mmol/L Cl-: 95 mmol/L Creatinine: 0.9 mg/dl BUN: 52 mg/dl Glucose: 254 mg/dl Ketones positive Arterial blood gases • • • • • pH: 7.19 PO2: 100 mm Hg HCO3: 10 mEq/l PCO2: 20 mm Hg SAO2: 98% (room air) Medications Nick’s daily insulin doses are as follows: • • mane 16U 30/70 Humulin nocte 12U 30/70 Humulin Whilst in Emergency, the priority of care for Nick was the correction of the following: fluid loss with intravenous fluids, hyperglycaemia with insulin, electrolyte disturbance, particularly potassium loss, and his acid-base balance. Fortunately, he responded well to his treatment, and once his blood studies began to improve and he was able to tolerate oral fluids and food, he was transferred to the medical ward for ongoing assessment over the next three to five days. Treatment on the ward Nick arrives on the ward with the following orders: • • • • • • • IV 0/9% normal saline q6h Strict fluid balance chart Diabetic diet, as tolerated Hourly blood glucose test q6h blood tests (including full blood count, serum electrolytes and chemistry, venous blood gas, glucose, urea) Test all urine Continue with his insulin regime