Nur2300 Evidence Based Nursing Practice: Assessment Answers
Answer:
Introduction
In the healthcare industry, usually the communication skills of the nurses are ignored. They are employed based on their knowledge of techniques and methods while the skill of communication often takes a backseat. Studies say that due to inadequate communication between the patient and nurse, the treatment of the patient undergoes a downfall. Exceptional communication skills of the nurse help to foster a dialogue and get the message across to the patient and his family (McCabe & Timmins, 2013). The report deals with the importance of communication in nursing. The report further elaborates on the treatment that must be rendered to Mr. Brown to keep him fit. He should be taught certain procedures that must be followed at home when he is discharged such as insulin injection and blood monitoring. Presently, family members are also involved in the care of the patients where they share their opinions. They are given appropriate training on various aspects to handle the patients (Arnold & Boggs, 2015).
Discussion
As per the case of Mr. Brown, he is 66 years old with chest pain, breathing problem, Type 2 diabetes, obesity and hyperlipidaemia. He has several beers and cigarettes per day. He has to be given proper clinical care and nursing techniques for his survival. Clinical care standards are sets of recommendations that all patients with the same medical conditions are treated with suitable care irrespective of location. The Acute Coronary Syndrome (ACS) clinical care standard helps to support healthcare officers and improvise the quality of healthcare. The appropriate nursing care for the Mr. Brown will be discussed in detail.
Symptoms of patients with hyperglycaemia and coronary heart disease
Diabetes is a complex disease that has a critical societal impact. It is seen in 90% of diabetes-inflicted patients. Type 2 diabetes mellitus affects multiple organs such as the liver, pancreas, kidney brain and gastrointestinal tract. There is a low sensitivity to insulin and a decreased amount of beta-cell function of pancreas. This leads to hyperglycaemia (Bell et al., 2014). In the case of Mr. Brown, his ideal weight should be between 53-65 kg but he is 143 kg that clearly shows that he is overweight. In addition, his diet is unhealthy since he has a couple of beers and a packet of cigarettes every day. When Mr. Brown was admitted in the hospital, he had acute chest pain with difficulty in breathing. These are the signs of an Acute Coronary Syndrome (ACS).
Appropriate nursing care for Mr. Brown in hospital
In hyperglycaemia, there is not only renal failure but also cardiovascular diseases and blindness. Mr. Brown has to be checked twice a year for glycated haemoglobin. When Mr. Brown is hospitalized, the nurse should execute a correct diagnosis and keep a medical record. The basic tests of blood and urine should be done (Martin?Gronert & Ozanne, 2012). Many tests are performed on the patient. They are such as urine test, HbA1c and eye dilation test. A detailed eye dilation test should be performed to check whether the diabetes has affected the eye blood vessels. There should be an HbA1c test done on the patient. It is a kind of test to check the amount of haemoglobin in glycosylated blood. A urine test should be done to check the levels of sugar or ketones. The urine of the patient is collected and a strip is dipped in that urine. SA change in colour will depict the presence of ketones. This kind of test also helps to detect microalbumin. This is a kind of protein, found in urine of diabetic patients. To analyse the heart attack, Troponin tests are also done. This kind of test is usually performed when the patient has been admitted with chest pain, shortness of breath, cold sweat and nausea. Troponin I and T are heart muscle proteins, which are released into the blood in case of heart damage. If the results of the patient show a high level of Troponin, then it must be understood that he had a heart attack or any other form of heart disease. Post heart