The Care and Management of Gestational Diabetes Insipidus - Essay Example

Reflective clinical case study on gestational diabetes insipidus Name: Institution: Date: Reflective clinical case study on gestational diabetes insipidus Introduction Reflective practice is considered a significant feature in nursing profession, thus this essay will discuss appropriate medical management, assessments, intervention, treatment and education of patient in nursing care concerning a patient with diabetes insipidus. The case study is about a 30 years old female diagnosed with gestational diabetes insipidus. Australian Nursing and Midwifery Council code of professional conduct calls for confidentiality hence the patient will be addressed as Mrs. X. Mrs. X was brought to the hospital complaining of excessive feeling of thirst. She also complained of frequent urination especially at night. She noted that her urine was in large amount and very dilute. She thought these were due to the effects of her pregnancy but sought for medical attention when she felt her situation was not normal. On physical examination, she was seven months pregnant; the patient was weak, had cracked lips, dry skin and felt dizzy although she could make little phrases. In the course of taking her history, she stated that her family has a history of diabetes mellitus. The patient consistently complained of muscle pains, unexplained weakness, and was very irritable. Since she was expectant, her medical record indicated her consistency in attending ante natal clinic and was referred to our department for further check up of her medical condition. Various laboratory tests were carried out and results indicated an increase in sodium concentration (hypernatremia) and significant reduction in urinary osmolarity. Measurement of uric acid, serum creatinine and hepatic transaminase were also taken and they revealed significant reduction from the normal value. Blood glucose was found to be normal. Medical management and modalities of treatment Etiology of DI in relation to case study Diabetes insipidus (DI) is condition in which a person experiences the urge to urinate more frequently while feeling thirsty constantly (Dehvi Remedies). DI in the course of pregnancy is not a frequent phenomenon since its occurrence is approximated within two to six incidences per 100,000 cases of pregnancies (Ananthakrishnan, 2009). DI is brought about by various causes. The most common cause is deficiency in hypothalamo-hypophyseal ADH secretion, and this normally leads to central or neurogenic DI (Neurogenic diabetes insipidus, 2006). Another cause of DI is insensitivity of renal tubular to ADH leading to peripheral or nephrogenic DI, but this is not common (Pituitary diabetes insipidus, nephrogenic diabetes insipidus). Deficiency in production of ADH due to excessive intake of fluid is another cause of DI (Ball, 2009). During pregnancy, there can be an abnormal rise in hormone clearance which might result in deficiency of ADH thus trigger gestational DI (Ananthakrishnan, 2009). GDI occurs with an unusual vasopressinase activity increase. This increase is normally linked with hepatic function anomalies and preeclampsia. Patients like Mrs. X have hepatic function disturbance that may take place in preeclampsia, an idiopathic condition, or in acute fatty liver. The hypothetical basis is hepatic anomalies that decrease degradation of vasopressinase, significantly rising circulating vasopressinase concentrations and consequently rising vasopressin clearance, eventually leading to DI (Ball, 2009). According to Ananthakrishnan (2009), Preeclampsia accompanied by hepatic function decrease could add to elevated activity of vasopressinase by a reduction in its degradation. Medical management and treatment The medical management and modalities of treatment is aimed at minimizing the damage of GDI, preserve both renal and neurological functions and prevent any complications particularly in pregnancy. Diagnosis of GDI is basically based on clinical presentations of the patient and laboratory tests like urinalysis (Ananthakrishnan, 2009). With regards to Mrs. X’s case, she presented with clinical features like weakness, dizziness, cracked lips and dry skin all of which are presentations of DI. These presentations were supported with various complains that the patient stated like polydipsia which is excessive thirst, polyuria which is frequent urination and nocturia which is night urination. During pregnancy, the placenta is likely to generate an enzyme that reduces ADH in its mother. This leads to the development of GDI and is normally managed with desmopressin which acts on the collecting ducts and distal tubules of the kidney to enhance reabsorption of water (Gharahbaghia et al. 2008). Rarely, the mechanism of thirst, not ADH, is distressed, in which case there is insignificance of desmopressin. Pharmacotherapy priority for Mrs. X in GDI management is intranasal desamino-D arginine vasopressin (DDAVP) administration (Nursing Care Plan, 2012). Different from natural vasopressin, DDAVP, which is a synthetic vasopressin analogue, is resistance to vasopressinase degradation. DDAVP doses need to be slightly higher or equal to doses