Abstract
This paper answers four questions. In addition, through a case study, the paper illustrates considerations made in order to prioritize care given to hospitalized patients. A case study is given of six patients with various complications and care needs. The paper points out that those with airway problems are usually considered first for care delivery before other patients with other conditions. This is because airway problems pose more acute danger than other conditions. In this case, the paper gives a case study of patients with various complications and how the complications are managed. In addition, the paper, through another case study, illustrates implications of hypoglycemia and how it can be managed. The case study given is of a hospitalized patient with a history of type 2 diabetes. The paper outlines measures to be taken in managing the condition. In conclusion, this paper provides some insight into management of patients with various complications in a ward setting. It provides information that can help in planning on how to conduct an effective ward round such that intended patient outcome can be realized.
Question 1: Prioritization of How I Would Assess My Care
Upper gastrointestinal surgical wards house patients with upper gastrointestinal disorders who are in either preoperative or post-operative phase. In post operative care, concerns are given to the following in order of their criticality: airway concerns, pain, mental status, wound care, deep venous thrombosis, fever, and urinary retention (Asensio & Trunkey, 2008). For diabetics, Plasma glucose levels monitoring is given priority. During a usual ward round at a surgical ward, a nurse is bound to encounter patients with diverse complications that vary in criticality. Consequently, there is need to prioritize assessment and other care delivery activities depending on patients’ conditions and treatments). Based on our case study, I would prioritize my assessments and treatments as explained below.
First, I would review Philip who is the patient on bed 4 since he is prone to airway obstructions. Airway occlusion is a medical emergency since it can cause cardiac arrest. Usually, human body maintains patency of airways through mechanisms such as coughing and actions of mucociliary system, macrophages, and lymphatics. However, owing to Philip’s condition, these mechanisms may be inadequate. Consequently, suctioning would be necessary.
I would start by assessing the patency of air way. This would be done through checking for such signs as snoring, gurgling, abnormal breath signs or stridor, agitation, paradoxical chest movement, dyspnea, and cyanosis. If tracheostomy tube is patent, high flow oxygen would be given. Pulse oximetry and ABG would be instrumental in monitoring the respiratory state of the patient. ABG guides adjustments of ventilator parameters in mechanically-ventilated patients. It determines whether one is acidemic or alkalemic. Suctioning would also be done regularly to remove respiratory secretions. Any sign of respiratory distress would be addressed and a doctor called in case of serious complications.
Haematemesis and Melaena require emergency care since they indicate bleeding of oesophageal varices ad can cause shock (Venkatesh, 2007). It should be considered after airway issues. Consequently, since Colleen has been admitted for this condition, she would be reviewed next. I would start by assessing the level of her tissue perfusion by checking for signs of hypovolaemia such as cold clammy skin, tachycardia, decrease in urine output, restlessness, and increased shallow peripheral pulse. Then her level of consciousness would be monitored. She would also be assessed for any signs of bleeding such as reduced volume of urine. Monitoring of vital signs would also be done. Interventions that include; administering of oxygen, blood transfusion, and provision of IV fluids to restore fluid volume and replace deficient electrolytes would be carried out.
The next patient to be reviewed would be the patient on bed 6, Tony. Other than epigastric pain, Tony has history of non-compliant type 2 diabetes. This implies that Tony is in need of glycemic control since suboptimal glycemic control in hospitalized patients bear adverse consequences on their treatment outcome. To achieve glycemic control, I would measure fingerstick blood sugar level every hour and adjust the rate of infusion according to the ward protocol until Tony’s condition stabilizes. Since he is currently on insulin infusion running at the rate of 4units per hour, his blood glucose level must be laying between 15mmol/L to 20mmol/L based on the infusion protocol. This infusion rate would be adjusted depending on subsequent fluctuations in blood glucose levels. Alongside controlling Tony’s glycemic level, assessing his level of consciousness mainly by means of AVU scale would be done.
Patient on bed 3, who is called Max, would be reviewed next. Since he is on pantoprazole infusion, I would check for signs and symptoms of body reactions to the drug. Precisely, any sign of angioedema or severe skin reactions such as loosening of skin, itching, or skin rush would be noted and reported. I would also ensure that the infusion is running correctly. Max would also be assessed for GI bleeding by noting such signs as haematemesis, hypotension, and tachycardia.
Next to be reviewed would be Linda, patient on bed 1. I would start by assessing fever. Both oral and rectal temperatures would be taken and used as indicators of fever. The management process would focus on three things: decreasing body heat production, promoting body heat loss, and monitoring and maintaining body functions. For instance, to decrease body heat production, I would advise Linda to take complete bed rest. I would also advice her to wear light clothes to promote heat loss.
Lastly, I would review Jayne; patient on bed 2.Clinical observations as well as interrogations would help me assess her condition. After the assessment, I would carry out a diagnosis. Based on observed dark urine and jaundice, Jayne could probably be suffering from pancreatic cancer. This implies that she may need to be taken on procedures such as endoscopy. Consequently, appropriate preoperative care would be given.
Question 2: How I Would Manage Hypoglycemia in Patient 6
Usually, treatment of hyperglycemia with insulin results into hypoglycemia. Hypoglycemia is a condition in which blood sugar level falls below 4mmol per liter. It is one of the most common reactions in diabetic treatment (Pickup, 2012). As a matter of fact, if it were not for the condition, treatment of diabetes would be easier. The condition presents with several symptoms that include; blurry or double vision, fast heartbeat, feeling of aggressiveness, shakiness, sweating, numbness or tingling of the skin, fatigue, convulsion, confusion, hunger, unclear thinking, and trouble sleeping.
