Diabetes: A Nursing Analysis

Ms. Rita is a 15 year old female. She is a known case of poor control of sugar level since one month without regular medication. When patient was admitted to hospital her random blood sugar =300mg/dl. She had no history of vomiting, breathlessness, altered sensorium or bowel trouble. She had a history of weight loss. On her initial examination she was calm, conscious and cooperative and well oriented to time, place and person. Her BP was 140/90mmhg, pulse-80 per minute, abdomen soft non- tender and no organomegaly. She had a history of polyuria and weight loss and increased thirst. Chest vesicular breathing, no added sound. CVSSI, S2 heard normally.

Investigations:-
Urine Color                Pale, turbid
Reaction                     6.0
Albumin                     + + +
Sugar                          + +
Ketones                     Negative
Glucose (F)               303mg/dl
Hb                              8.3gm/dl
TLC                            9000/Ul
DLC                            N-49%L-47%M-2%E-2%
Platelets                    4.15 lacs
Total cholesterol     160mg/dl
DHLcholestrol         30mg/dl
LDL                           100mg/dl
VLDL                         30mg/dl
Triglycerides            150mg/dl
T. Cholesterol ratio           5.33
Glucose (F)             253mg/dl

FINAL DIAGNOSIS:-Type 1 Diabetes mellitus

Diabetes Mellitus type 1 is a chronic disorder of carbohydrate, fat and protein metabolism. A defective or deficient insulin secretary response, which translates into impaired carbohydrate (glucose) use, is a characteristic feature of diabetes mellitus (Goodman and Gillman’s, 2001).

Type 1 diabetes is also called Insulin Dependent Diabetes Mellitus (IDDM) and was previously referred to as juvenile onsetdiabetes. It occurs due to decreased insulin production and unchecked glucose production by the liver. Insulin enables the sugar to get out of the blood and into the cells where it is needed for the cells to function.Diabetes results from a severe, absolute lack of insulin resulting in reduction in beta cell mass. Beta cells are a type of cell in the pancreas in areas called the islets of langerhans. These beta cells produce insulin. The function of insulin is to counter the action of a number of hyperglycemia-generating hormones and to maintain low blood glucose levels. Due to lack of insulin sugar will not be able to get into the cells so, there will be a high concentration in the blood. On the other hand, high amount of insulin shifts too much sugar into the cells and there will be not enough sugar left in the blood (Mohan, 2000). Lack of insulin affects them because insulin allows for the absorption of glucose by cells in the body and is secreted by the beta cells, in response to elevated glucose in the blood (Chatterjea, 2000).

To treat the high level of glucose insulin was given to the patient. Insulin works to lower blood glucose by promoting the transport of glucose into cells and by inhibiting the conversion of glycogen and amino acids to glucose (Smeltzer, 2004).

Ms. Rita was suffering from polyuria which is increased amount of urine (Smeltzer, 2004). When the blood glucose level is significantly elevated, (it is also mentioned in the above paragraph) the kidneys are unable to handle the workload and therefore allow the excess glucose to spill over into the urine. The glucose in urine acts osmotically means higher concentration to lower concentration to draw more water into the urine, resulting in polyuria (Cotran, 2000).

Mrs. Rita’s urine was pale and turbid color. It occurs because concentration of glucose in the blood rises. The renal threshold for glucose is, usually 180 to 200mg/dl. When blood glucose increases, the kidneys may not reabsorb all the filtered glucose and the glucose than appears in the urine making it pale and turbid (Smeltzer et al, 2004).

She had a problem of Polydypsia which means excessive thirst. As explained above glucose in the urine is increase, rising the osmotic pressure of the urine, this ways pulls the water along with the glucose in to the urine which leads to excessive urination called polyuria, causing a lack of overall body fluids making the blood hypertonic. This hypertonicity provokes the brain to initiate thirst as a compensatory mechanism of dehydration so that loss of water can be fulfill (Chaudhuri, 2002).

She was suffering from problem of weight loss. Loss of tissue mass occurs in the insulin- dependent form of the disease (the consequence of glycosuria) that characterizes the illness. Role of insulin is to provide entry of glucose into the cells. Insulin deficiency result in non utilization of glucose as it cannot enter into the cells leading to impaired synthesis of protein, fat and simultaneously cause accelerated breakdown of proteins and fats for production of energy causing a catabolic state. It means there is accelerated breakdown of fat and muscle secondary to insulin deficiency leading to weight loss.

Ms. Rita’s blood pressure was 140/90mmhg. The reasons for the increased blood pressure are hyperinsulinemia, glucose intolerance and reduced level of HDL cholesterol. In a normal physiological state nitric oxide synthesis is stimulated by insulin besides decreased synthesis and responsiveness to non insulin resistant states have been associated with increased level of endothelin-1 and potent vasoconstrictor and proarthero sclerotic vascular hormone associated with hypertension 4ia,, e.of Pathologrica..outh.within the central nervous system, all these hormonal changes may play a major role in the gastr(Kumar and Clark, 2005).

Overall management was good and Ms. Rita discharged in satisfactory condition.

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REINVIGORATE TO LIFE WITH THERAPEUTIC HYPOTHERMIA

Successful resuscitation and therapeutic hypothermia determines the best clinical outcome after a cardiac arrest. Therapeutic hypothermia is not limited to cardiac arrest but its been used extensively in patients with stroke, traumatic brain injuries, during cardiac catheterization surgeries and neonatal resuscitations. Hypothermia increases the chances of good neurological outcome. American Heart Association’s chain of survival emphasizes the need for post cardiac arrest care and recommends therapeutic hypothermia during Return of Spontaneous Circulation (ROSC) management and care.