recommended for neurogenic DI in non-pregnant situation (Ball, 2009). Alternatively, hydrochlorothiazide can be considered for management of GDI. However, potential complications associated with hydrochlorozide are neonatal DI and fetal hypoglycemia thus treatment need to be discontinued immediately after reduction of DI, which takes place two or three weeks following delivery (Better Health Channel, 2011). Nursing care With regards to RN scope of practice, registered nurses employ the knowledge of nursing and multifaceted nursing judgment to make assessment of health needs and offer care, and to give advice and support the people in need to take care of their health. They also provide exclusive assessments to innovate, execute, and appraise an incorporated health care plan, and offer interventions that call for significant professional and scientific knowledge, skills and decision making that is clinical based (Nursing file.com, 2010). In accordance to above RN scope of practice, Mrs. X needs appropriate nursing care for her situation. Nursing care plan entails physical examination, primary nursing diagnosis, nursing intervention and treatment plan and patient education. In nursing care plan physical examination and assessment for Mrs. X, it is important to note that patients with DI complain of polyuria, excessive thirst, and nocturia. The onset is usually abrupt. Urinary output is basically within 4 to 15 L/day range although is likely to be 30 L/day. The patient should be assessed for a past history in order to establish the causative factor. For instance, Mrs. X’s causative factor of DI is pregnancy. The patient also reports a history of weakness and weight loss. DI even in pregnancy is linked with a couple of physical signs. Apart from unusual scenarios, dehydration is insufficient to be obvious on physical examination. The nurse should examine dehydration’s signs and symptoms which include dry skin, cracked lips, feeling of excessive thirst, dizziness, and reduction in tear formation (William & Hopper, 2011). Regardless of dehydration, urine is pale and plentiful. With respect to enhance effective nursing care to patients, it is essential to establish a primary nursing diagnosis. With this in mind, the primary nursing diagnosis established for Mrs. X is change in urinary elimination secondary to polyuria (Nursing Care Plan, 2012). As the nursing scope of practice stipulates, there is need for nursing intervention and treatment plan (William & Hopper, 2011). DI treatment is basically pharmacologic. Additional to medication like DDAVP, there is need for replacement of fluid to uphold vascular volume. Rapid hypernatremia correction is potentially risky due to the likelihood of a quick water shift into cells of the brain, which enhances the risk of cerebral edema or seizures (Cooperman, 2012). Water insufficiency is corrected slowly for more than three days with water by nasogastric tube or mouth or intravenously with quarter- or half-isotonic saline. The most significant focus of nursing interventions is upholding a sufficient balance of intake and output of fluid (Cooperman, 2012). To establish the balance of intake and output, the nurse should monitor and keenly record the intake of fluid orally and urine volume for more than 24-hour duration (Nursing Care Plan, 2012). To reduce dehydration, the patient should be taught about thirst mechanisms as an incentive to take oral fluids (Cooperman, 2012). In prevention of polyuria, the patient needs to be educated on salt restriction as well as caffeinated products because caffeine contains exaggerated diuretic effects (Simmons, 2010). It is important to be certain that the patient comprehends the medications provided, as well dosage, administration route, and mechanism of action, unwanted effects, and the importance for regular laboratory evaluation for DDAVP (Aleksandrov et al, 2010). Personal reflection I considered Gibbs’ reflection model for my reflection practice. The framework entails six substantial stages that make up a complete model. The Gibb’s cycle will facilitate my improvement in nursing profession and practice as a whole. The initial stage entails incidence description, the subsequent stage concerns feelings analysis, third is evaluation of the experience, fourth is the personal analysis to bring out sense from the experience; the fifth stage concerns a conclusion of what I could have done (Gibb’s 2006). Last stage is dealing with the action plan. Research shows that reflection is significant to an individual since it develops practice knowledge, facilitate students to adjust to new circumstances, generate satisfaction and self-esteem (Gibb’s 2006). It also develops, acknowledges and professionalizes practice. Further studies endorse this point that student reflection concerns identification and improvement, acquiring self-esteem, learning from personal mistakes and behavior, getting knowledge from the perspectives of other people, and learners enhancing their future via learning things from the past. According to reflection of an incident that occurred during my clinical placement at a medical department, I took part in various clinical practices and care of patients. During my placement, I