Identify a patient, stating the reason for admission/appointment.

Identify a patient, stating the reason for admission/appointment.

 

Identify a patient, stating the reasonfor admission/appointment. It must be on diabetes. Describe a specific problemthat has been highlighted from the assessment process. Explore causes thatmay have led to their hospital admission/appointment. This could includephysical psychological and social aspects.

Case details

 

In this essay we shall discuss thecase of Mrs Singh. She is an elderly lady of 76 yrs. old. who lives in wardenassisted accommodation. She has done so for the last ten years simply because herhusband died. She has had Type II diabetes mellitus for your last 17 years, andcopes reasonably well considering her age and her comparative infirmity. Shehas been able to go out and get her shopping within the nearby shops and is otherwiseself-caring, clean and tidy.

 

According for the referral letterfrom her General Practitioner, who arranged this admission to hospital, anumber of persons had recently commented that she looked ill and was not caringfor herself as well as she employed to do. Her family members live a substantial distanceaway from her and, whilst they see her about once or twice a month, they donot stay for lengthy as they've a company to run.

 

When she was admitted she was foundto be lucid and coherent but her family told us that she had had a quantity ofepisodes of confusion recently. She was occasionally extremely sleepy and had leftthe gas burning on 1 occasion. She had a large infected ulcer on her leftshin, which had clearly been there to your matter of weeks, but due to herhabit of wearing lengthy skirts, no 1 had noticed it. She had a degree of ankleoedema, but her physical examination was otherwise unremarkable, apart type thefact that she had a BMI in excess of 29. She is really a moderate smoker.

Discussion

 

Mrs Singh as somebody isclearly unique, but sadly, she also represents a excellent numerous elderly diabeticpatients who live in similar conditions. The thrust of this particulardiscussion is the aetiology and management of her condition with particularrelevance to her leg ulcer.

 

Diabetes Mellitus, an overview

 

Diabetes is really a comparatively commondisease process during the UK. In young children it's the commonest major illness(after childhood infections). You'll find approximately 1.5 million diabeticpatients within the UK at produce as well as the variety is relentlessly increasing.(Devendra et al 2004)

 

The 1.5 million are not equallyspread across all segments on the population. Individuals from the Asian andAfro-Caribbean ethnic backgrounds have a markedly elevated risk of developingDiabetes Mellitus (UKPDSG 1998) with a single in four of all Afro-Caribbean womenover the age of 55 becoming diabetic. (Nathan 1998)

 

Increasing age and BMI also areboth independent risk causes for Diabetes Mellitus (James 1997)

 

Of this number, it's expected thatabout 10% will develop some form of lower limb ulceration though they arediabetic. (Amos et al 1997). To some extent, it's statistically far more likelythat those people patients who have poor manage of their diabetic land will developulceration (and other complications) than those people patients who have great control.

 

The other factor which is relevantin the aetiology of leg ulceration will be the length of time another person is diabetic.Chronicity in the disease program is an independent variable for legulceration. (Simon P et al 2004)

 

A quantity of authorities haveestimated the burden of cost of Diabetes Mellitus to the NHS. A recent discover byNewrick (et al 2000) regarded as that 9% of the total NHS budget was spent ondiabetes and diabetic related issues. By far the biggest single portion of thatamount (over half) was on the treatment of difficulties and also the commonestclinically relevant complication is that of venous ulceration(Ellison et al2002)

 

We can start by thinking thepathophysiology of Diabetes Mellitus

Pathophysiology

 

This is a large subject in its ownright and we shall as a result provide a brief overview as far because it is relevantto Mrs Singh.

 

In broad terms Diabetes Mellitus isa condition exactly where the body looses the capability to metabolise carbohydrates ingeneral and glucose in particular.

 

Glucose is absorbed during the gut,transported towards liver where is is also stored as glycogen, and thentransported from the bloodstream towards cells from the periphery in the body,where it is one on the primary metabolic substrates. It is absorbed inside bloodinto the cells by a specific molecular carrier technique and this really is totallyinsulin dependant.

 

If there is a failure of insulinproduction, then the circulating level of insulin falls as well as the glucose is nottransported into the cells. This leads, initially to hyperglycaemia and finallyto ketosis and metabolic failure. This really is the situation of Type I diabetesmellitus.

 

The alternative is Type II diabetesmellitus in which the cells loose the ability to respond towards the circulatinginsulin levels. This also final results in hyperglycaemia and eventual metabolicfailure but is characterised by high levels of circulating insulin. In generalterms, Sort I diabetes mellitus is really a comparatively acute illness whereas TypeII diabetes mellitus tends to become much more chronic, sometimes taking several monthsor even many years to be clinically apparent. (after Donnelly et al 2000)

 

The complications of DiabetesMellitus are many. The largest group are the micro- and macrovascular group ofthe cardiovascular complications.

