Unstable angina and Hyperosmolar hypoglycaemic nontetotic - Case Study Example

?Nursing Case Study: Unstable angina and Hyperosmolar hypoglycaemic nontetotic syndrome Question one Of the five problems (Dehydration, Tachycardia, Decreased level of consciousness, Hyperglycemia, and Hyperkalemia), Hyperglycemia should be given first priority. Hyperglycemia is defined as a condition in whereby there is an excessive circulation of glucose in the blood. This refers to a glucose level that is above 11.1mmol/l or 200 mg/dl. Hyperglycemia is the main characteristic of diabetes mellitus, and it occurs due to reduced levels of insulin. Reduced levels of insulin make it hard for the body to convert glucose into glycogen resulting into excess levels in the blood (Hu, Pan, & Sun, 2012). Hyperglycemia can result into other complications such as ketoacidosis and hyperkalemia. Insulin deficiency results into a potassium shift from the intra-cellular to the extracellular space (Margassey & Bastani, 2001). This can also occur due to increased osmolality that accompanies hyperglycemia. Hyperglycemia also results into dehydration as the body disposes excess glucose through urine leading to excessive water loss. The complication is also responsible for decreased consciousness. Therefore, by treating hyperglycemia, one will prevent worsening of the other three conditions. Insulin, infusion should be conducted first to deal with hyperglycemia. This will further result into the movement of potassium from the extra-cellular space to the intracellular space (Lehnardt & Kemper, 2011). Treatment of hyperglycemia will have an immediate impact on dehydration and decreased consciousness, and will stop worsening of Hyperkalemia and tachycardia by extension. Hyperglycemia can be treated in different ways. Glucotrol can be used to stimulate the pancreas to release insulin. Acarbose can be used to block enzymatic action on carbohydrates, while metformin or pioglitazone can be used to increase tissue sensitivity to insulin (Ripsin, H, & Urban, 2009). The goal tachycardia therapy should be to slow down the first heart rate. Several strategies might be used such as the Vagal maneuvers and medications. In practice, medications are offered when the vagal maneuvers fail. Patients can take flecainide or propafenone. Cardioversion can also be used in emergency situations (University of Michigan Health System, 2012). The management of Tachycardia should be conducted with the help of ECG monitoring Hyperkalemia should then be tackled. Examination of Hyperkalemia must be conducted in a systematic level and this should include cardiac function, in addition to the urinary tract, hydration status and neurological processes (Margassey & Bastani, 2001). Normally, individualized therapeutic strategies should always be employed in the management of hyperkalemia. The management should be guided by the specific findings regarding the level of potassium in the blood. Treatment needs to be hurried up due to the fact that the faster the rise of potassium level the greater the chances of toxicity (Karet, 2009). Identification of the cause is key to establishing the desired treatment procedure. In the current case, it is evident that the hyperkalemia results from hyperosmolar hyperglyceamic Nonketotic syndrome which the patient is known to have. The condition is described as a complicated case of diabetes mellitus, particularly type 2, in which high levels of blood sugar result into dehydration, increase in osmolarity, and an increased rate of complications that might result into death (Karet, 2009). The current case of hyperkalemia is most likely as a result of the increased shift of potassium from the intracellular to the extracellular space (Barker, Burton, & Zieve, 2003). Question two Hyperthermia refers to a state where body temperatures are elevated due to a failure in thermoregulation mechanism characterized by the absorption of more heat than that which is eliminated (Hauber, Mohamed, Johnson, & Falvey, 2009). There are several causes of hyperthermia which include effects of drugs, heat stroke and other medical conditions. Identification of the cause is crucial to the management strategy employment. Most medical conditions that result into impaired medical condition have the chance of resulting into hyperthermia. Hyperthermia may have several symptoms and complications which might include the following: rashes, fever, Iyell’s