Nursing Health History - Case Study Example

Nursing Health History Dorothy is a 52 year old woman who has been married for 28 years. She lives in the suburbs with her niece who takes care of her, as her husband, whom she rarely sees is working in another state. They have no children, but Dorothy claims that this was a decision that she and her husband made before they got married. More than 5 years ago, Dorothy experienced abnormal increase in urination, and sometimes numbness of feet as well. She consulted a physician, and from then, was a known diabetes mellitus patient. Because of this diagnosis, Dorothy decided to retire from her post as chef in a restaurant of a well-known hotel, and stay home. After three years of taking the prescribed diabetic medications (Metformin), Dorothy discontinued taking the drugs without consulting her physician. Three months prior to admission, the patient accidentally burned her left foot. This then caused the wound to progress to a small ulcer in the plantar aspect of her left foot. Two months later, Dorothy noticed that the wound is becoming bigger and worse and has moved up to the lower portion of the leg. The persistence of this wound prompted the patient to consult the emergency department of the hospital. Dorothy does not smoke, but claims to drink a few glasses of wine on occasion. She leads a sedentary lifestyle, performing minimal household chores. Tending to her garden every morning is the most exercise that she does. There is history of Diabetes Mellitus on the maternal side of the patient, while on the paternal side, there is history of hypertension. Despite this knowledge, Dorothy still liked eating cakes and pastries. There is no history of asthma. Theoretical Framework Dorothea Orem wanted to construct a practical and realistic framework to organize nursing knowledge and practice (Delaune & Ladner, 2006). In 1971, she published her nursing concepts of practice known as the Self Care theory (Berman, Erb, Kozier, & Snyder, 2004). She sought to answer the questions "what is nursing" and "when do people need nursing care", from which she concluded that people need nursing when they are unable to care for themselves (Delaune & Ladner, 2006). Orem's Self Care theory revolves around four concepts: (1) self care; (2) self care agency (which consists of two agents: the self care agent and a dependent care agent); (3) self care requisites; and (4) therapeutic self care demand (Berman, Erb, Kozier, & Sydney, 2004). Self care pertains to the activities an individual practices independently throughout the course of life to promote and maintain health and wellness, while self care agency refers to the individual's ability to carry out these activities (Berman, Erb, Kozier, & Sydney, 2004). The self care agent is the independent individual who cares for himself, while the dependent care agent is another person who provides the care. Examples of a self care agent and a dependent care agent are adults and children respectively (Berman, Erb, Kozier, & Snyder, 2004). Lastly, therapeutic self care demand pertains to every activity done by an individual to fulfill self care demands, which stems from the need to be responsible (Berman, Erb, Kozier, & Sydney, 2004). In short, it refers to actions taken to maintain health and wellness. Self Care Deficit Model courtesy of www.nursing.uiowa.edu Self care is performed by oneself for oneself. It is a gradually learned and deliberate behavior for the purpose of bringing about a condition of well-being (Delaune & Ladner, 2006). It is an individual's right and at the same time a personal responsibility. It may be effective or ineffective, and therapeutic and non-therapeutic (University of Iowa, n.d.). According to this theory, it is the self care deficit that presents the need for nursing care, not the medical condition (Delaune & Ladner, 2006). Self care deficit is subdivided into three categories: universal self care requisites, developmental self care requisites, and health deviation self care requisite (Orem's Conceptual Framework, n.d.). "The universal self-care requisite is defined as the essential needs of the person for the intake of food, water and air, for the living conditions that support life processes, and the formation and maintenance of structural integrity and the promotion of activities that contribute to normal life processes. Next are developmental self-care requisites. These are essential elements required by the human body for normal growth and development from intrauterine life through infancy, childhood, adulthood, and old age. And third is the health- deviation self-care requisite, which is defined as genetic and conditional deviations from normal." (Orem's Conceptual Framework, n.d.) Nursing agency, on the other hand, comes into the picture when there is self care deficit (Delaune & Ladner, 2006). It pertains to helping methods such as acting for or doing for another, offering guidance and direction, health teachings, physical or emotional support, and providing and maintaining an environment that supports health, wellness, and development (Orem's Conceptual Framework, n.d.). In addition to this, there are different conditioning factors. The basic conditioning factors are as follows: age; gender; developmental state; sociocultural orientation; health state; family system factors; health care system factors; patterns of living; environmental factors; and available resources (Unniversity of Iowa, n.d.). Pathophysiology Diabetes is a permanent alteration in the internal chemistry of the body, resulting to the blood containing a very high amount of glucose because of a very low amount or absence thereof of the hormone insulin (Clark, 2004). When a person ingests food and fluids, it is broken down into components, including sugar or glucose, so that the body can perform its functions. Sugar or glucose is then absorbed into the bloodstream to stimulate the pancreas to secrete insulin. Insulin is a hormone produced by the pancreas, which controls the amount of sugar in the blood and transports the sugar from the blood to the cells ("Diabetes Mellitus," 2003). Once inside the cells, the sugar or glucose is then converted into Adenosine Triphosphate, or energy, which