Clinical Reasoning Assessment - Report Example

Clinical Reasoning Assessment –Part B (Word Count 1000 words) Upon further assessment the patient, a 51 year old male d Douglas Adams with Type Idiabetes admitted to emergency the night before, is shown to be suffering from hypoglycemia, as was hypothesized in the original diagnosis in Part A. The most obvious physical symptoms were slurred speech and weakness, which are among the symptoms of hypoglycemia, allowing the nurse observer to make the original assessment (McAulay et al., 2001). Additional investigation however, reveals that the patient did not actually eat breakfast in the morning, negating the possibility that the condition is more specifically a case of reactive hypoglycemia, which would only occur in situation where the patient has recently eaten prior to the episode (Collazo-Clavell, 2008). The patient’s tested blood glucose level was 2.1 mmol/l, revealing that the patient is experiencing low blood glucose levels. A blood glucose level below 60 mg/dl, or approximately 3.3 mmol/l, is considered a sign of hypoglycemia (Comer, 2005). The patient is also experiencing a tightened airway and normal levels of oxygen saturation. The patients Glasgow coma score is 13, and the patient is disoriented. These symptoms all correspond to the diagnosis of hypoglycemia in Part A, and the ward protocol for handling hypoglycemia is initiated after consultation with the ward medical officer. The patient is given approximately 20 grams of carbohydrates in 125 grams of orange soft drink, and a blood glucose test is administer after 30 minutes. This test shows a 4.7 mmol/l blood glucose level, well above to 3.3 mmol/l level of hypoglycemia. The patient has a Glascow Coma score of 15, indicating very mild traumatic symptoms and a drastic improvement in state of consciousness from the original score of 13 (Teasdale, 1974). The patient exhibits a normal heart rate of 72 beats/min, a normal respiration rate of 16 breaths/min, a temperature on the high end of the normal range at 37.3 degrees Celsius, a blood pressure score on the low end of the normal range at 105/65, and a normal oxygen saturation of 99% (Dugdale, 2009; Saunders, 2001). The effectiveness in hypoglycemia treatment in alleviating symptoms serves as additional validation that the assessment of hypoglycemia in Part A was correct. Because the nurse is most likely party to initially observe patients with hypoglycaemia, it is important that the nurse be able to prioritize the patient’s problems. In the next two hours, the care plan should ensure patient returns to a normal state of consciousness, alleviate patient discomfort, and familiarize patient with carbohydrate self-administration. The most important initial concerns in order of priority are patient consciousness, regulation of blood glucose levels, respiratory and circulatory status, last food intake and amount, and IV access. For the nurse administering care, patient consciousness is the foremost problem because it determines if the condition may be simply treated by administration of oral carbohydrates. The Glasgow Coma result provides information on the patient consciousness level that may be useful in treatment. In unconscious patients treatment becomes more complex, as IV treatment with carbohydrates can place patients at risk for fluid overload, and intramuscular injection of glucagon is often used instead (Tomky, 2005). The nurse should recognize the condition, consult the medical officer, and initiate treatment before the patient loses consciousness wherever possible. Treating the actual imbalance of glucose levels is the next priority. If the patient is conscious, he may be treated with any variety of oral carbohydrate, such as the carbohydrate administered in orange drink in the scenario given. Glucose tablets, containing four to five grams of carbohydrates, can be placed at the bedside of the patient in order to standardize and speed up treatment. Oral administration of three tablets would provide 12-15 grams of carbohydrate, and be enough to alleviate the symptoms of hypoglycemia visibly within a fifteen minute period (Anthony 2008). In the event of unavailability of glucose tablets or difficulty in administering them the patient, 15 grams of carbohydrates can be found in a number of products, including 4 oz. of non-diet cola, apple juice, or orange juice or 6 oz. of ginger ale (Tomkay, 2005). Restoring a normal level of blood glucose is critical to alleviating the condition and ensuring patient recovery. Because hypoglycemia can result in life threatening complications such as seizures and other complications, the next priority is diligent monitoring of the patient’s regulatory and circulatory status (McAulay et al., 2001). Monitoring the oxygen saturation in patient is critical, and may be accomplished through pulse oximetry on any arteriolar bed such as those found in the finger, great toe, earlobe, or nose (Saunders, 2001). Hyperglycaemia may also induce osmotic diuresis, so it is important to monitor the hydration level of the patient. Dry mucous membranes, thirst in conscious patients, tachycardia and hypotension can be indicative of deficient fluid volumes, and must be carefully observed by the nurse administering care (Comer, 2005). Peripheral ineffective tissue perfusion may be associated with dehydration. It is important to observe whether the patient responds to treatment in a normal time range of fifteen to thirty minutes because dehydration may result in orally administered glucose not being distributed at normal rate to cells in the body, indicative of dehydration. Low blood pressure can be indicative of dehydration, and as such should be closely monitored. In order to meet the care needs of the patients, the nurse should first check for consciousness and gauge the consciousness level. If the patient is unconscious, the nurse should attempt to bring the patient to consciousness and verify that the patient is not simply sleeping. Once the consciousness level of the patient is established the nurse should consult the medical officer and begin treatment. For patients that are conscious this simply means oral administration of carbohydrates, as discussed above. For unconscious patients the medical officer should be consulted, and administration of non-oral carbohydrates, such as intramuscular dextrose injection, should be completed. After administration of carbohydrates, the nurse should continue to monitor blood pressure, fluid intake, and oxygen saturation carefully in order to ensure that glucose is penetrating the tissue and alleviating patient symptoms of hypoglycemia. The nurse providing care is most likely to be in direct contact with the patient, and must plan care that allows the patient to return to a normal state of consciousness, alleviates patient pain, and familiarizes him with carbohydrate self-administration within the first two hour period. As such, it is imperative that the nurse recognize the signs of onset of hypoglycemia and understand how to prioritize their actions in patient treatment by gauging consciousness, administering carbohydrates, and monitoring circulatory and regulatory symptoms in order to ensure patient recovery. References Anthony, Maureen. (Feb. 2008) Hypoglycemia in Hospitalized Adults. MedSurg Nursing. Collazo-Clavell, M. (2008) Reactive hypoglycemia: What causes it? MayoClinic. Mayo Foundation for Medical Education and Research (MFMER). Brochure. Comer, Sheree. (2005) Delmars Critical Care: Nursing Care Plans. Second Edition. New York, NY: Thomson Delmar Learning. Dugdale, David. (2009). Vital Signs. MedlinePlus: U.S. National Library of Medicine from the National Institutes of Health. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/002341.htm McAulay, V, Deary, J, and Frier, M. (September 2001). Symptoms of Hypoglycaemia in People with Diabetes. Diabetic Medicine, 18(9), 690–705. Saunders, W.B. (2001) Chapter 14: Oxygen Saturation Monitoring by Pulse Oximetry. AACN Procedure Manual for Critical Care. Fourth Edition. Philladelphia, PA: W.B. Saunders Company Teasdale G., Jennett B. (13 July 1974). Assessment of coma and impaired consciousness: A practical scale. Lancet, 2(7872), 81-84. Tomky, Donna, MSN. (Jan. 2005) Detection, Prevention, and Treatment of Hypoglycemia in the Hospital. Diabetes Spectrum. American Diabetes Association. 18(1), 39-44. Read More