Nursing Care and Diagnosis in Emergency Department

Introduction

Douglas Adams, a 51-year-old male, well-built and of 70 kg, a tall person of height 190 cm, has been brought to the emergency department by a friend who found him in a disoriented and confused state at home where he lived alone. His Glasgow Coma Score was 14 out of 15, which can be interpreted as (Rowlett et al., 2001). He was having treatment for Type I diabetes, an autoimmune illness with genetic and environmental factors (Sperling, 2003). Perindopril, which the patient used, is also believed to produce hypoglycemia as a side-effect by reducing adrenergic symptoms (Hanas, 2007) for 38 people as reported in September 2011 (E-healthMe, 2011). The patient used aspirin since low doses of aspirin in diabetics provide a primary prevention strategy (Ogawa et al., 2008). Being allergic to Penicillin was the only negative medical history. Addicted to smoking, he surprisingly avoided alcohol.

Assessment of the patient’s clinical condition was made from the history and preliminary examination of the patient. The detailed history indicated that Douglas had taken his 26 units of insulin but had not eaten his breakfast. His slurred speech, fatigue, restlessness, irritability and blood sugar reading of 2.1mmols were the signals of reactive hypoglycemia. The normal blood sugar level is 4-7mmols/L. Glucose is the sugar forming the largest amount of monosaccharide in the blood (Seager and Slabaugh, 2010). Douglas must have had hypoglycemic unawareness whereby, he was not in the right condition or did not remember to consume food, because his brain symptoms having taken over following the hypoglycemia (Hanas, 2007). It is usually noted in Type I diabetes as in Douglas and Type II using insulin for therapy (Bales and Ritchie, 2009).

First Nursing Diagnosis: Reactive Hypoglycemia

Ward protocol for reactive hypoglycemia for the next two hours has to be instituted so that Douglas can return to a stable condition when his blood sugar readings and his vital signs return to normal. He should also come out of restlessness and irritability and resume his normal speech (Ellsi, 1998). There is only a small chance that hypoglycemia in Douglas could also be due to the anti-hypertensive he takes.

It must be marked, though, that the reasons for the reactive hypoglycemia are rather vague. Even with the achievements of modern medicine, it is often yard to state the reasons for certain diseases. In the given case, it is reasonable to presuppose that the reactive hypoglycemia could have been caused by unhealthful dietary habits (Ottoboni & Ottoboni, 2002).

The following interventions may be used for the moderate hypoglycemia in Douglas.

  1. One of the possible decisions for Douglas to improve his state of health and help him overcome the disease are numerous exercises designed to fight the disease. According to Goroll & Murely (2009), it could be a good idea to use all possible forms of aerobic exercises to help Douglas fight hypoglycemia. As Goroll & Murley (2009) assert, any type of active aerobic exercise will be of great help for the patient since it will help to conduct glucose control in the body and do not have any side effects. It must be mentioned, though, that the exercises must be performed “three times per week for 30 to 60 minutes” (Goroll & Murley, 2009).
  2. Blood glucose readings are to be documented every 30 minutes to watch the progress of the patient (White, 2005). This patient showed a result of 4.7mmol/L. from the initial 2.1 mmol/L. Lowering the sugar levels in the blood leads to activation of various hormones followed by body symptoms like irritability, hunger, tremors, anxiety, and palpitations (Hanas, 2007). A really low level of blood sugar produces brain symptoms like dizziness, difficulty walking, poor judgment, confusion and lapsing into unconsciousness (Hanas, 2007). Glucose is essential for the functioning of the brain (Hanas, 2007). Douglas’ symptoms may be explained as brain symptoms. Increasing the blood sugar level through nutrition will convert the symptoms (Gibney, 2005) and Douglas would return to a normal stable state.
  3. Taking into consideration Douglas’s state of health, one must recommend him to absorb as much glucose as possible for the patient to fight the state of experiencing ifficulties “in attention, processing speed, verbal memory and visual-spatial skills,” as Ollendick & Schroeder (2003) explain.