syndrome, erythema muitiforme, nausea, vomiting, and pneumonia (Kadirvelu, Sadasivan, & Hui, 2012). The nature of symptoms observed underlying medical conditions play an important role in the choice of drugs to be used for treatment of Hyperthermia. In the present case, the patient diagnosed with unstable angina which developed as a complication of Hyperosmolar Hyperglycaemic Nonketotic Syndrome. In most cases, hyperthermia is treated with drugs such as “Tylenol, Ibuprofen, Acetaminophenm Motrin, Advil, and aspirin” (Hauber, Mohamed, Johnson, & Falvey, 2009). In the current case, the patient suffers from hyperthermia most likely due to impaired metabolic function. Generally, differential diagnosis conducted on hyperthermic cases often includes, “sepsis, trauma, heat stroke, neuroleptic malignant syndrome, serotonin syndrome, thyroid storn,anticholinergic delirium, and malignant hyperthermia” (Ripsin, H, & Urban, 2009). Hyperkalemia and metabolic acidosis have been implicated as possible causes of hyperthermia. It has also been established that antihypertensive drugs could also result into hyperthermia. Therefore, in the present case the hyperthermia could be due to of the two possibilities the three possibilities (Metabolic acidosis, hyperkalemia and the use of anti-hypertensive drugs). Anti hypertensive drugs that might cause hyperthermia include calcium channel blockers and beta blockers. Hyperthermia often results as a complication of the various side effects of such drugs. In the current case, the exact drugs being used by the patient have not been stated (Hauber, Mohamed, Johnson, & Falvey, 2009). Therefore, the chance of establishing whether hyperthermia is a direct result of drug activity is very minimal. Attention now shifts to the establishment of whether paracetamol provides adequate intervention for the treatment of hyperthermia, whether it results into toxicity or whether it antagonizes activities of common drugs used in the management of complications outlined in the current case. While contra-indications have been observed with several drugs that are used to treat hyperthermia, paracetamol has not been associated with any side effects if used within recommended doses (University of Michigan Health System, 2012). The drug has been approved by World Health Organization (WHO) for use in hyperthermia (fever) reduction in individuals belonging to any age group (University of Michigan Health System, 2012). The drug does not antagonize actions of most drugs used to treat hypertension. I n the current case, I will discontinue the anti-hypertensive therapy if the drug used has hyperthermia as one of its side effects. I will restart the patient on another regimen that does not cause hyperthermia, and give paracetamol for treatment of hyperthermia (Karet, 2009). Paracetamal works by selective inhibition of COX-3 enzyme both in the brain and the spinal cord and, therefore, it relieves pain and fever without causing undesired gastrointestinal effects (Chandrasekharan, 2002). Question three A patient who is diagnosed with diabetes must be trained effectively in order to increase chances of survival and reduce associated diseases such as kidney failure and heart disease (Hauber, Mohamed, Johnson, & Falvey, 2009). Self-management lessons provide patients with a knowledge required for behavior change and keep chronic illness under control. Such training enables patients to minimize negative impacts on their physical health functioning and enables them to cope psychosocial effects of their illness (University of Michigan Health System, 2012). There are several self-management strategies that can be employed by patients suffering from type II diabetes which include taking blood glucose measurements on regular basis, taking medications as directed by the physician, recognizing symptoms and responding to them, physical activity, maintaining an optimal diet, weight management, managing acute episodes , and responding to psychological challenges (Shrivastava, Prateek, & Ramasay, 2013). All these areas are important in the management of the current case. However, if three areas are to be prioritized then the following should be selected: Medication compliance Patients suffering from chronic diabetes are often faced with several other diseases and, therefore, end up taking several medications. Adherence to prescribed medical regimens has remained a crucial factor in the