Evidence-Based Practice on Hyperosomar Hyperglycaemia - Essay Example

? [EVIDENCE BASED CASE STUDY ON HYPEROSOMAR HYPERGLYCAEMIA] Evidence Based Case Study on Hyperosomar Hyperglycaemia Introduction The rate of hospital hyperosomar hyperglycaemia state has been increasing gradually. However, it accounts for few cases of all primary diabetic admissions. Despite the significant advances in the understanding of their pathogenesis and universal agreement about their treatment and diagnosis, hyperosomar emergencies are important causes of morbidity and mortality among diabetic patients (Sinclair, 2009, p, 198). Hyperosomar hyperglycaemia state is a state whereby alteration of sensation may often be present without comma, and it may consist of moderate to variable degrees of clinical ketosis. Therefore, Emergency Department nurses should be keen when assessing for diabetes because older patients may in hyperosomar hyperglycaemia condition. This paper reflects the aspects of care that were provided to a patient, Mr. B, in the Accident and Emergency department, while applying triage, A-G assessment, ECG and fluid management competencies. Triage Triage involves the separation of a patient who requires prioritized care because of the severity his or her condition. This applies most in the Emergency Departments, where doctors and nurses have to determine who gets care first. According to the English Dictionary, the term triage refers to the process of determining the most important people or things from among a large number that requires attention (Oxford University Press, 2013). In medical use, triage is the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties. Since every day, Emergency Departments have to attend to a large number of patients who suffer from a wide range of problems, it is essential to have a system that ensures that these patients are seen in order of their clinical need, rather than in order of attendance. Triage manages a patient flow safely when clinical needs exceed capacity. It involves identification of the problem, determination of the alternatives and selection of the most appropriate alternative (Manchester Triage Group, 2008, p, 7). Identification of the problem involves obtaining information from the patients, their careers and any pre-hospital care personnel. (Manchester Triage Group, 2008). The Emergency Department acts as a transfer station through which the casualties should pass, as quickly as possible, on their way to surgery, intensive care, or a ward (Nutbeam & Boylan, 2013, p, 181). In this case, the patient was triaged by an experienced emergency nurse who has undergone specialist training. In the problem identification phase, information was collected from the patient’s son who provided past history of the patient. From the history, it was established that the patient experienced sudden onsets of lethargy, strange behaviour such as waking up at three in the morning to have a shower, reduced frequency in mitcuration and reduced drinking. When the patient was examined, it was found that the patient was alert, did not exhibit limb weakness, and was quiet, which is unusual. Besides, the patient was not clammy or sweaty. The vital signs awarded an early-warning score of 1, given that a tachycardia of 112 beats per minute was exhibited. Consequently, the patient was placed into priority category three, as per the Manchester Triage System. This required the patient to see the doctor within one hour. However, the patient was seen by a doctor, four hours after triage, which is against the requirements of priority three allocations, at triage. Furthermore, due to lack of trolleys and large volume of patients in the department, the patient was allocated on majors’ chairs instead of trolley. A-G Assessment A-G assessment is essential in facilitating the diagnosis and administration of severe and chronic primary health problems that are found in adult clients, especially the aging patients. The assessment also aids nurses in various areas such as in a patient’s physical assessment and in clinical decision-making. It is through A-G assessment that one can carry out a comprehensive assessment of patients, especially the nonverbal, cognitively impaired or functionally impaired ones. Also, assessment of physiological and functional changes that occur because of aging can be done. This includes the assessment of age specific risk factors. Further, a health practitioner can assess the interaction between acute and chronic physical problems. A-G assessment uses valid and reliable age-appropriate assessment instruments to assess acute and chronic health concerns among patients. Finally, assessment of manifestation of health disorders such as dehydration can be done by use of A-G assessment model. In this case, the patient was assisted onto the trolley by family members because he was unsteady on his feet. He changed into a hospital gown, and was attached to electrical cardiogram monitor. This was to assess the patient’s heart activity. The patient was assessed with an A-G assessment model, as per trust policy. The patient was allowed to maintain own airway, and respiratory rate was found to have increased, as compared to triage rate. Furthermore, oxygen saturation was below the normal range. This implies low cellular perfusion of oxygen in blood, which can