injury, the levels of Troponin can get elevated within 3-4 hours and remain in this condition for 10-14 days. There can be non-invasive and invasive tests done to diagnose a patient with heart attack. Non-invasive include imaging with a needle stick while invasive test include insertion of a tube. A pain assessment tool should be reliable and precise to give the correct amount of information (Mahar, 2012). The staff and the patient should be knowledgeable enough to use the tools. PQRST in nursing is an acronym for Provoke, Quality, Radiates, Severity and Time. Provokes includes the question as what has caused the pain, Quality includes what the pain feel like and Radiates involves the site of origination of the pain. Severity includes the magnitude of pain and Time is the duration of the pain. PQRST helps the nurses to analyse the complete situation of the patient when he is admitted in the hospital (D'Arcy, 2013). A complete set of questions is asked to the patient to know his medical condition. There are many pain scales to such as the Numerical Rating Scale (NRS), Visual Analog Scale (VAS) and an image or pictorial scale. In NRS, the patient has to rate his pain on a scale of zero to 10, zero being lowest and 10 being the most severe. In VAS, the patient has to depict his pain on a scale without the use of numbers while in an image scale the there are range of faces with a smiling face to a crying face using which the patient has to communicate his pain. In case of heart attack, a time window of 10 minutes is permissible for the patient to be treated and an experienced paramedic can perform the ECG (Macintyre & Schug, 2014). Morphine, soluble aspirin and intravenous (IV) nitro-glycerine should be given as the primary treatment. The symptoms of Mr. Brown have to be observed carefully and then determined as to what kind of medicines should be given to him. Patients with low-risk symptoms should be assessed with biomarkers and administered aspirin and beta-blockers while patients with high-risk symptoms should be given aspirin, clopidogrel and beta-blocker. Angiography is considered as one of the options (Abbate et al., 2012).
Steps to be taken by Mr. Brown post discharge
There has to be a definite change in lifestyle and weight. There should also be self-monitoring of glucose, thorough check-up and self-management knowledge. With respect to self-monitoring of blood sugar, there are simple steps that the nurse must teach the patient, in this case Mr. Brown. The first method is by using a meter. The patient has to prick his finger with a needle and then place the drop of blood on a strip. The strip is then placed on a meter that will depict the blood sugar count. These kinds of meters are found at local pharmacies and they vary in size, speed, portability and cost. These meters take about 15 seconds to show the results, store the results for future use and sometimes carry a software kit that inputs the results and displays the relevant graphs and charts. This kind of method is the most traditional way to test the glucose. There are new devices that enable the patient to check the blood sugar from his thigh, upper arm or fore arm. The results definitely vary between the blood taken from the thumb and the arm. Insulin pumps are tools that help to check the blood sugar level and enable to find the changing trends in the sugar level. The nurse should properly demonstrate Mr. Brown on how to monitor his blood sugar levels. It is recommended that the patient with type 2 diabetes should check his blood sugar levels at least twice or more a day. The kind of monitoring should be done at early morning prior to eating or drinking anything. If the early morning sugar is high then the patient should wake up at around 3 am at night to check. Pre meal testing is very important since it shows a baseline reading of the sugar level before meals. Since diabetes is a complex disease varies from person to person, the relationship between food and blood sugar of a patient has to be observed. Hence, post meal blood checking is also encouraged.
