In this assignment the topics discussed is a nursing problem related to a medical diagnosis taking from an example of a patient dealt with while the nursing student was out on clinical placement. For this assignment the patient has a diagnosis of Type 1 Diabetes Mellitus. Kevin Brophy (pseudonym) is a 9 year old boy that had come into the Paediatric Unit. He is of the Roman Catholic religion. He lives with only his mother and she is educated about his disease of Diabetes. His mother’s sister is a nurse also and knew how to manage his Diabetes and looked after him if his mother was busy. The multidisciplinary team have been treating him for the condition for 4 years. He gets hospitalized often to regulate his blood sugar levels and monitor his insulin intake. The nursing problem associated with his diagnosis is related to his diet and nutritional status and being able to monitor these with caution and ease. The nurse had a form for filling out what had he eaten that day and what time this had happened at in the ‘end of bed’ chart which was with his other documentation such as his vital signs and also the fluid balance intake and output chat.
There was also a section in this form for documenting what level his blood sugars were and was directed to take record of them after every meal. The nurse then had an idea of what sort of food he was eating and also a report of his blood sugars which were monitored closely throughout the day. The nurses primary responsibility was to ensure this boy was eating correctly and following the dietary guidelines of a Diabetic patient. The model of assessment/care used to treat Kevin was devised from Roper, Logan and Tierney (1980). The Roper, Logan and Tierney’s’ activity of living (AL) model of nursing consists of twelve activities of living. According to Aggleton & Chalmers (2000 P46), “Each AL specifies a relatively distinct type of human behaviour related to meeting a particular need.”
Information was obtained from a booklet containing facts and advice on Diabetes and Healthy Eating from the Department of Health and Dietetics in Waterford Regional Hospital. This has described diabetes as a condition where the body is unable to control the amount of glucose i.e. sugar in the blood. Everyone’s blood has some glucose in it because your body needs glucose for energy. Normally your body breaks food down into glucose and sends it to the bloodstream. Insulin, a hormone made by the pancreas, helps to get the glucose from the bloodstream into the cells to be used for energy. In people with Type 2 Diabetes, the pancreas is not making enough insulin or is unable to use the insulin properly, or both. In people with Type 1 Diabetes, the pancreas is unable to make insulin full stop. Without insulin in the body, the blood glucose rises (Department of Nutrition and Dietetics, Waterford Regional Hospital 2006). To manage diabetes in paediatrics is primarily challenging and much more complicated than dealing with the diagnosis in adults with Diabetes (DH Diabetes Policy Team 2007, Christie et al 2009).
Nurses have to educate and facilitate the self management of Diabetes and also introduce skills to gain the best possible control over the patient’s blood sugars i.e. glycaemic control. If these skills are not executed properly then diseases such as micro-vascular e.g. nephropathy or retinopathy or cardiovascular diseases (macro-vascular), which decreases the quality of life and a reduced life span (The Diabetes Control and Complications Study Group,1994). The nurses and patients responsibility is to monitor and control the intake of food and also be educated on what can have a negative or positive effect on the body. This is a major nursing problem associated with the Diabetic patient and intervention by the nurse is necessary throughout. In doing so, the nurse must follow the Nursing Process in relation to their diet. Assessment
Patients diagnosed with type 1 Diabetes are assessed for signs of Diabetic Ketoacidosis, including ketonuria, Kussmaul respirations, orthostatic hypotension, and lethargy. The patient is asked about symptoms of DKA, such as nausea, vomiting, and abdominal pain. Laboratory results are monitored for metabolic acidosis (i.e. decreased pH and decreased bicarbonate level) and for electrolyte imbalance. If the patient exhibits signs and symptoms of DKA, the nursing care first focuses on treatment of these acute complications, as outlined earlier. Once these complications are resolving, nursing care then focuses on long-term management of diabetes. The patient’s emotional status is assessed by observing his or her general demeanour (e.g., withdrawn, anxious) and body language (e.g., avoids eye contact). The patient is asked about major concerns and fears about diabetes; this allows the nurse to assess for any misconceptions or misinformation regarding diabetes. The nurse is also assessing the vital signs of the patient such as temperature, respiration, blood pressure etc. and develops a baseline of these results. In this case the patients normal vital signs were as follows : Temperature- 36.4◦, Blood Pressure- 114/70, Respiration rate- 18 breaths per minute.
Based on the assessment data, the main diagnoses the nurse must adhere to are as following: Risk for fluid volume deficit in relation to polyuria and dehydration, imbalanced nutrition related to imbalance of insulin, food, and physical activity. The main ones that are focussed on in this essay are the imbalance of insulin and the patient’s diet.
