The Clinical Reasoning Cycle with Data about Patient with Type 2 Diabetes Mellitus - Case Study Example

Assessment Task 3: Client Report Name Institution Instructor Course Date of submission The following is the report of my Client, Mrs. Y who was admitted in our agency with type 2 diabetes mellitus. This report uses the Clinical reasoning cycle to enumerate various information about Mrs. Y. Introduction and context: (Clinical reasoning: context and client situation) I approached my client, Mrs. Y, introduced myself and then obtained consent for the nursing procedure to be done. I then sought advice from my clinical educator who advised me to constantly ensure privacy and confidentiality since it demonstrates professionalism. On reviewing the client, I established that Mrs. Y was a middle-aged woman diagnosed with type 2 diabetes mellitus and lives in the rural part of Australia. I assured her of privacy and confidentiality unless deemed otherwise. Brunner, Suddarth and Smeltzer (2010, p. 30-40) emphasize that confidentiality and privacy are ethical principles that should always be observed by any nurse. Ensuring confidentiality and privacy while handling a patient not only promotes trust between the nurse and the patient but also cooperation during medical and nursing procedures. On further dialogue it was established that Mrs. Y is an educationist and married to one husband, Mr. Y who has hypertension. She has two children, Tom who is 15 years old and Liz who is aged 20 years. Tom is in good state of health but Liz is asthmatic. From this information, I reflected on how occupation, social life and environmental factors like stress can impact the health of an individual. From the reflection and clinical reasoning, I realized that insufficient financial resources to take care of one’s needs and having loved ones who are sick can be a source of stress that impacts negatively on health status. It has been posited that there is a relationship between stress and illnesses like hypertension. Thus, teaching the patient on stress management techniques can be a good health promotion undertaking (Timmins 2006, p. 49 – 54). Holistic Assessment: (Clinical reasoning: collecting cues and gathering information) Subjective data To advance the interview, I sought to gather information on medical, family, psychosocial history. Mrs. Y reported that her condition began a couple of weeks prior to admission when she started feeling very thirsty, increased frequency of hunger pangs and passing a lot of urine. She added that her urine had a sweat smell and experienced blurred vision and general body weakness. She tried to continue with her daily activities until when she felt dizzy and fainted two days later. Mrs. Y was then rushed to the nearest health facility accompanied by her son (Tom) and daughter (Liz) where she was assessed and diagnosed with type II diabetes mellitus and referred to our agency for specialized care. On reaching our agency (Mater hospital), Mrs. Y reported that she was feeling dizzy, and weak. She also complained of increased thirst, hunger, and amount of urine that at times had a sweat smell. These symptoms started two weeks prior to admission to our facility. She thought it was a normal occurrence so she never took any medication to relieve any of the complaints. Reflecting on how Mrs. Y was handled before reaching our facility, I realized that critical and creative thinking is needed when encountering a patient for the first time. This is because any decision one makes can determine whether the patient gets the best and most effective medical attention or not. I also realized that it is prudent to always consult and/or arrange for referral of cases one cannot handle or manage. Furthermore, nurses play a fundamental role as patient advocates to ensure the best care for the patient and the entire family (Nettina 2006, p. 140-188). History taking is an undertaking that is done by both the nurse and the physician so as to gain a background idea of what may have contributed to the patient’s current illness. Thus, on taking her past medical and surgical history, it was found out that Mrs. Y had suffered gestational diabetes during the pregnancies of her two children. She was managed well in both situations and the gestational diabetes was treated. Her first pregnancy was 20 years ago while the second was five years later. She further reported that she has been taking a couple of drugs for flu and cold. Mrs. Y has never experienced any adverse drug reactions or allergies. Additionally, Mrs. Y has never undergone any other surgical operation except for two caesarean sections. Mrs. Y’s family medical history and genogram for two generations was reviewed to identify age, current health status and cause of death of second order relatives of Mrs. Y (Figure 1). Brunner, Suddarth and Smeltzer (2008, p. 145-210) advise that using a genogram is one of the best and easiest ways of recording family-medical history. Figure 1: Family medical history and genogram Key Patient (Mrs. Y) Female Male Diseased Psychosocial assessment of Mrs. Y was done and it was established that she is an educationist by profession. She studied up to masters’ level and lives in rural Australia together with her hypertensive husband and her daughter, Liz who is asthmatic. Mrs. Y reported that she has a stable income that accrues from her earning. Also the husband offers financial and emotional support. Mrs. Y claims to receive social support from work mates, friends, and relatives. Concerning her beliefs, Mrs. Y reported that she is a staunch Christian who believes in God. Psychosocial consideration when assessing a patient is an essential practice. I searched literature and realized that Semple et al. (2005, p. 26-98) reported that having a disturbed or distressed ‘psyche’ could lead to manifestation of somatoform disorders as well as cause delay in recovery from some illness. Her interests and hobbies includes reading motivational books, adventure and engaging in humanitarian activities; in fact, Mrs. Y reported that she is a member of a charitable women group organization from her church that