The hyperglycaemic emergencies are associated with proper management and care. The nurse should educate Mr. Brown on how to inject insulin at home, if needed. Insulin therapy should be determined by β-hydroxybutyrate normalization (Inzucchi, 2015). Initial dose of insulin is not required and fixed rate insulin combination represents the best option to suppress hepatic glucose production, ketogenesis and lipolysis. For type 2 patients, insulin injection is always not recommended. It is said that along with life style changes and medicines the blood sugar level can be reduced. However, it might occur that the patient will want to take insulin as it helps to lower the blood sugar level and is cheaper than other diabetic medicines. The optimum range for insulin should be between 100-250 mg/dL of glucose in the blood. If the patient has an initial level of A1C more than 9% or if he has uncontrolled diabetes, then a recommended insulin level of 0.3 units per kg should be used. The nurse or the doctor will chart the accurate insulin dosage that Mr. Brown will take depending on the weight, age and diet. The insulin can be injected at thighs, arms, abdomen, and hips (Pledger et al., 2012). The patient should avoid scars, moles or broken blood vessels for his injection. The same injection site should not be used repetitively. The insulin when injected in the abdomen is absorbed rapidly and works fast. Syringes, needles and pens are used to inject the insulin. The needle should be of 12 mm in length. Insulin pump is another invention in this field that helps to administer the insulin into the body (Savage et al., 2012). It is a kind of device that that is worn externally. It has a tube and a needle that send the insulin into the body. However, a lot of training is required to execute this process. The process in which the insulin is injected is stated in detail. The patient should first wash his hands with soap water, hold the syringe down and pull the plunger to the dosage level. He should then remove the caps from the insulin vial and needle, push the needle into the stopper and push the plunger down to take in the air inside. He has to turn the needle upside down and push the plunger so that the top of the back plunger has reached the dosage level. If there are bubbles in the syringe, the patient has to tap it lightly and push the syringe to send the bubbles into the vial. The insulin vial has to be held down along with the syringe with the finger placed off the plunger. The injection site has to be swapped with an alcohol pad, a one to two inch of skin is pinched and then the needle is inserted at 90-degree angle. The plunger has to be taken all the way down and waited for 10 seconds. The pinched skin is released immediately and the needle is removed. Bandage can be used of bleeding occurs. The nurse can give some tips to the patient for a comfortable procedure, such as, the patient can numb his skin with ice before alcohol is applied or he should not inject at the roots of body hair. There are various kinds of insulin that can be taken by the patient depending on the speed or purpose of action. They can be rapid acting, short acting, intermediate acting, and long acting and pre-mixed.
There has to be some dietary changes that need to be done to cure the patient (Hayashino, 2012). Mr. Brown should eat regularly in small portions, swap high calorie food with vegetables and fruits eat whole grains, pulses and beans and eliminate added sugars and salt from his diet (Mohamed, 2014). Exercise is an integral part of the patient’s treatment. The patient should do both aerobic exercise and strength training. Aerobic exercises include brisk walking, swimming, jogging and dancing. Strength training comprise lifting free weights and working with weight and resistance machines. Prior to exercise the patient should check the levels of glucose in his blood.
Patient and family centred care
Presently, patients and family care is gradually becoming popular and communication has a major role to play in it. It is a two-way system. The decision of the patient is valued and on the other hand, the relatives are seen as advisors for health care practices (Flynn & Preuster, 2014). The relatives or the family members of the patient are invited to share their opinion regarding the care of their patient. The family members of the patient are involved to help the nurses in case of emergency. These family members are known as caregivers who interact with the nurses and doctors for the correct treatment of the patient (Reinhard, Levine & Samis, 2012). Caregivers spend a lot of time with their patient and get educated about the techniques that should be used after discharge. A pain education program is arranged for the caregivers where they are educated on assessment of pain, pharmacologic and non-pharmacologic intervention (Kim & Rich, 2016). Nurses also teach the caregivers about problem solving skills and safe medication management. The caregivers are taught ways in which they can manage the various behavioural changes of the patient. Anthony M.DiGioia and his team at the University of Pittsburgh Medical Centre first developed this methodology (Verbeek, 2012). It is a six-step process, the first step consists of describing the entire program along with the start and end and the second step involves the creation of a council to lead the process. The third step is defining the current situation of the process; the fourth step is expanding the council to a group. The fifth step is to create an ideal story from the patient’s and family’s perspective and the sixth step involve creating teams to bridge the gaps between the current and ideal situation. This process helps to maintain accountability and ethical value since the family members are seen as partners to the patient’s care system (Gillick, 2013).
Conclusion
Therefore, from the above discussion it can be concluded that the nurses should follow a certain number of protocols for the cure of their patients. In the case of Mr. Brown, due to his obesity and unhealthy diet he has been diagnosed with both type 2 diabetes and cardiac disease. A holistic care by the nurse is needed for his treatment. A nurse will not only devise a proper diet and exercise plan for the patients but will also try to establish a healthy relationship with him and his family members. Patient oriented care, new methods for injecting insulin, consistent glucose check and minimum pain during angiography are some of the measures taken by the nursing workforce. Nursing is both science and art. The nurses should educate the patients on the correct usage of insulin and the monitoring of blood sugar levels. The family members who are seen as caregivers are also included in the care of the patient and their opinions are given importance. The caregivers are considered crucial to the healthcare system and they must interact with the nurses to obtain information, equipments and services. This will help to build a healthy relationship between the patients, his family and the nurses.
