The case of Mr. B.
Mr. Paul B. is a 58 year old Caucasian man who was admitted to the neuroscience ward with complaints of sudden onset of headache, confusion, loss of balance, and numbness/weakness on one side of his body. He is a married Roman Catholic and works as a supervisor at Sears. On his health history, he has type 2 Diabetes, hypertension, mild dysarthria, autonomic dysfunction, and a previous stroke which presented with a Right occipital cerebrovascular accident (CVA). On the family history, he reports that his mother had type 2 Diabetes while his father was a smoker. Mr. B. is a smoker who normally smokes one pack per day.
His nutrition history reveals that he does not have a strict diet at home. He eats whatever he likes eating, mostly being fast foods and high carbohydrate food such as potatoes and pastas. He also eats out with his wife at a Chinese buffet restaurant at least once a week. He gets a good night sleep daily and on weekends sleeps for about ten hours. On activity and recreation, he says that he does not exercise since he does not have enough time to do it. He sometimes goes camping in the summer for recreation. Whenever he is stressed, Mr. B. says that he smokes two packs of cigarette per day instead of the usual one pack per day. He does not have any problem with his self-esteem and he describes his relationship with his wife as good. Whenever they have a conflict, he says that they resolve it the right way.
The admission diagnosis for Mr. B. was left cerebrovascular accident (CVA). This diagnosis is consistent with his complaints of sudden headache, confusion, loss of balance and weakness on one side of the body. On assessment, his speech was found to be thick with some word searching and delayed processing, which could be explained by the stroke.
Diagnostic tests did include carotid duplex from whose findings a new 1.7cm infarction was determined in the left deep parietal white matter, just above the basal ganglia. Laboratory investigations showed that his red blood cell (RBC) count was at 4.13, hemoglobin at 128 and blood urea nitrogen (BUN) at 12mmol/L. The normal range of the above parameters is 4.20-5.80, 135-170 and 2.0-8.2 respectively. This shows that his RBC count and hemoglobin were slightly low, while his BUN was elevated.
The patient was on several drugs prior to admission. These included ASA once daily, NPH insulin twice daily, Timolol eye drops twice daily and bimatoprost eye drops at night. He is also on captopril which is administered as needed depending on blood pressure.
CVA occurs when blood supply to a part of the brain is compromised, cutting off the supply of oxygen and nutrients to that part and leading to death of the ischemic tissues (Russel, 1999). Diabetes, hypertension and smoking, are risk factors attributed to stroke and are evident in Mr. B. High cholesterol, or the patient could have some genetic trait. (Russel, 1999). The symptoms of CVA include headache, confusion, headache, slurred speech, numbness and weakness, loss of balance, blurred vision, and nausea and vomiting, most of which are seen in Mr. B (Russel, 1999). These symptoms are due to loss of function of the affected part of the brain. The fact that Mr. B. is a smoker increases the risk of CVA and other complications of diabetes.
Exposure to high levels of glucose, like in diabetics, can lead to nerve damage resulting in diabetic neuropathy. This mostly presents as peripheral neuropathy, but autonomic neuropathy also occurs (Russel, 1999). In cases of the latter, autonomic dysfunction is seen. Mr. B’s last bowel movement was two days prior to admission, which could be due to autonomic dysfunction (see appendix).
Risk of foot ulcer
Foot ulcer is a serious potential problem that Mr. Paul is facing. Being a diabetic, he is at risk of developing foot ulcer at any time, whether in the hospital or at home. Diabetes can cause peripheral neuropathy and ischemia, both of which predispose to development of ulcers (Armstrong and Lavery, 1998). Macrovascular disease in diabetes can lead to ischemia of the feet. Ischemia is followed by death of tissues and subsequently ulcers. Pedal pulse is present in Mr. Paul thus ischemia is an unlikely cause of foot ulcers in him (see Appendix). However, he had decreased sensation in both lower limbs, a sign of diabetic neuropathy (see Appendix). Pain sensation is protective as it alerts us on the presence or harmful stimuli. When this sensation is lost in peripheral neuropathy, a person is more prone to harm like cuts and blisters.
Peripheral neuropathy can present as abnormalities of sensation in the feet (Edmonds, 2006). Numbness, the inability to perceive pain and changes in temperature properly, is one of the symptoms and it is present in Mr. Paul. Other symptoms include; burning and tingling sensations, feeling of being pricked with pins and sharp pains in the feet. The risk of developing peripheral neuropathy in a diabetic is increased in those who have hypertension and smoke cigarettes, like Mr. B.
Mr. B. presents with a complaint of numbness and examination has decreased sensation on both lower limbs (see appendix). This gives an impression of peripheral neuropathy and thus the risk of foot ulcers is real. Diabetic foot ulcers can hinder a person’s movement abilities. Infection of the wound is almost inevitable and causes serious health problems with spread of the infection (Younes, Albsoul and Awad, 2004). There is the danger of amputation of the affected limp (Larsson et al, 1994). There is therefore a need to formulate interventions to prevent the development of foot ulcers in the patient.
Use of 10g monofilament and neurothesiometer
The 10g filament is used in the diagnosis of peripheral neuropathy and assessment of loss of protective sensation in the feet. The filament exerts force against the skin and buckles at a force of 10 grams. Failure to feel any force as the filament buckles is more often associated with loss of protective sensation and an increased risk of developing foot ulcer (Dros et al, 2009). A neurothesiometer is a devise used to check for the sensation of vibration.
Its use in the patient is important since in peripheral neuropathy, the sensation of vibration is among the first sensations to be affected (O’neill, McCannn and Lagan, 2005). The use of the monofilament and neurothesiometer enables early detection of peripheral neuropathy and thus protective measures are adopted in time to prevent development of foot ulcer (Williams, 2006).