give back to the community. Mrs. Y denies active involvement in tobacco use, alcohol consumption, and abuse of illicit substances. She reports that she attends aerobics session at a local gym facility to exercise and remain physically fit. She also has one sexual partner to whom she is faithful. She further claimed that she has no allergy to any food or drinks. Her diet included sufficient amounts of meat, vegetables, and calories with ‘very little salt’. She added that she is a big fan of roasted meat and canned food. She reported that she never expected to be admitted and especially diagnosed with diabetes and that it was hard for her to accept her ailing condition. She also reported that her husband and daughter were ailing and neither in optimal state of good health. She reported that some of her friends who were diagnosed with a similar condition (diabetes) ended up losing one or both of their limbs or dying. She expressed fear and uncertainty of her prognosis claiming that she may end up like some of her friends. From a clinical reasoning point of view, Timmins (2006) stated that lifestyle and dietary habits play a critical role in causing or contributing to the prognosis of disease. For example, alcohol and tobacco use can predispose the individual to both cardiovascular and respiratory illnesses like hypertension and chronic bronchitis respectively (Nettina 2006, p. 140-188). Thus, taking psychosocial history enabled me relate theory with practice. Objective data After taking Mrs. Y’s history, permission was sought to conduct a physical assessment while assuring confidentiality and privacy. A physical assessment was then conducted using the four techniques of physical assessment, namely, inspection, palpation, percussion, and auscultation. Vital signs that include body temperature, pulse rate, respiratory rate, blood pressure, blood gas analysis, random blood sugar, and body mass index were assessed using the various techniques of physical assessment (Douglas, Nicol, and Robertson 2007). Axillary temperature was taken using a mercury thermometer and the reading was 36.5oC. Blood pressure was taken when the patient was seated upright the reading was 120/70 mmHg. The random blood sugar was taken using a glucometer and it was found to be 12mmol/L, respiratory rate was 18breaths per minute, radial pulse rate was 80 beats per minute and the oxygen saturation was 96% of pulse-oximetry. All findings were accurately and promptly recorded in the relevant charts (Nettina, 2006, p. 140-188). Extreme variations in temperature may signal presence of infective or inflammatory disorder. Whereas extremes in blood pressure and pulse may indicate cardiovascular and respiratory systems compromise (Brunner, Suddarth and Smeltzer, 2010, pp. 30-40). However, variations also depend on other factors like age, emotional state and position of patient at the time of assessment. For example, temperature for young adults is usually higher than for the older person by about 0.4oC [oF] (Nettina 2006, p. 140-188). A review of systems was then done on cardiovascular, neurologic, musculoskeletal, integumentary, respiratory, and digestive systems was done. According to my findings, I realized that the endocrine system needed care. This is because there was a reduced ability of the body to regulate blood sugar level leading to elevated plasma glucose concentration. Insulin is the hormone responsible for regulating high plasma glucose levels. Failure of production or reduced sensitivity of insulin receptors leads to elevated glucose levels in blood. In Mrs. Y’s condition, there is production of insulin as indicated by the lab report on hormones analysis. This leaves only one possibility that the insulin receptors have reduced their sensitivity to insulin. Thus, leading to hyperglycaemia as evidenced by a random blood sugar of 12mmol/L; for this reason, the endocrine system needs to be addressed to reduce continued increasing in plasma glucose levels beyond the normal values (Timmins 2006). During clinical reasoning I appreciated the importance of systemic review while assessing a patient. I also realized that it is always prudent to involve the multidisciplinary team. This is because there is likelihood of overlooking some aspects of the systems when reviewing the patient alone. Mrs. Y was then put on treatment that included rapid acting soluble insulin (Actrapid), 10 I.U subcutaneous injections twice a day. The client co-operated well during medication time and was even taught on how it should be done. The side effects of the drug that includes hypoglycaemia, allergic reaction at injection site and weight gain were explained and Mrs. Y expressed understanding. Other forms of management included regular blood sugar monitoring, vital signs charting, input and output chart monitoring (Nettina 2006, p. 140-188). Health messages were shared through health education on the risk factors, pathophysiology, management and prognosis of diabetes to improve client’s knowledge and understanding of the disease. Nettina (2006, p. 140-188) stated that health education is part of health promotion roles of the nurse. Thus, after carrying out health education, I realized that the patient’s level of anxiety and knowledge deficiency had started fading away. A dietician did nutritional counselling on a favourable diet for diabetes. A counsellor also did psychosocial counselling. This is a form of psychological support that promotes coping and reduces stress. A physiotherapist was also involved in the care of Mrs. Y. He counselled Mrs. Y on activity, exercise and rest as well as how she can prevent injuries that could lead to diabetic toe/foot. Psychological assessment was performed and the findings were as follows. On self-awareness, the client has a high sense of self-esteem. She cooperates well during medical and nursing procedures. She relates well with people and expresses an excellent personality (Semple 2005, p. 26-98). A mental status examination was done various findings were obtained. On appearance, Mrs. Y looked well-groomed and maintained good personal hygiene. On behaviour, she displayed an