 

(Stratton I et al 2000)

 

The macrovascular group are usuallyrelated towards system of atherosclerosis and produce with either degrees of myocardialischaemia or as peripheral impairment such as intermittent claudication orulceration. In general terms the incidence of this kind of complication isdirectly associated of the average levels of HbA1 (which is a extended termindicator of diabetic control) (HSG 1997)

Nursing interventions

 

The major nursing intervention todiscuss right here may be the management of the leg ulcer. In any medical intervention itis significant to establish a sound evidence base (Sackett, 1996). We shalltherefore quote the literature relevant to every point.

 

The first, and arguably mostimportant consideration is regardless of whether the ulcer is primarily venous, arterial or(more rarely) neuropathic in origin. This is comparatively simply determined byan assessment of the ankle/brachial pressure ratio. This really is measured by meansof a Doppler measure as well as the ratio is simply calculated. If it's less than thecritical level of 0.8 it's likely that an important arterial element is present.(Partsch H. 2003)

 

Mrs Singh was treated having a 4layer bandage. He ratio was a lot above the 0.8 threshold as well as the mainaetiology of her ulcer was consequently judged to become venous.

The composition and construction ofa 4-layer bandage is really specific but it really is individually modified to suitthe wants from the person patient. The first layer is really a cotton wool basedbandage from the main functionality of absorbing the copious amounts of exudatesthat are favorite with this sort of ulcer. It also has the secondary function ofspreading the pressure evenly across the underlying tissues the second layer isa crepe bandage which has the prime functionality of holding the lower layer inplace. The third layer is a compressive layer, usually an elastic sort ofbandage is then used and this can be covered by a final binding layer. (Nelsonet al. 2004).

 

The rationale behind the bandage isthat from the typical diabetic venous ulcer there is an increased pressure atthe venous end from the capillary bed which translates into stagnation in thecapillary blood flow which renders the tissues a smaller amount viable due to pooroxygenation. By exerting physical pressure of about 40 mm Hg over a tissues,this increase of venous pressure is negated and also the circulation improved.(Thomas S. 2003)

 

Clearly it follows that in anarterial ulcer, as there is a reduction inside the arterial pressure at thearterial end in the capillary bed, any increase in physical pressure couldfurther reduce the blood flow across the capillary bed, that is certainly why it isvital to differentiate in between the two sorts prior to applying the bandage.(Marston W et al. 2003)

 

The second primary nursing intervention, and almost certainly much more great inside longer term, would be theHealth Promoting aspects from the nursing relationship. Mrs Singh is overweight. Her BMI is about 29 which means that her weight isn't only contributing to thereduction in venous return, and thereby contributing to each the aetiology andthe persistence of her ulcer, but the obesity is also a major issue in theaetiology of her Kind II diabetes mellitus. If Mrs Singh can also be persuaded toreduce her weight, her require for hypoglycaemic medication might lessen. Itis possible that it may well reduce to the point that she could manage her conditionon diet alone. (Terry T-K et al 2003)

 

Smoking isn't only an independentrisk thing for Sort II diabetes mellitus, but it's also a risk point forcardiovascular disease. A major wellness promoting measure would consequently be tohelp Mrs Singh to give up smoking. This is not a short word measure, so is notparticularly suited for hospital intervention, although the nursing staff spenta considerable amount of time with Mrs Singh to explain the problemsassociated with smoking. (Marks-Moran & Rose 1996)

 

On discharge she was refered to,and observed by, the smoking cessation nurse at the local main healthcare team.

 

The whole notion of patientempowerment and education is most important in this field. If a patientunderstands why they're getting asked to accomplish something, they're additional likelyto comply with the request within the healthcare professional (Marinker M.1997).

 

The pounds reduction requirements to becarefully managed if it is to become successful. She was refered on the dieticianwho prescribed a low fat, carbohydrate regulated, 1,200 cal. per day diet.Because this is clearly going being a extended word intervention, arrangements weremade for Mrs Singh being followed up in the community dietetic clinic.

 

Mrs Singh was in hospital for sevendays once the multidisciplinary discharge team had been able to arrange herdischarge. This involved the support of an occupational therapist to assistwith minor house modifications and also the community nurses who continued thetreatment from the 4 layer bandage.

 

(Harrison, I. D et al 2005) Thediabetic specialist nurse was also involved. As Mrs Singh's weight slowly reduced she was able to reduce and finally arrive off her hypoglycaemicmedication.

 

 

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