Correct Measurement of the Glucose Level, Correlation between Pantoprazole Infusion and Blood-Stained Sputum from the Tracheostomy - Assignment Example

Student’s name Institution Course Lecturer Task Date Q1. Prioritise and discuss how you will initially assess your care according to your patients’ conditions and treatment (500 words). In such a multiple patient care set up, there is need to prioritize care based on their immediate threat to life. Airway management takes priority, then Breathing and ventilation, circulation and haemorrhage control and disability and neurological assessment in that order. . I would focus first care on Phillip in bed 4. Enquire of any respiratory discomforts, neck pain and irritation as well as any other complications such as bleeding .Check the nature and pattern of breathing and any features of respiratory distress such as tachypnoea, use of accessory muscles and abnormal sounds. Secretions and blood clots can obstruct the tracheostomy tube while hematomas in the neck spaces obstruct the trachea impairing airway delivery to the alveoli. Haemorrhage into the airways up to the terminal alveoli impairs gaseous exchange across alveoli-capillary membrane. All these lead to impaired oxygen delivery to tissues causing hypoxia that results in features of respiratory distress above that have to be assessed. I would suction any secretions obstructing the stoma and maintain humidity of the stoma and give oxygen therapy if features of progression of hypoxia occur. Second in priority is Colleen in bed 5 who has gastrointestinal bleeding with risk of shock. Liver disease leads to impaired synthesis of vitamin K dependent coagulation factors while chronic alcoholism can lead to liver cirrhosis causing Porto-systemic shunting with variceal bleeding. Blood loss from gastrointestinal bleeding can leads to hypovolemic shock causing tissue hypoxia and anaerobic metabolism due to inadequate tissue perfusion. Changes in blood pressure, pulse rate, neurological status and extremity temperature occur as compensatory mechanism which would be assessed in my examination. I would institute rapid resuscitation for shock with crystalloid such as Normal saline or blood products. Then check the therapy the patient is on and ensures it is in expected state and review any areas that may need adjustments. Third in my list of care is in bed 6, who is a diabetic patient on insulin therapy and he is nil per mouth. There exists a risk of hypoglycaemia from insulin therapy as well as due to absence of feeding. Insulin causes glucose entry to cells especially liver, adipose tissue and skeletal muscle from circulation. Hypoglycaemia leads to autonomic symptoms such as sweating and trembling, neuroglycopenic symptoms such as confusion and drowsiness and other non specific symptoms such as headache and tiredness. I would assess for above symptoms and monitor blood glucose levels and enquire about the pain and other symptoms that may have developed. Also perform an abdominal and neurologic exam and ensure insulin and dextrose infusions are as expected. Ensure that she followed the medical instructions given such as nil per oral and others before endoscopy. Next in priority is Max in bed 3 with peptic ulcer disease has a risk of shock from haematemesis. Bleeding occurs from blood vessels at the base of the ulcer, commonly gastro duodenal artery in posterior second part of the duodenum. Ulceration with its risk of bleeding results from hyperacidity and peptic enzymes which overwhelm the protective mechanisms. Pantoprazole is proton pump inhibitor which inhibits both fasting and meal-stimulated secretion of pepsin and gastric acid by blocking the final common pathway reducing risk of ulcer bleeding and epigastric pain. I would enquire of haematemesis episodes and epigastric pain. Examine the vital signs such as BP, pulse rate and any other features of shock. Check for the urine outputs and the Pantoprazole infusion to ensure it is in the expected state and any side effects such as diarrhoea, headache and abdominal pain as well as those of long term use such as respiratory and enteric infections. Prepare the patient for any investigations needed such as endoscopy and any urgent surgical intervention needed in case of recurrent bleeding or other complications such as perforation. Fifth on my priority of care is Jayne in bed 2, I would do a clinical assessment and enquire of the progress of changes in colour of skin and eyes and the nature of pain. Note any new complaints such as neurological symptoms, and examine for degree of