is then immediately utilised by the body, or stored for future use. Without insulin, blood sugar levels or blood glucose levels become extremely high due to the fact that it was not transported from the blood to the cells. Because of this, glucose begins to overflow into the urine since the kidney tubules cannot reabsorb it fast enough. Water is then flushed out of the system along with glucose, resulting to dehydration. (Marieb, 2004) Because insulin production is either inhibited or impaired, glucose stays in the blood, and thus cannot be converted into energy. Cells break down fats and protein instead of glucose to meet its energy requirements (Marieb, 2004). This can lead to a series of complications. Since fats are broken down for energy instead of glucose, ketones may form in the blood as it has become very acidic; hence, ketoacidosis may arise. Apart from this, since protein is also utilised as an energy source, the body's defense mechanisms become weak, and there is loss of weight and muscle tone. The three cardinal signs of Diabetes Mellitus to be watched out for are the three polys. First is polyuria, which is excessive urination. This arises because, as mentioned above, the excessive amount of glucose is flushed out of the system, along with ketones. Second is polydipsia, which is extreme thirst due to dehydration from excessive water flushing, and last is polyphagia or excessive hunger resulting from the inability of the cells to use glucose for energy and the breakdown of fats and proteins. Type II diabetes, or late onset Diabetes is non-insulin dependent. This is because the pancreas is able to produce insulin, only that the body has developed resistance to its effects. Hence, there is still not enough insulin to meet the body requirements ("Diabetes Mellitus," 2003). Over time, Diabetes can lead to blindness, kidney failure, and atherosclerosis, which arises due to the hardening and narrowing of the arteries, brought about by irregular cardiac workload (Mathur, 2006). This may lead to Cardiovascular Accidents or strokes, coronary heart diseases, and other blood vessel diseases. Medical/Surgical Interventions Due to the gangrenous wound on the patient's left foot, below the knee amputation was necessary to prevent further necrosis of the foot. Amputation is the surgical removal of an extremity or part of a limb as a result of peripheral vascular diseases usually secondary to Diabetes Mellitus (Smeltzer et. al., 2008). Apart from this surgical procedure, her blood glucose is constantly monitored through CBG monitoring four times a day. A glycated hemoglobin test was also indicated for Dorothy. A BUN and creatinine laboratory exam was also performed to be able to determine if kidney failure is already on the way. The Pharmacologic Therapy prescribed for Dorothy is the following: Cilostazol 50mg/tab twice a day for the management of peripheral vascular disease Diltiazem 30mg/tab twice a day for management of acute hypertension secondary to Diabetes Mellitus. Tianeptin 1 tablet twice a day which is used as an antidepressant and improves the uptake of serotonin (Clayton & Stock, 2001) Clindamycin Phosphate 300mg/1 capsule three times a day to treat infections such that of the gangrenous wound. This drug was used post-operatively to prevent further infections. Ciprofloxacin 500mg three times a day was used as an adjunct to Clindamycin Gliclazide 500mg three times a day for the stimulation of insulin release from the beta cells of the pancreas (Deglin & Vallerand, 2007) Metformin 500 mg three times a day to decrease glucose production and to improve insulin sensitivity (Deglin & Valerand, 2007) Calcium Carbonate 1 tablet twice a day to prevent the occurrence of osteoporosis Health Problem As Dorothy's left foot was recently amputated, Dorothy was worried about having no left foot. She was concerned about being ridiculed about this, as well as how she would not easily be able to do the things she used to do before. In addition to this, she was worried that her niece would tire of her as she would be more dependent on her niece with her present condition. Dorothy has been living with her niece since her condition was diagnosed. However, as much as her niece reminded her to stop eating sweets and to continue seeing her physician, Dorothy maintained confidence that she is well. In knowing this, Dorothy was worried that her niece would blame her because of her present condition. There were a lot of things that Dorothy was worrying about due to the recent amputation of her leg. However, the primary health problem identified in her case is adjusting to her altered body image. Nursing Care Plan References Berman, A., Erb, G., Kozier, B., & Snyder, S.J. (2004). Fundamentals of nursing: Concepts, process, and practice. (7th ed.). Singapore: Pearson Education. Clark, M. (2004). Understandind diabetes. Hoboken, NJ: Wiley. Clayton, B.D. & Stock Y.N. (2001). Basic pharmacology for nurses (12th ed.). Missouri: Mosby. Deglin, J.H. & Vallerand, A.H. (2007). Davis's drug guide for nurses (10th ed.). Philadelphia: F.A. Davis Company. Delaune, S.C. & Ladner, P.K. (2006). Fundamentals of Nursing: Standards and practice. Singapore: Delmar Learning. "Diabetes Mellitus." (2003 February). The Merck Manuals. Retrieved May 17, 2006, from http://www.merck.com/mmhe/sec13/ch165/ch165a.html Doenges, M.E., Moorhouse, M.F., & Geissler-Murr, A.C. (2004). Nurses' pocket guide: Diagnoses, interventions, and rationales (9th ed.). Philadelphia: F.A. Davis Company. Marieb, E.N. (2004). Essentials of human anatomy and physiology (7th ed.). San Francisco, CA: Pearson Education, Inc. Mathur, R. (2006). Diabetes Mellitus. Retrieved May 17, 2006, from MedicineNet.com: http://www.medicinenet.com/diabetes_mellitus/article.htm University of Iowa. (n.d.). Nursing's unique knowledge base. Retrieved April 18, 2008, from http://www.nursing.uiowa.edu/sites/users/hbutcher/Powerpoint/Oremweb_files/frame.htm Orem's conceptual framework. (n.d.). retrieved March 11, 2008, from http://www.sacn.edu/catalog_hdbk_objectives.html Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2008). Brunner & suddarth's textbook of medical-surgical nursing. Philadelphia: Lippincott Williams & Wilkins Read More