upright posture while seated and interacted well with the interviewer. She was fluent while speaking, the volume of speech was neither loud nor low and there was no pressured speech (Semple 2005, p. 26-98). She expressed euthymic mood. She was neither angry nor happy. However, she was anxious of when she would recover and be discharged home. On assessment of her thought content and process, Mrs. Y denied experiencing hallucinations, delusions, illusions or suicidal thoughts (Semple 2005, p. 26-98). She neither had poverty of speech or tangentiality. Neologism and looseness of association were neither observed. On cognitive evaluation, Mrs. Y was fully conscious and orientated to time, place and person. Nursing diagnosis: (Clinical reasoning: processing information, and identifying problems) Brunner, Suddarth and Smeltzer (2010, pp. 30-40) stated that planning of care should not be the sole responsibility of the nurse. The patient and even the family should be involved in the planning and prioritization process. In addition, the patient should be at the centre of the care planning process as the decision maker. Thus, based on the various assessment findings it was established in concert with Mrs. Y that there was hyperglycaemia related to elevated plasma glucose level. It was also established that there was anxiety related to hospitalization and unknown health outcome. Knowledge deficit was also evident since Mrs. Y asked many questions related to causes, pathogenesis, management and complications of diabetes mellitus. Based on the above-agreed health concerns, a care plan was developed on management of Mrs. Y. The interventions were based on the assessment and priority concerns. In order to manage the plasma glucose level, interventions included regular monitoring of plasma glucose levels for early identification of elevated glucose levels and promptly act to reduce them to normal levels. Another intervention included timely administration of prescribed insulin to reduce plasma glucose levels and prevent complications associated with hyperglycaemia (Brunner, Suddarth and Smeltzer 2008). Monitoring of vital signs at appropriate time intervals was done to detect any derangements or complications. Temperature, pulse and respiration rates were monitored two hourly while blood pressure was monitored four hourly (Brunner, Suddarth and Smeltzer, 2008, p. 145-210). Input and output chart was maintained to assess level of hydration and electrolytes loss especially through urine. Multidisciplinary input was also involved. The nutritionist was consulted to provide nutritional counselling on best food and dietary composition for a diabetic. As I reflected on the care of Mrs. Y, I further appreciated that the multidisciplinary team are professionals who have specialized in various disciplines and therefore their role in patient management is unfathomed. The primary nurse educated the client on diabetes mellitus including management protocol and complications to relieve anxiety and promote coping. The social worker and counsellor were contacted to provide psychosocial counselling as well as encourage family and relatives support. The physician and pharmacists advised Mrs. Y on how to appropriately take the prescribed medication and the expected side effects. Mrs. Y was viewed as the decision maker since she was the one at the centre of care. She was greatly involved in the care process and a lot of health education was done to empower her on self-management in case she is discharged (Brunner, Suddarth and Smeltzer 2008, p. 145-210). Evaluation (Clinical reasoning: evaluate the effectiveness of actions and outcomes) Mrs. Y progressed well with the care. Anxiety was relieved, blood sugars were well monitored and managed and there were no complications during the care process. Multidisciplinary involvement was important since it enhanced client’s understanding of the disease, promoted coping, relieved anxiety and led to a good prognosis. The client and her family were involved in the care process and this was a valuable input that led to a good prognosis that empowered Mrs. Y with self-management prowess. Reflection (Clinical reasoning: reflect on process and new learning) Handling Mrs. Y and being involved in her primary care process rejuvenated my confidence and boosted my self-esteem as a nurse practitioner. The information gathering process despite being tiresome, since it involved obtaining comprehensive information, it was a worthwhile endeavour. I learnt that it is important to ensure privacy, confidentiality and to always engage the patient during the entire assessment period. I also discovered that holistic approach as well as multidisciplinary involvement in the care of any patient is very important as it ensures social, emotional and psychological support, which enhances individual and family coping. What might have been overlooked in this experience is the profit of team work among the nursing staff. There was scanty involvement of the nursing staff in the care of Mrs. Y. Lastly, this experience was worthwhile and enabled me develop technical skills. For example, my critical thinking, communication and decision making capabilities were greatly enhanced. I developed competency in physical assessment and nursing care using the nursing process. I also understood nurses’ roles in the multidisciplinary team. Consequently, this clinical experience enriched my professional knowledge and skills which will further enhance my motivation in the nursing career. List of References Brunner, L S, Suddarth, D S, & Smeltzer, S C 2010. Brunner & Suddarth textbook of medical-surgical nursing. Philadelphia, Lippincott Williams & Wilkins. p. 145-210 Douglas, G, Nicol, F and Robertson, C (Ed.). 2007. Macleod’s Clinical Examination. Elsevier Inc. Nettina, S M 2006. Lippincott Manual of Nursing Practice. Maryland, Lippincott Williams & Wilkins. 140-188 Semple, D et al. 2005. Oxford Handbook of Psychiatry, London, Oxford University Press, p. 26-98 Timmins, F 2006. Critical practice in nursing care: analysis, action and reflexivity. Dublin, Nursing Standard, 20 (39) p. 49 – 54 Read More