was allocated a DI patient under the supervision of a registered nurse who was also my mentor. With regards to Gibb’s cycle particularly the first stage which is about description of the incidence, I was taking care of a GDI patient who had been hospitalized with various clinical symptoms like cracked lips, dry skin, third trimester pregnancy, complaints of excessive thirst and polyuria. Upon various tests done on the patient, I noted that the patient had hypernatremia, low POsm and orthostatcic hypotension. Under the supervision of the registered nurse, I was able to carry out physical examination on Mrs. X as the initial nursing assessment so as to prioritize her management of care. After the complication of performing the relevant assessments with Mrs. X, I gladly informed my mentor who was the registered nurse; she documented all that I had done in Mrs. X’s medical file. Since the management of GDI is principally based on pharmacotherapy, I keenly administered DDVAP to Mrs. X alongside the IV fluids to uphold water balance. The incidence I remember during her management that she confessed her passion for coffee and on several occasions, I found her taking coffee even after I provided dietary education to her about various drinks like tea and coffee that could slow down her management. This is because caffeinated substances like coffee exaggerated diuretic effects. Although Mrs. X was hesitant to my plea regarding restriction to coffee, I insisted that all I wanted for her is to get better and learn how to adapt to the new life style that comes with DI. She then promised to comply and I was happy. According to the second stage of Gibb’s cycle which is about analysis of feelings, I was happy that my mentor was pleased with what I had done regarding the situation. She also endorsed to me that patient education is very important in nursing practice because patients are able to adjust to new lifestyle thus enhancing the prognosis of their condition. My mentor approached Mrs. X in a professional manner stating that I was a nursing student on clinical placement and that she had confident in me managing her case which involves various nursing assessment, interventions and patient education. With regards to the third stage which is evaluating the experience, I felt more confident in my nursing practice because I was able to help a patient understand the need for lifestyle change which includes restriction to certain foods and drinks as a way of managing their condition. As a matter of fact, Mrs. X insisted on taking plain milk as a way of cutting down her craving for coffee drinks and this made me happy. I learnt that nursing calls for patience with patients since various people have their specific needs and preferences hence, a professional way of dealing with them brings about a positive outcome which all add up to effective healthcare delivery. This taught me that use of intercommunication skills is highly substantial in nursing practice. According to Gibb’s framework of reflection, I was able to confidently prioritize the needs of the patient which is education on dietary restriction regardless of her preferences with my mentor’s support in the course of the care process. I monitored her effectively for the signs of positive outcome and I made sure that she gets prompt treatment. Clinical assessment of the patient will enable the registered nurse to make identification of the problems of the patient, make priorities of care and establish any change that happens to the patient. Analysis and evaluation of performance in accordance to (RNs) ANMC Competency Standards Regarding Mrs. X’s case I was able to carry out appropriate assessments and nursing interventions within my potential scope of nursing practice. According to the Australian nursing and midwifery council (ANMC, 2005) professional conduct code which calls for confidentiality of patient’s information, I was able to name to name my patient Mrs. X thus practicing confidentiality in clinical practice. With regards to ANMC guidelines point 1.2, I successfully managed to fulfill the task of care to the patient whereby I executed various nursing interventions with respect to the acknowledged standards of practice (ANMC, 2005). Since the role of nurses is to promote effective health care delivery to patients, I confidently carried out my role so as to promote delivery of care to Mrs. X. I also explained to the patient the roles for elements of care stating prevention of harm so as to enhance the patient’s confidence in the care I was providing. Since ANMC standards necessitates that registered nurses inform their patients about the medication and treatment used on them, I carried out an appropriate procedure of treatment on Mrs. X with regards to this guideline (ANMC, 2005). The fact that I confidently accepted to manage Mrs. X without considering gender, age, race and culture, I am certain that my attitude towards my work influenced my help to her because she was able to comply not only to medication but also with lifestyle change regardless of it being tricky. Since I value the rights of people, I was able to listen to her but at the same time endorsing the medical importance of certain features