jaundice, abdominal signs and any neuropsychiatric symptoms of hepatic encephalopathy due to exposure to neurotoxins that are usually biotransformed in the liver. Intravenous drug users have increased risk of transmission of hepatitis infections especially hepatitis B. This can cause acute fulminant hepatitis and acute liver failure; chronic hepatitis and ultimately liver cirrhosis, hepatocellular carcinoma and chronic liver failure. Care includes low protein and high carbohydrate diet as well as minimising and manages other precipitants such as dehydration and infections Last patient is Linda in Bed 1, who has pain suggestive of gallbladder origin, (Cholelithiasis or Cholecystitis) .Abdominal pain results from acute inflammation of gall bladder following obstruction by gallstone and Cholecystitis. Monitoring the pain and tenderness is important as progressive pain can occur with progression of inflammation leading to empyema or perforation with peritonitis both which requires urgent surgical care. I would assess her pain for current character and severity and associated features such as fever or chills, jaundice, vomiting and other new symptoms. Then examine for signs peritonitis such as guarding, rigidity and rebound tenderness and specific signs such as Murphy’s sign. This would give information whether pain management is adequate and whether to institute any emergency surgical care in case of peritonitis or to continue with conservative care and any additional antibiotics that may be needed. Q2. While assessing your patients, you record a blood glucose level (BGL) on patient 6. Your reading on the BGL monitor returns a level of 1.5 mmol/L. The patient responds to voice on the AVPU scale, he is cool and clammy to touch. What is the significance of this result? Referring to the ward protocol attached (page 24), rationalise your actions (500 words). This shows severe hypoglycaemia, given the patient is on insulin this is the most likely cause and the patient is also nil per oral. The patient has type 2 diabetes and may have impaired hypoglycaemia awareness due to autonomic neuropathy and impaired counter-regulatory hormones. I would rapidly repeat the Blood Glucose Levels (BGL) to confirm the levels. If reading remains at 1.5mmol/L I would reduce the insulin infusion to 0.5mls/hr to maintain low insulin levels and prevent insulin from running out with a risk of developing ketoacidosis. Then give a STAT dose of 25mls of 50% dextrose and continue with the 5% dextrose infusion at 100mls per hour. Thereafter repeat BGL in 5 minutes and continue to check blood glucose levels every 15minutes until BGLs are above 6.5mol/L and the patient’s cognitive functions normalise where I would increase the insulin dose. The deprivation of glucose in the brain (neuroglycopenia) causes depressed level of consciousness due to deficient energy required to maintain electrical pumps. Therefore, to restore the pump action glucose infusion is mandatory and insulin infusion is reduced to lowest rate to enhance a rapid increase in blood glucose levels in the brain and avoid severe neurological damage. Also check for the patency of airway and adequacy of breathing simultaneously as you give dextrose infusion and reduce insulin. Also position the patient in a position that prevents aspiration. This may be compromise due to reduced level of consciousness. Breathing pattern may change due to ketoacidosis from reduced insulin and glucose infusion. Monitoring of this is therefore important. If Tony’s condition deteriorates to semi-comatose or worse from hypoglycaemia, with reduced insulin infusion to the minimum I would notify the rapid response team. The patient had cool and clammy extremities which could also signify shock and I would rule out this by checking the adequacy of circulation by Blood pressure and Pulse. Any features of upper GI bleeding, internal bleeding or dehydration would be sought so as not to miss. In case of any volume loss, rapid intravenous fluid infusion would be instituted to curtail this. The cool extremities could as well be due to resultant cooling effect from sweating which is an autonomic response to hypoglycaemia. This would then improve with glucose infusion. Q3. It is now 2000hrs. You find that much of the nursing care you are trying to provide to your patients is taking longer than you expected and you haven’t had an opportunity to record your 1800hr observations or administer your medications. Discuss why it is important to seek assistance and identify who may be the resource people that can assist you (250 