It is also essential to mention that, since hypoglycemia “is associated with some degree of central nervous system dysfunction such as confusion or abnormal behavior,” (Stephen, McPhee, & Papadakis, 2009), the active treatment of the patient at this particular stage of the disease evolution is crucial. Therefore, for the hypoglycemia symptoms to ebb away and for the disease to stop, active treatment measures are to be undertaken. According to what Stephen, McPhee, & Papadakis (2009) say, the treatment involving intravenous glucagon injections (1 mg over 1 minute) are recommended. With these measures, the patient will be treated in the fastest and the most efficient way.

The chance of Douglas developing a rebound hypoglycemiais is plausible (Dart, 2004). This happens usually after the patient has been iatrogenically administered sugar to raise his blood sugar level. The iatrogenic sugar stimulates the pancreas to produce more insulin and hence the rebound hypoglycemia (Dart, 2004). Documentation of the blood sugar at 30 minute intervals keeps us informed.

  1. Diarrhea or vomiting must be watched for as they could produce imbalance and dehydration which could further worsen the clinical condition of the patient (White, 2005). If these complaints are present, fluid loss must be corrected. Electrolyte imbalance must be checked through serum electrolyte estimation.
  2. The condition of the heart needs to be monitored through examination of pulse, BP, auscultation and if necessary, an ECG, since further on, hypoglycemia is believed to trigger heart attacks (ADA, 2008).

Second Nursing Diagnosis: Falling in Hospital

Since a fall is the evidence of the progressive hypoglycemia, it is obvious that the prevention of a fall must be considered. A fall prevention protocol must be adopted to prevent Douglas from meeting this misfortune while being treated for another condition. There is a risk of Douglas falling as he is unsteady in gait and has dizziness. My target is to prevent Douglas from having a fall in hospital as it could produce serious injury and be fatal in turn.

  1. Douglas will be placed in a cot with railings for the patient to stay safe if the symptoms appear again (Ruggiero, 2002).
  2. He will be instructed to remain in bed preferably and avoid going to the toilet alone and also insist on assistance when he wants to move around. I will be on hand for helping him if the symptoms appear again and the patient is too weak to handle himself (Ruggiero, 2002).
  3. The SAFE of Staff against Falls Everywhere programme must be enforced in the hospital (McCarter-Bayer, 2005). The multi-disciplinary team must be so motivated that the risk of falls becomes nil (Haines et al, 2004)

Third Nursing Diagnosis: Severe Hypoglycemia

Severe hypoglycemic reactions like seizures, coma or shallow respiration with unlaboured breathing must also be taken into account as the patient has a risk of worsening if appropriate treatment is not provided in time (White, 2005). This symptom is to be prevented as it could end fatally (Kummerer, 2004). Timely management of the moderate hypoglycemia would prevent it.

  1. Assessment by the Glasgow Coma Scale – A downward trend in the score of 15 raises the possibility of Douglas developing severe hypoglycemia (Shah & Kelly, 1999), since the state of the patient’s health is obviously getting better.
  2. Documentation of Blood glucose readings at 30 minute intervals to monitor a swing for the worst (Porte et al., 2003).
  3. Watching for the development of seizures or coma and being prepared for the worst, since at the given age and in the given conditions, the worsening of the patient’s state is highly credible (Wheeler et al., 2008).

Conclusion

Intensive monitoring of the patient for the two hours and documentation would help Douglas recover from his reactive hypoglycemia. Complications of heart attack and rebound hypoglycemia would be prevented. Should fluid imbalance occur due to diarrhea or vomiting, timely correction and maintenance of fluid balance would help Douglas maintain stability. The risk of fall injuries is reduced through the SAFE measures. Severe hypoglycemia would be prevented by appropriate measures taken. Douglas would go home stable and happy after his ordeal. The patient will be educated on the prevention of hypoglycemia. He will be encouraged to live with his family so that the risk of hypoglycemic unawareness does not cause any more problems.

References

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Haines, T. P., Bennel, K. L., Osborne, R. H., & Hill, K. D. (2004). Effectiveness of targeted falls prevention programme in subacute hospital setting: randomized controlled trial. BMJ 2004 Vol. 328: 676.

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