The transtheoretical model
The transtheoretical model (TTM) focuses on behavior change by patients, with encouragement of physical activity (Jackson, Asiminakopoulou and Scammel, 2007). Physical activity reduces the risk of diabetic complications due to its effects on carbohydrate metabolism and blood glucose level. Behavior change with respect to smoking and eating habits is also necessary. The commitment to health (CTH) theory should also come in as it requires the patient to be actively engaged in their own behavior change and this increases the chances of success in behavior change (Kelly, 2008). Through motivational interviewing, the patient can be led to conclude that a particular behavior has risks and harms that outweigh its benefits (Duran, 2003). The patient will then see the need of behavior change as a personal initiative. However, motivational interviewing needs long-term contact between the patient and the clinician and it is time consuming (Duran, 2003).
Referral to a diabetes nurse specialist
Nurse specialists play a key role in the handling of patients. The nurses offer education and foster better understanding of the patient’s disease. They also promote acquisition of physical skills by the patient. Diabetic patients are in need of psychological support and the nurses provide this as well as giving individualized care to the patient. Promotion of self-care and safety for the patient is also done by the diabetes nurse specialists (Ardottir, 1999).
Plan of care
Mr. B. is at risk of foot ulcers due to his diabetic status. Nursing interventions need to be put into place to prevent this. One of the intervention measures should focus on special assessment tools, in this case the 10g monofilament and neurothesiometer (O’neill, McCannn and Lagan, 2005). This is necessary for the early diagnosis of peripheral neuropathy which predisposes to development of foot ulcers.
These tools should be used as soon as possible to maintain the relevance of their findings in prevention. The monofilament is portable and can be used even outside the setting of the ward. Mr. B. presented with numbness, giving an impression of neuropathy and necessitating the use of these tools. The filament is used to test the plantar surface of the feet as the patient closes his eyes by compressing it perpendicularly to test site , then bowing it for one second (American College of Physicians, 2007). Repeat the procedure twice and also ask the patient feels the pressure while you are not applying the filament and the patient is unaware of this (American College of Physicians, 2007).
Health promotion strategies
The transtheoretical model needs to be applied in the case of Mr. B. since he engages in some unhealthy lifestyle practices like smoking, lack of exercise and poor feeding habits. The aim of using the TTM is to change these practices (Jackson, Asiminakopoulou and Scammel, 2007). The patient is made aware of the harm some of his practices can cause and that they outweigh the benefits of the practice. The need of change in behavior is generated and the patient is motivated to undertake it (Duran, 2003).
This model should be instituted early as it is time consuming and early glycemic control lowers the risk of complications (Russel, 1999). It is uncommon for nurses to go over their patients because of such things as the patient’s time for exercise, workload and knowledge on TTM. TTM is time consuming and can take up to two years and this means that care continues even outside the ward. Therefore, his family needs to support him as he tries to change behavior. This can be done by encouraging him to exercise and providing proper diet at home. Health care personnel should also follow up to ensure that the patient is adhering to the intervention and evaluate its effectiveness.
Utilization of other health care team members
The patient needs to be referred to a diabetic nurse specialist who has better knowledge on the management of diabetic patients. As shown in the literature review, the nurse has several roles to play in the management of diabetic patients (Ardottir, 1999). He/she can refer the patient to appropriate community resources like peer coaches and podiatrists. Podiatry deals with disorders affecting the leg, foot and ankle and thus it is significant in the case of diabetic foot (Williams, 2006).
The nurse follows up the patient after discharge from the ward to evaluate adherence to interventions instituted and progress of the patient. The effectiveness of this intervention can be evaluated by assessing the patient’s progress in terms of health and knowledge. Referral is to be done two days before discharge to allow the nurse to educate and plan community resources for the patient. The lack of such specialists can hinder this process. The patient’s family should cooperate with the specialist to help implement the measures put in place.
- General survey – the appearance of the patient at a glance. The patient was lying comfortably in bed; he was alert and conscious as he opened his eyes as soon as I walked into the room. He was cooperative and pleasant too.
- Neurological system – the mental status and the level of pain on a scale of 0-10 of the patient is tested.His mucous membranes were moist, there was no facial droop, and his pupils were bilaterally and equally reactive to light. He reports feeling no pain.
- Respiratory system – this is examination of the chest and airways. His respiratory rate was 20 breathes per minute, chest wall appeared symmetric, he was not using accessory muscles of respiration. His oxygen saturation was 96% on room air. Upon auscultation, there was noted decreased air entry to the lower lung fields bilaterally, no adventitious sounds were noted.
- Cardiovascular and peripheral vascular system – no peripheral edema was noted. CWMS and capillary refill were satisfactory. Radial and pedal pulses were present bilaterally. His apical heart rate was 62 beats per minute, rhythm was regular.
- Gastrointestinal system – there was no distention noted. His abdomen was soft. Upon auscultation, bowel sounds were present in all the four quadrants. His last bowel movement was 2 days ago and he reports to be passing gas.
- Genitourinary system – he reports normal bowel movements. He walks to the toilet to void and defecate. He reports voiding clear yellow urine.
- Musculoskeletal system – he reports mild weakness in his right lower limb and decreased sensation in both his lower limbs. (These are signs of diabetic neuropathy).
- Integumentary system – the skin looked well perfused, no dryness noted and no pressure sores or bruises noted over the pressure areas such as the coccyx, heel.
- Equipment and tubes – he has a peripheral IV line in his left forearm which is infusing normal saline running at 50ml/hr (this is required to keep his vein open). He also has a telemetry attached in order to find out where the infarct originated.
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