lead to less oxygen supply to the brain, resulting to confusion and drowsiness. The patient exhibited symptoms such as dry lips, pale face, which is a common phenomenon where patients tend to be hyperkalaemic, caused by the hyperglycaemia. This is a result of the increased osmotic pressure that causes potassium loss from cells into the blood stream and sodium into the cells, and is followed by dieresis, which leads to dehydration. Therefore, the A-G assessment model was used because the patient was old, and most of the old age patients who exhibit the aforementioned symptoms may be having undiagnosed diabetes, and they could be in risk of other illnesses. It could help prevent the patient from further infection. ECG The electrocardiogram being a simple and useful test that records the electrical activity and rhythm of a patient’s heart, it detects problems with one’s heart rate or heart rhythm. These problems are referred to as arrhythmiasis. A critical care nurse can use the ECG to detect whether the patient is having a heart attack, or if the patient a heart attack in the past (British Heart Foundation, 2013). However, it should be noted that clinical diagnosis by the use ECG is dependent on a patient’s history, and not the physical examination itself. ECG may provide evidence to support a diagnosis. It is extremely crucial for patient management. ECG should be used as a tool, and not an end itself (Hampton, 2008). In this case, ECG was adopted as a tool because it is an essential tool for diagnosis, and therefore, can be vital in the management of abnormal cardiac rhythms. In reading ECG, peaked T waves are normally characteristic of hyperkalaemia, and flat T waves are normally characteristic of hypokalemia (Rowlands & Sargent, 2011, p, 57). ECG monitoring is therefore, important when taking care of a critically ill patient, especially an old age patient. This is because it avoids misinterpretation of arrhythmias, wasted investigations, mistaken diagnosis and mismanagement of the patient. A nurse ought to be keen to treat the patient, and not the ECG monitors (Jevon & Ewens, 2012, p, 114). When a critical care nurse notices a serious problem from the ECG trace and the loss of arterial pressure, he or she can call for assistance from doctors (Adam & Osborne, 2005, p, 210). ECG is a pillar of decision making for nurses in Emergency Departments of hospitals (Kucia & Quinn, 2013). Accurate ECG interpretation of cardiac arrhythmias is essential to ensure that most appropriate managements. Therefore, a systematic approach to ECG interpretation of cardiac arrhythmias is paramount in nursing care for patients who are in critical conditions (Jevon, ECGs for Nurses, 2009, p, 40). It is also important to note that Dieresis, if not corrected in time, may lead to cardiac arrhythmiasis, including cardiac arrest, restlessness, confusion and drowsiness. These conditions are life threatening during a period when blood sugar levels are abnormal, peripheral blood sugar is high and the whole body is characterized with weakness. That is why ECG was used to assess possibilities of any underlying danger facing the patient. Fluid Management Fluid management is essential in determining whether the patient requires rehydration to prevent deterioration of his or her health status. Such risks include hypovolaemic shock, among others. Hypovolaemic shock is a common symptom among old age patients. Another condition that is common among such patients is myocardial infarction or cerebrovascular accident. Hypovolaemic shock is a preload problem in which there is inadequate circulating plasma volume (Hardin & Kaplow, 2006, p, 246). It is a state of inadequate tissue perfusion with decreased blood flow, oxygen delivery and glucose supply to vital tissues and organs of the body such as the brain. This state can be as a result of blood loss or fluid loss (Bond, Hastings, and Pollak, & Kling, 2010, p, 76). A nurse has a role of preventing an altered fluid balance. This can be done by measuring fluid balance to ensure optimal hydration. Fluid management is crucial in ascertaining whether the patient has fluid balance, which is the balance of fluid input and output in the body to allow the functionality of metabolic processes. For instance, severe dehydration is likely to cause hypovolaemic shock, and even organ failure. Fluid management comprises of clinical assessment, urine output and body weight. It can also be done by reviewing the chemistry of blood, as well as, fluid balance charts (Shepherd, 2011). Urine output is essential in fluid management because it can be used as an observation of the patient to make any early-warning sign score (Mackay & Arrowsmith, 2012, p, 412). It is an observation that can lead to the formulation of vital inferences. For instance, an increased urinary output is an indication that the patient’s health may be deteriorating (Traynor, 2012, p, 181). Therefore, there should be proper fluid management for patients presenting with diabetic ketoacidois or HHS to facilitate rehydration. In this case, the insertion of a goal cannula in the patient’s left arm, using a septic procedure by the doctor, to test for normal saline on intravenous fluids is an important step towards fluid management. Secondly, venous gases were done to rule PH within the normal range, and this began on