management of chronic conditions such as diabetes, and hypertension. Medication compliance is the basic intervention that is needed to deal with metabolic control, which is by far the most pressing problem in type II diabetes. A study conducted in the United States showed that up to 67% of patients suffering from type II diabetes were not following the guidelines stipulated by the American Diabetes Association (ADA). Patient education is crucial in providing patients with the knowledge required for long-term compliance. This should however be coupled with behavioral intervention for optimal results (Hauber, Mohamed, Johnson, & Falvey, 2009). In the current case, the patient has other conditions such as hypertension, and therefore, has a complex medication program with an increased risk of non-adherence. Physical activity Physical activity is has been reported as one of the priority areas that help minimize chances of patients suffering from type II diabetes to develop complications. Physical activity is crucial in the following areas: minimization of cardiovascular events reduces the risk for metabolic syndrome, strengthen bones and muscles, and improve one’s mental health (Kadirvelu, Sadasivan, & Hui, 2012). In the current case, the patient should concentrate on moderately intense aerobic activity such as brisk walking, which has long found to be generally safe for most individuals (Shrivastava, Prateek, & Ramasay, 2013). Maintaining an optimal diet Good diet is crucial in weight control, prevention of metabolic episodes and controlling of blood sugar levels. Patients suffering from type II diabetes are advised to fresh fruits and vegetables such as cantaloupes, carrots, broccoli, spinach and tomatoes. They should also avoid bad carbohydrates such as processed foods that have high levels of sugar. Health grains that be prescribed to the patient include oats, brown rice, and barley. These foods have a lower rating on the glycaemic index (GI), which is often used to measure the effect of carbohydrates on the levels of blood glucose (Hu, Pan, & Sun, 2012). Observing one’s diet is very important as high levels of glucose can result into insulin resistance (Thomas & Elliot, 2009). References Barker, R. L., Burton, J. R., & Zieve, P. D. (2003). Principles of Ambulatory Medicine. Philadelphia: Lippinocott, Wilkins & Williams. Centers for Disease Control and Prevention. (2013). Physical Activity and Health. Retrieved March 8, 2013, from http://www.cdc.gov/physicalactivity/everyone/health/index.html Chandrasekan, N. V. (2002). A cyclooxygenase-1 variant inhibited by acetaminophen and other analgesic/antipyretic drugs: cloning, structure, and expression. Proc. Natl. Acad. Sci. USA, 99, 13926-13931. Fasanmade, O. A., Odeniyi, I. A., & Ogbera, A. O. (2008). Diabetic ketoacidosis: diagnosis and management. African journal of medicine and medical sciences , 37 (2): 99–105. Hauber, A., Mohamed, A. F., Johnson, F. R., & Falvey, H. (2009). Treatment preferences and medication adherence of people with Type 2 diabetes using oral glucose-lowering agents. Diabet Med , 26(4):416-24. Hu, E. A., Pan, A., & Sun, V. (2012). White rice consuupmtion and risk of type II diabetes: meta-analysis and systematic review. BMJ (Clinical research ed.) , 344: e1454. Kadirvelu, A., Sadasivan, S., & Hui, S. (2012). Social support in type II diabetes care: a case of too little, too late. Diabetes Metab Syndr Obes , 5: 407–417. Karet, F. E. (2009). Mechanisms in hyperkalemic renal tubular acidosis. J Am Soc Nephrol , 20:251–254. Lehnardt, A., & Kemper, M. (2011). Pathogenesis, diagnosis and management of hyperkalemia. Pediatric Nephrology , 26(3): 377–384. Margassey, S., & Bastani, B. (2001). Life-threatening hyperkalemia and acidosis secondary to trimethoprim-sulfamethoxazole treatment. J Nephrol , 4:410–414. Ripsin, C. M., H, K., & Urban, R. J. (2009). Management of blood glucose in type 2 diabetes mellitus. Am Fam Physician , 79 (1): 29–36. Shrivastava, S. R., Prateek, S., & Ramasay, J. (2013). Role of self-care in management of diabetes mellitus. Journal of Diabetes & Metabolic Disorders , 12:14. Thomas, D., & Elliot, E. J. (2009). Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database Syst Rev , 1): CD006296. University of Michigan Health System. (2012). Management of type 2 Diabetes Mellitus. Retrieved March 9, 2013, from http://www.med.umich.edu/1info/fhp/practiceguides/diabetes/dm.pdf Read More