The blood glucose level of 1.5mmol/L and the feeling of clamminess on touching noted in the patient in our case study clearly indicate that he is severely hypoglycemic. Severe hypoglycemia exhibits certain dangers. It can lead to unconsciousness, seizer, or even permanent neural impairments. This mainly occurs when a hypoglycemic condition continues for a relatively long period of time. The patient in our case study is at risk of dangers associated with hypoglycemia despite being partly conscious as indicated by his ability to respond to voice on AVU scale. Consequently, care should be taken to ensure that hypoglycemia is controlled. Given that the patient has been on insulin infusion, interventions given should take into consideration the likelihood of re-occurrence of hyperglycemia and risk of ketoacidocis. Therefore, my care process for the patient would proceed as follows.
First, I would repeat BGL to confirm hypoglycemia. If the level of glucoe remains below 3mmol/L, I would reduce the rate as per the ward protocol. I would also ensure that the infusion given is made up with 50ml syringes and delivered by a syringe driver. The ward protocol outlines infusion rates to be given at various blood glucose levels. When the glucose level falls below 5mmol/L, the protocol recommends that infusion rate of 0.5ml/hr should be administered. In the case study, blood glucose level of the patient falls below 5mmol/L (1.5mmol/L). Consequently, insulin infusion would be lowered to 0.5ml/hr. Even though the patient is hypoglycemic, I would not stop insulin infusion as this may induce ketoacidocis since insulin already given may run out in a matter of 30 minutes.
Next, since the patient is nil by mouth, I would give STAT dose of 25ml of 50% dextrose IV. Then, I would repeat BGL after 5 minutes as indicated in the protocol. The BGL would be repeated after every 15 to 30 minutes until the blood glucose levels rise above 6.5 mmol/L. if the patient becomes semi-comatoes, I would reduce insulin infusion to the lowest rate provided in the protocol and then call rapid response team. The actions are aimed at preventing serious neural injuries that may occur due to hypoglycemia.
Treatment of diabetic condition through insulin therapy is a challenging task. This is mainly attributed to the fact that it induces hypoglycemia. Hypoglycemia presents other dangers other than inhibiting glycemic control. Therefore, it is crucial to approach the condition of the patient cautiously so that the target glycemic levels can be achieved and maintained.
Question 3: Why It Is Important To Seek Assistance and People from Whom Assistance Can Be Sought
In a ward setting, any given patient is seen by more than one health practitioners. Each practitioner relies on another for information regarding the patient. For instance, before any medication is given to a patient, the patient’s medical history must be reviewed and information obtained documented for easy communication among the staff. Therefore, keeping records is a patient safety issue.
Medications are prescribed to various patients on timely basis. Therefore, schedule should not be violated. The fact that medications have not been administered poses threat to positive patient outcome. Since it appears that I may not accomplish all activities within a given recommended time, I should seek assistance.
Seeking assistance is crucial in times of emergency. Patients in the ward in our case study all require services given on timely basis. Since it appears that I may not handle all the patients alone on timely basis, it would be important to seek assistance. This would help ensure that all medications are given in time and emergency cases attended to. Besides, being a student, I do not have much experience. In addition, a mistake made may lead to serious consequences on the patients’ conditions. Therefore, it would be important to seek assistance whenever I am not sure of anything. In my situation, I need assistance from qualified personnel who can do observation for me while I do medication. I would seek help from AIN, RN, nurse in charge and even the ward TL. Senior and junior staff would help.
Question 4: Interventions to Address Breathing Difficulty in a Patient with Tracheostomy
In our scenario, I would attend to patient on bed 4 first since threatened airway is a medical emergency. First, I would check for the patient’s responsiveness through shaking and shouting. If the patient is unconscious, I would call for rapid response team. Then, I would check for airway patency at the tracheostomy opening. This would involve lifting and tilting the patient’s head to observe the position of the tracheostomy. Position of tracheostomy may be the cause of airway occlusion. Wrongly positioned, tarcheostomy may corrode the wall of trachea and expose arteries. This makes them to bleed hence causing occlusion.
Next, I would suction the patient. In this case, I would use 1 to 2mls of saline to suction any clot that may be causing the occlusion. The next step would be doing breathing check. This would take about ten seconds. Breathing check involve the following steps: looking for chest movement and vital signs; listening for movement of air at the opening of the tracheostomy opening; and feeling with my cheek at the opening of the tracheostomy.
Next, I would monitor oxygen saturation level using pulse oximetry. If spO2 values fall below 90%, supplemental oxygen would be administered. For our case, high dose of oxygen would be needed. A small soft valve-mask would be placed over the stoma and made to form a seal around the neck. With assistance from a colleague, I would fix the bag to the mask while my colleague holds the mask in place.
References
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Asensio, J. A., & Trunkey, D. D. (2008). Current therapy of trauma and surgical critical care. Philadelphia: Mosby/Elsevier.
Chikwe, J., Walther, A., & Jones, P. (2009). Perioperative Medicine: Managing surgical patients with medical problems. Oxford: OUP Oxford.
Stanisstreet, D., Walden, E., Jones, C., &Graveling, A. (2010). The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus. London: NHS.
Pickup, J. C. (January 01, 2012). Management of diabetes mellitus: is the pump mightier than the pen?. Nature Reviews. Endocrinology, 8, 7, 425-33.