human soluble insulin infusion by use of a sliding-scale regime, as per trust policy. It was through these procedures that observations were made, and recommendation was made for an aggressive treatment with intravenous fluids. Further tests on the patient’s blood and the patient’s blood pressure implied that the patient was hypertensive. Therefore, the patient was found to be in hypovolaemic shock and was restless. The patient did not pass urine, but was reviewed frequently, and arterial gases were repeated. The results showed compensated metabolic acidosis. Further tests on the patient’s blood indicated that blood sugar was still high. On insertion of a second venflon into the patient’s right hand, it was established that insulin infusion rate had changed. The doctor inserted a catheter, draining concentrated urine to monitor fluid output. The urine was tested for ketones, and the results obtained were negative. Therefore, fluid management was extremely essential in assessing the patient’s health condition. Nursing Care and Medical Intervention and Investigations Nursing care in Emergency Departments requires that patients in critical conditions should be triaged. Mr. B was triaged by an experienced emergency so that he could be attended by the doctor because of clinical needs. Appropriate protocol was observed such as problem identification, where information was collected from Mr. B’s son about history of the patient. It was from this history that important information was acquired. For instance, the patient experienced abrupt onsets of lethargy, reduced frequency in mitcuration, reduced drinking and strange behaviour such as waking up at three in the morning to have a shower. Further nursing care involved patient examination, which revealed that Mr. B was alert, did not exhibit limb weakness, and was quiet, which is unusual. In addition, examination of the patient showed that the patient was not clammy or sweaty. These examinations were used to rank the patient into priority category three, as per the Manchester Triage System. Therefore, Mr. B’s clinical needs required that he was to see the doctor within one hour. The Emergency department did all it could to attend to the patient. For instance, it allocated Mr. B on majors’ chairs instead of trolley because of lack of trolleys and large volume of patients in the department. Further nursing care was provided to Mr. B, given that he was old. He was assisted onto the trolley by family members because he was unsteady on his feet, and was attached to an ECG monitor to assess his heart activity. Mr. B was assessed with an A-G assessment model, as per trust policy. The use of the A-G assessment model was a crucial step to take because Mr. B is in old age. Majority of the old age patients who exhibit symptoms such as abrupt onsets of lethargy, reduced frequency in mitcuration, reduced drinking and strange behaviour such as waking up at three in the morning to have a shower may be having undiagnosed diabetes. This means that they be in risk of other illnesses. A-G assessment model can help prevent the patient from further infection. Also, ECG was used to assess possibilities of any underlying danger that may be facing Mr. B. Medical interventions such as procedures to test for normal saline on intravenous fluids are imperative steps towards fluid management. It was through these procedures that observations were made, and recommendation was made for an aggressive treatment with intravenous fluids. For instance, tests on the patient’s blood and the patient’s blood pressure implied that Mr. B was hypertensive, and was therefore, found to be in hypovolaemic shock and was restless. Furthermore, from the repetition of arterial gases, results showed compensated metabolic acidosis. Further tests on Mr. B’s blood indicated that blood sugar was still high. The insertion of a second venflon into the patient’s right hand, it was established that insulin infusion rate had changed. The insertion of a catheter by the doctor to drain concentrated urine that could be to monitor fluid output was an important step to take. It was after the urine was tested for ketones, that negative results were obtained. Therefore, fluid management was exceptionally necessary in assessing Mr. B’s health condition. Most of the nursing care and medical intervention and investigations that were applied in the Emergency Department for the treatment and care of Mr. B are in line with the current practice guidelines. First, the nursing care and medical intervention and investigations involved the carrying out of diagnostic tests to find out the causes, and probably the treatment for HHS. Secondly, provision of care and treatment was done according to protocols. Third, the nursing care and medical intervention and investigations prioritised patient safety interventions, given that HHS and DKA are among the serious medical emergencies. DKA is characterised by hyperglycaemia in association with metabolic acidosis and increased circulating ketone bodies. It should be noted that typical patients with HHS have undiagnosed diabetes, and in most cases are aged between fifty five and seventy years (Sinclair, 2009, p, 198). Evaluation of Care Given As noted earlier, most of the nursing care and medical intervention and investigations that were applied in the Emergency