Physicians and researchers have been using this for ages. Hippocrates recommended the use of topical cooling to stop bleeding .In the early 1990, it was found that mild hypothermia, even after the cardiac arrest had benefit for the brain. Peter Safar added the word H after the A,B,C,D…. of resuscitation. The history of inducing hypothermia began in the 1950s with elective moderate hypothermia (28-32) of the brain for the protection and preservation of the brain. Recently, former formula1 champion Michael Schumacher was kept in therapeutic hypothermia after traumatic brain injury. Four randomized control trials done among 417 patients who were successfully resuscitated from cardiac arrest proved that, it improves neurologic outcome.

Therapeutic hypothermia otherwise also known as mild therapeutic hypothermia, induced hypothermia is of two types invasive and non invasive. Invasive methods include intravascular cooling catheters and ice cooled infusions whereas non invasive methods include cooling pads, fans, alcohol baths, cooling blankets, ice packs, perfluorocarbon into the nasal cavity. There are different types of cooling which ranges from mild cooling (32-34) to severe cooling up to 28 .

AHA recommends that all unconscious patients achieving ROSC after out-of-hospital VF cardiac arrests receive induced hypothermia it also state that induced hypothermia may be beneficial in non-VF arrest for out-of-hospital or in-hospital arrest.

Nursing care plays a pivotal role in preventing irreversible brain damage and adverse outcomes after cardiac arrest. A close and continuous monitoring of vital signs which includes temperature, pulse, blood pressure, oxygen saturation ECG, input output and shivering scale monitoring should be performed during the maintenance phase of Inducing therapeutic hypothermia. Intravenous fluids with glucose content should be avoided. Close observation s required as patient is under analgesia and sedation. There is a high risk for getting infection if there is any delay in wound healing, aspiration and ventilator associated pneumonia. Fluid and electrolytes such as potassium, magnesium phosphorous calcium should be monitored and replaced. Other laboratory values such as haemo concentration, PT, INR, PTT should also be checked at frequent intervals.

Re warming plays a crucial role in Therapeutic hypothermia;warming should be done at a slow pace to prevent complications. Rebound hyperthermia seizure, cerebral edema, hypotension and ventricular fibrillation are other potential life threatening complications.

A prospective cohort study of four years conducted among 67,48 patients from 538 hospitals concluded that after in- hospital cardiac arrest, therapeutic hypothermia was used rarely and once initiated the target temperature was commonly not achieved. Post cardiac arrest care is a multidisciplinary approach. Ignorance, lack of knowledge, lesser facilities could be the reason for not initiating post cardiac arrest care, educational modules, simulation exercises, protocol development and continuing education can increase awareness and can translate laboratory researches into bedside actions.

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NURSES – NO MORE HANDSHAKES

As Nurses we offer handshakes to meet patient’s expectations and to develop a rapport with them. In developing countries such as India, shaking hands has become common, especially in the large cities among nurses and other health care workers dealing with patients.^{1, 2} Ritualistic touching plays a crucial role in many cultures. Though handshakes give a profound impact in better patient outcomes, it also has the potential for greater efficiency of pathogen transmission, and handshakes are known to transmit bacteria.^3,4In India though significant advances have been made in infection control, inadequate practices and surveillance systems persist and there is often a high risk. Several food borne disease outbreaks have been reported which are associated with poor personal hygiene. The US Centers for Disease Control and Prevention says that one in 25 hospitalized patients develop an HAI and 75,000 patients with HAIs die during their hospitalization each year. Scientists at Aberystwyth University in Wales have shown that a shake transfers more bacteria compared to other forms of hand-on-hand action. Health care providers like nurse’s hands spread potentially harmful germs to patients that leads to healthcare-associated infections (HAI) i.e., infections acquired in health care also called as “nosocomial” and “hospital” infections.⁷According to WHO, out of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection. The endemic burden of HAI is also significantly higher in low as well as middle income than in high-income countries, in particular in patients admitted to intensive care units and in neonates.⁵

So what next? Will fist bumps (also called dap, pound, fist pound, brofist, donsafe, spudding, fo’ knucks, box, Bust, pound dog, props, Bones, respect knuckles, bumping the rock, or knuckle crunching) replace handshakes in the hospital or any public places? Fist Bumps are basically an urban form of greeting one another by the bumping of fists together, meant as a form of respect.

When you do a fist bump, a smaller amount of surface area is in contact between the two hands. According to a new study “Fist bumping” transmits less bacteria than either handshaking or high-fiving while still addressing the cultural expectation of hand-to-hand contact among patients nurses and clinicians.⁶ A British study has found that high-fives pass less germs as the traditional greeting and the fist bump is even cleaner.⁷In an another study the West Virginia researchers found that the individuals who shook hands had four times as many pathogens on their hands as the individuals who fist-bumped, according to results published last year in the Journal of Hospital Infection.⁸

There have been calls in the Journal of the American Medical Association to ban handshakes from hospitals and make it a global best practice.⁹ American Medical Association, suggested that hospitals, clinics and other healthcare facilities post signs with messages as “Handshake-free zone: to protect your health and the health of those around you, please refrain from shaking hands while on these premises.”¹⁰

If we go back to the Victorian age; when on meeting someone you bow or curtsy from a respectful distance . NURSES – NO MORE HANDSHAKES. Next time you want to say “hi,” show off how casual you are with a friendly fist bump or just bow and say a Namasthe!

The question remains if healthcare facilities implement the fist bump and make it a global best practice.

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