The major goals for the patient may include maintenance of fluid and electrolyte balance, optimal control of blood glucose levels. The nurse would plan suitable charts and regimes for the patient to follow. Intake and output are measured. IV fluids and electrolytes are administered as prescribed, and oral fluid intake is encouraged when it is permitted. Vital signs are monitored hourly for signs of dehydration (tachycardia, orthostatic hypotension) along with assessment of breath sounds, level of consciousness, presence of oedema, and cardiac status. If the patient agrees with the diet plan and increases his fruit and vegetable intake this can highly optimise nutritional health, promote a healthy image and reduce the chances of obesity (Lock et al., 2005). In Diabetes, diet is a chief obstacle in the control of the condition (Watson et. al 1997). The patient’s goals in agreeing with a healthy diet for their Diabetes are as follows: 1) To regulate and sustain lipid levels and blood glucose back to their normal state. 2) To avoid fluctuations in their blood glucose levels during the day. 3)
To manage and control a desirable body weight. 4) To prevent or hinder the growth or advancement of renal, neurological or cardiovascular difficulties (Watson et. al 1997). The nurse should introduce a dietary plan for the patient with the Diabetes. This controls the amount of calories that are needed for each day and the magnitude of these calories to be assigned to carbohydrate, protein and lipids. This is determined by a person’s age, weight, gender, activity and their dietary intake before they discovered the disease. In general, the amount of targeted calories allocated to each food type is in the region of 50-60% carbohydrate, 10-15% protein and under 30% of fat (Rees and Williams,1995). In the diet, the concentrated sugars should be strictly limited e.g. sweets, jam, cake, and should only represent a minute part of a meal to prevent rapid increase in the blood sugar levels. The unrefined carbohydrates such as whole-meal bread, fruit and vegetables, and also fibre-rich foods, should be consumed as an alternative to the refined carbohydrates as mentioned before.
Meal planning is put into practice, with the control of glucose as the primary goal. The nurse must consider factors before beginning to intervene such as the patient’s lifestyle, cultural background, activity level, and their food preferences. A suitable caloric intake allows the patient to achieve and maintain the desired body weight. The nurse would encourage the patient to eat complete and wholesome meals including snacks that have been prescribed in the diet that the team has devised for Kevin. The nurse needs to take into consideration of the fluid intake and keeps records of IV and other fluid intake, also record urine output measurements. Hypoglycaemia is the most dreaded acute difficulty in the disease of Diabetes, and can be a major factor in the hindering of the metabolic control in the body. Night-time hypoglycaemia states, more common in the paediatric side of Diabetes, places an immense worry for the child themselves but also the parents, as it more likely to go unnoticed and care for (Nordfeldt S, Ludvigsson J 2005). Hypoglycaemia may occur if the patient skips or delays meals, does not follow the prescribed meal plan, or greatly increases the amount of exercise without modifying food intake and insulin. In addition, hospitalized patients or outpatients who fast in preparation for diagnostic testing are at risk for hypoglycaemia. Juice, milk, or glucose tablets are used for treatment of hypoglycaemia. The patient is encouraged to eat full meals and snacks as prescribed in the meal plan. If hypoglycaemia is a recurring problem, the whole dietary plan must be looked over and improved if needed. The risk of hypoglycaemia with rigorous insulin routines, it is of the utmost importance for the nurse to review with the patient the signs and symptoms, possible causes, and measures for prevention and treatment of hypoglycaemia. The nurse should emphasise to the patient and family the importance of having information on diabetes at home for reference.
After putting this plan into practice, the nurse found that it helped in the treatment and care of Kevin Brophy in managing and controlling his Diabetes. After following the Roper Logan and Tierney model of Nursing it helped understand his Activities of Daily Living and how the patient could work his new dietary plan into these ADL’s and control his blood glucose to prevent hypoglycaemia. Kevin will also be able to be knowledgeable of and carry out duties in a way to control his diabetes mellitus and also maintain adequate fluid volume in the body. He will be able to monitor his blood glucose periodically throughout the day, administer his own insulin, increase his own fluid balance and monitor his urine output. He should demonstrate a participation in activities that include having a proper diet, exercise and lifestyle (Palandri, M.K. 1993). He also should be wary of and identify community, outpatient resources for obtaining further diabetes education.
To conclude, Kevin will need continuous assessment and advice on managing and controlling his Diabetes diagnosis. He will need support from his mother and also help from the multidisciplinary team that works with him and his mother in the hospital. In following the Roper Logan and Tierney model he will then be able to manage his ADL’s better and be more understanding with the condition of Diabetes. He will be able to control his dietary intake and follow a routine throughout life to deal with his diagnosis.
Aggleton, P., Chalmers, H. (2000)Nursing Models and Nursing Practice. (2nd edn). London: Macmillan.
Lock, K., Pomerleau, J., Causer, L., Altmann, D.R. & McKee, M. (2005) The global burden of disease attributable to low consumption of fruit and vegetables. Bull. World. Health. Organ. 83, 100–8.
Nordfeldt S, Ludvigsson J. Fear and other disturbances of severe Hypoglycaemia in Children and Adolescents with Type 1 Diabetes. J. Pediatr. Endocrinol. Metab. 2005; 18: 83–91.
Palandri, M.K. and Sorrentino, C.R. (1993). Black and Matassarin – Jacobs, Pocket Companion for Luckmann and Sorensen’s Medical – Surgical Nursing: A Psychophysiologic Approach. 4th Edition. W.B. Saunders. The Diabetes Control and complications Study Group (1994) Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial Research Group. J. Pediatr. 125, 177–188.
Waterford Regional Hospital (2006) Department of Nutrition and Dietetics
Watson et. al (1997) Clinical Nursing and Related Sciences 5th edn. Bailliere Tindall, 24-28 Oval Road, London NW1 7DX.
Patricia Power Sorcha Dineen Miriam Cass 20053881 Patricia Chesser Smyth Nursing in the Community Module Leaders