Department for the treatment and care of Mr. B are in line with the current practice guidelines. The emergency department nurse is required to monitor response to therapy, ensure that there is surveillance for complications, assess mental status changes such as confusion and assess potential signs such as hypotension. She or he is also required to administer prescribed fluids. The nurse should also monitor symptoms of circulatory overload because a patient may be having existing illness such as heart failure and kidney failure. Therefore, symptoms of circulatory overload should be monitored (Urden, 2013). A nurse is required to offer patient education, when the patient’s condition improves. However, there is one aspect of the nursing care, medical intervention and investigation that was against the current practice requirements. The patient was placed into priority category three, as per the Manchester Triage System. This required the patient to see the doctor within one hour. On the contrary, Mr. B was seen by a doctor, four hours after triage, which is against the requirements of priority three allocations, at triage. Therefore, the aspect of avoiding delay in medical treatment for a patient was violated. Conclusion and Recommendations Nursing care in Emergency Departments requires that patients in critical conditions should be triaged so that they can be attended to by a doctor in order of their clinical need. It also ensures a safe patient flow when clinical needs exceed the capacity of an Emergency Department. Therefore, the most critical patients are attended first to prevent deterioration of their conditions. A-G assessment model is an important tool to use in an Emergency department. This is because it facilitates diagnosis and administration of severe and chronic, primary health problems that are found in adult clients, especially old patients. It is also helpful to nurses in carrying out the physical assessment of a patient and in clinical decision-making. The electrocardiogram (ECG) is essential in an Emergency Department because records the electrical activity and rhythm of a patient’s heart to detect problems with a patient’s heart rate or heart rhythm. Finally, fluid management is also essential in determining whether the patient requires rehydration to prevent deterioration of his or her health status, especially for old age patients. It is recommended that in the future, service should be designed around patients. Secondly, nursing care and medical intervention and investigations should be consistent, regardless of where the patient was initially attended to. Furthermore, attendance to the patient should be addressed with professional and best skills to meet their needs. The Emergency Departments will have to ensure that there are no delays in the care processes, especially after triage. The right response to the continued increase in patient attendances and reduce waiting times is extremely essential. This is because the emergency departments should be accessible to the public. Future nursing care and medical intervention and investigations should have clear and consistent, measurable standards. Nursing care and medical intervention and investigations should be designed so that patients receive optimum effectiveness from treatment (Dolan & Holt, 2008). Finally, in future, Emergency Department nurses should seek to develop partnerships and good relations with patients and relatives. References Adam, S. K., & Osborne, S. 2005. Critical Care Nursing: Science and Practice. Oxford : Oxford University Press. Bond, C., Hastings, P. R., Pollak, A. N., & Kling, J. 2010. 68W Advanced Field Craft: Combat Medic Skills. Boston: Jones and Bartlett Publishers. British Heart Foundation. 2013. ECG. From http://www.bhf.org.uk/heart-health/tests/ecg.aspx Dolan, B., & Holt, L. 2008. Accident & Emergency: Theory Into Practice. Edinburgh: Baillie?re Tindall Elsevier Press. Hampton, J. R. 2008. The ECG Made Easy. Edinburgh : Elsevier . Hardin, S. R., & Kaplow, R. 2006. Critical Care Nursing: Synergy for Optimal Outcomes. London: Jones and Bartlett Publishers . Jevon, P. 2009. ECGs for Nurses. Chichester: Wiley-Blackwell Press. Jevon, P., & Ewens, B. 2012. Monitoring the Critically Ill Patient. Chichester: Wiley-Blackwell Press. Kucia, A., & Quinn, T. 2013. Acute Cardiac Care: A Practical Guide for Nurses. Chichester: Wiley-Blackwell Press. Mackay, J. H., & Arrowsmith, J. E. 2012. Core Topics in Cardiac Anesthesia. Cambridge: Cambridge University Press. ManchesterTriageGroup. 2008. Emergency Triage. Chichester: John Wiley & Sons Press. Nutbeam, T., & Boylan, M. 2013. ABC of Prehospital Emergency Medicine. Oxford : John Wiley & Sons Press. Oxford University Press. 2013. Triage. From http://oxforddictionaries.com/definition/english/triage Rowlands, A., & Sargent, A. 2011. The ECG Workbook. Keswick: M&K Publishing Ltd. Shepherd, A. 2011, July 15. Measuring and Managing Fluid Balance. From http://www.nursingtimes.net/nursing-practice/clinical-zones/nutrition/measuring-and-managing-fluid-balance/5032614.article Sinclair, A. 2009. Diabetes in Old Age. Chichester: Wiley-Blackwell Press. Traynor, M. 2012. Nurses! Test Yourself In Clinical Skills. Maidenhead: Open University Press. Urden, L. D. 2013. Critical Care Nursing: Diagnosis and Management. Edinburgh: Elsevier Mosby Press. Read More