References
Abbate, R., Cioni, G., Ricci, I., Miranda, M., & Gori, A. M. (2012). Thrombosis and acute coronary syndrome. Thrombosis research, 129(3), 235-240.
Arnold, E. C., & Boggs, K. U. (2015). Interpersonal Relationships-E-Book: Professional Communication Skills for Nurses. Elsevier Health Sciences..
Bell, K. J., Barclay, A. W., Petocz, P., Colagiuri, S., & Brand-Miller, J. C. (2014). Efficacy of carbohydrate counting in type 1 diabetes: a systematic review and meta-analysis. The Lancet Diabetes & Endocrinology, 2(2), 133-140.
D'Arcy, Y. M. (2013). Compact Clinical Guide to Critical Care, Trauma, and Emergency Pain Management: An Evidence-Based Approach for Nurses. Springer Publishing Company.
Flynn, L., & Preuster, C. (2014). Patient-and Family-Centered Care.
Gillick, M. R. (2013). The critical role of caregivers in achieving patient-centered care. Jama, 310(6), 575-576.
Hayashino, Y., Jackson, J. L., Fukumori, N., Nakamura, F., & Fukuhara, S. (2012). Effects of supervised exercise on lipid profiles and blood pressure control in people with type 2 diabetes mellitus: a meta-analysis of randomized controlled trials. Diabetes research and clinical practice, 98(3), 349-360.
Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., ... & Matthews, D. R. (2015). Management of hyperglycaemia in type 2 diabetes, 2015: a patient-centred approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia, 58(3), 429.
Kim, D. H., & Rich, M. W. (2016). Patient-centred care of older adults with cardiovascular disease and multiple chronic conditions. Canadian Journal of Cardiology, 32(9), 1097-1107.
Macintyre, P. E., & Schug, S. A. (2014). Acute pain management: a practical guide. CRC Press.
Mahar, P. D., Wasiak, J., O’Loughlin, C. J., Christelis, N., Arnold, C. A., Spinks, A. B., & Danilla, S. (2012). Frequency and use of pain assessment tools implemented in randomized controlled trials in the adult burns population: a systematic review. Burns, 38(2), 147-154.
Martin?Gronert, M. S., & Ozanne, S. E. (2012). Metabolic programming of insulin action and secretion. Diabetes, Obesity and Metabolism, 14(s3), 29-39.
McCabe, C., & Timmins, F. (2013). Communication skills for nursing practice. Palgrave Macmillan.
Mohamed, S. (2014). Functional foods against metabolic syndrome (obesity, diabetes, hypertension and dyslipidemia) and cardiovasular disease. Trends in Food Science & Technology, 35(2), 114-128.
Pledger, J., Hicks, D., Kirkland, F., & Down, S. (2012). Importance of injection technique in diabetes. Journal of Diabetes Nursing, 16(4).
Reinhard, S. C., Levine, C., & Samis, S. (2012). Home alone: Family caregivers providing complex chronic care. Washington, DC: AARP Public Policy Institute.
Savage, M. W., Dhatariya, K. K., Kilvert, A., Rayman, G., Rees, J. A. E., Courtney, C. H., ... & Hamersley, M. S. (2012). Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabetic Medicine, 28(5), 508-515.
Verbeek, H., Zwakhalen, S. M., van Rossum, E., Kempen, G. I., & Hamers, J. P. (2012). Small-scale, homelike facilities in dementia care: a process evaluation into the experiences of family caregivers and nursing staff. International journal of nursing studies, 49(1), 21-29.
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