words). Nursing care determines the quality of patient care, safety and the overall outcome. This includes Safety outcomes such as rates of errors in care and complications that are potentially preventable. Clinical outcomes such as mortality, length of stay, maintenance or improvement in functional status among others are also dependent on quality of nursing care. Despite the fact that very few positive clinical outcomes that have been studied by staffing-outcomes researchers, the general finding in some of the studies is that lower staffing levels are associated with poor quality of care and heightened risks of poor patient outcomes.s This quality of care depends among other things the number of nursing staff. Which highlights the need in such a situation to seek for assistance as the workload gets overwhelming and the patients care gets compromised and increased risk of serious errors or complications and hence poor clinical outcomes. Staffing levels related to nurse workload is related to occupational health issues (like needle stick injuries) and psychological states and experiences (such as burnout) which all translate to poor patient care and safety and also a high nurse turnover from specific units and from the profession. In this situation the overwhelming workload in this unit necessitates seeking assistance to avoid not only the above effects but also stop the vicious cycle that may develop if the trend is left without remedial assistance and more adverse effects more likely to occur. First I will notify the departmental nurse in charge. Thereafter as I wait for her interventions I would seek for help in the nearby vicinity. Resource persons that may assist include, Registered nurses present, fellow graduate nurses on internship rotation who may assist. Others include licensed practical nurses (LPNs) or vocational nurses, unlicensed assistive personnel (UAPs) and other nurse aids. In situation where these are unavailable any medical personnel who are around may be called to assist especially if emergency cases crop up. Q4. The alarm sounds on the infusion pump with your patient in bed 3. You find that the Pantoprazole infusion has completed and you are required to draw up a new one. You then notice the patient across the room in bed 4 has been coughing consistently and vigorously, and notice blood stained sputum from the tracheostomy. What would be your interventions in this case scenario and what would be the priority for your actions? (250 words) In this scenario, I would start with Phillip in bed 4 who has tracheostomy and airway compromise may ensue resulting in death if unattended to thereafter to bed 3 to replace the Pantoprazole infusion to prevent peptic ulcer bleeding. I will examine Phillip’s tracheostomy tube to ensure it is in situ and suction secretions and remove any obstruction. Airway obstruction leads to hypoxia and death if not corrected in time. Take the vital signs including the respiratory rate, BP and pulse rate and examine the respiratory system. Enquire for any complains such as the neck swellings and chest pain and then determine the need for supplemental oxygen therapy and any emergency condition such as pulmonary embolism. Humidify the tube and ensure skin care is as expected. Then I would shift to Max in Bed 3, draw up new Pantoprazole infusion and deliver at the prescribed flow rate. In patients with acute gastrointestinal bleeding due to peptic ulcers, the risk of rebleeding from ulcers especially in a visible vessel or adherent clot is increased. This is reduced significantly with use of proton pump inhibitors administered at a high-dose oral therapy or as a continuous intravenous infusion. Then assess his progress and enquire for any new complains, do a physical examination and address any emerging problems. References Kane, R. L., Shamliyan, T. & Mueller, C. (2007). Nursing staffing and quality of patient care. Evidence Report/Technology Assessment No. 151. AHRQ Publication No. 07-E005. Marlene, H. (2011). A Review of Medical-Surgical Nursing. London: Mc Graw Hill. Nicki, R. C., Brian, R. W. & Stuart, H. H. (2010). Davidson's Principles and Practice of Medicine. New York: Elsevier Saunders. Norman, S. W., Christopher, J. K. & O’Connel, P. R. (2008). Bailey and Love’s, Short practice of surgery (ed. 25). London: Hodder Arnold. Swash, M. & Glynn, M. (2012). Hutchison’s Clinical Methods. 23rd Edition. London: Elsevier Saunders. Suzanne C., O'Connell S.& Brenda G. B. (2009). Brunner and Suddarth's Textbook of Medical- Surgical Nursing (ed. 10). London: Lippincott & Wilkins. Read More