thus facilitating informed decisions. The role of a registered nurse is to recognize and respond in a correct way to unsafe and unprofessional practice by identifying interventions that obstruct care that is compromised, recognize appropriate mechanism of action to be employed in certain scenarios, identify and make clarification of other methods for intervention (ANMC, 2005). It is also important to spot behavior that is detrimental to achieving the nursing care that is excellent. For instance, according to the case study, I recognized that Mrs. X was taking a lot of coffee drinks which is not good for her management since caffeinated drinks exaggerated diuretic consequences. It is important that registered nurses work together as a team together with significant others so as to provide exclusive nursing care to patients. This is highly achieved when the concerned team of health care work amicably to provide care. For instance, in the case study, it is noted that Mrs. X had a strong passion for coffee drinks possibly because of her pregnancy but because nurses identify patient’s needs, team work was illustrated when my mentor was able to work together with me to give me a good exposure of clinical experience regardless of its challenges. Team work brings about a clear understanding of what should be done correctly in the clinical setting like preventing ineffective practices and enhancing proper delivery in healthcare (ANMC, 2005). Aspects I would consider for change During this clinical placement I encountered various medical conditions like DI. I have carried out several assessments regarding diabetes insipidus. When I came across GDI, I did not have enough confidence to perform the nursing intervention to the patient but my mentor was very supportive since she encouraged me to do it because she felt I had observed enough assessments. Once I got her moral support, I was confident that I would manage her situation effectively. Despite the confidence I developed after my mentor’s reassurance, I still feel I need to learn fresh skills on a daily basis, because every setting of care presents with a new challenge. For the support that I got from my mentor whom I also worked with, I feel it is very important for the medical staffs that are given the mandate to help the student nurses during their clinical placement should be very supportive and informative so that the process of learning is enhanced since people learn by doing. What I would like to do in future is to enhance my skills about interpersonal communication specifically with patients so that in case of any challenge, I implement a professional way of tackling the situation. GDI is a very rare condition thus expanding my knowledge about its management will be essential so that in case of such scenarios where patients stick to what they value most like preference of drinks during gestation, I should be in a position to confidently defend the rationale behind restriction to certain foods and drinks during medical conditions like GDI for better medical improvement. The process of reflection has enhanced my skills essential for the process of assessment and evaluation of the nursing practice I carry out to a patient and critically contemplate on the plan of action that should be taken for improvement of patient’s outcome. Conclusion In conclusion, the above essay has presented a case study on reflective analysis for a GDI patient. GDI is considered a rare condition thus calls for keen medical and nursing care because both mother and the baby are at risk. With proper pharmacotherapy like DDAVP, GDI can be managed effectively since it is the first line of treatment. With proper nursing care like fluid replacement and patient education about treatment and diet like restriction of salt and caffeine products since they exaggerate diuretic outcomes, the patient is in a better position to manage DI in pregnancy. Reflective practice is indeed essential in nursing practice because learners are able to critically evaluate their actions in nursing practice thus learn from their mistakes and enhance delivery of health care. Reference list Australian Nursing & Midwifery Council, (ANMC, 2005). National Competency Standards for the Registered Nurse. Retrieved on 10 August, 2012, from http://www.anmc.org.au/userfile/Competency_Standards/Competency_Standards_RN.pdf Gibbs, G. (2006). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. London: Oxford Brookes University. Ananthakrishnan, S. (2009). 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Gestational Diabetes Insipidus: A Review of an Underdiagnosed Condition. J Obstet Gynaecol Can. Vol. 32, Issue 3, pp 225-231. Cooperman, M. (2012). Diabetes Insipidus Treatment & Management. Retrieved on 10 August, 2012 from, http://emedicine.medscape.com/article/117648-treatment Nursing Care Plan / NCP Diabetes Insipidus. (2012). Retrieved on 10 August, 2012 from, http://www.enurse-careplan.com/2010/07/nursing-care-plan-ncp-diabetes.html Nursing file.com (2010). Nursing Interventions for Diabetes Insipidus. Retrieved on 10 August, 2012 from, http://nursingfile.com/nursing-care-plan/nursing-interventions/nursing- interventions-for-diabetes-insipidus.html   Read More