Example Nursing Essay
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 through the assessment process. Explore factors 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 since herhusband died. She has had Type II diabetes mellitus for the last 17 years, andcopes reasonably well considering her age and her comparative infirmity. Shehas been able to go out and get her shopping from the nearby shops and is otherwiseself-caring, clean and tidy.
According to the referral letterfrom her General Practitioner, who arranged this admission to hospital, anumber of people had recently commented that she looked ill and was not caringfor herself as well as she used to do. Her family live a considerable distanceaway from her and, although they see her about once or twice a month, they donot stay for long as they have a business to run.
When she was admitted she was foundto be lucid and coherent but her family told us that she had had a number ofepisodes of confusion recently. She was occasionally very sleepy and had leftthe gas burning on one occasion. She had a large infected ulcer on her leftshin, which had clearly been there for a matter of weeks, but because of herhabit of wearing long skirts, no one had noticed it. She had a degree of ankleoedema, but her physical examination was otherwise unremarkable, apart form thefact that she had a BMI in excess of 29. She is a moderate smoker.
Discussion
Mrs Singh as an individual isclearly unique, but sadly, she also represents a great many elderly diabeticpatients who live in similar conditions. The thrust of this particulardiscussion will be the aetiology and management of her condition with particularrelevance to her leg ulcer.
Diabetes Mellitus, an overview
Diabetes is a comparatively commondisease process in the UK. In children it is the commonest major illness(after childhood infections). There are approximately 1.5 million diabeticpatients in the UK at present and the number is relentlessly increasing.(Devendra et al 2004)
The 1.5 million are not equallyspread across all segments of the population. People from the Asian andAfro-Caribbean ethnic backgrounds have a markedly increased risk of developingDiabetes Mellitus (UKPDSG 1998) with one in four of all Afro-Caribbean womenover the age of 55 being diabetic. (Nathan 1998)
Increasing age and BMI also areboth independent risk factors for Diabetes Mellitus (James 1997)
Of this number, it is expected thatabout 10% will develop some form of lower limb ulceration while they arediabetic. (Amos et al 1997). To some extent, it is statistically more likelythat those patients who have poor control of their diabetic state will developulceration (and other complications) than those patients who have good control.
The other factor that is relevantin the aetiology of leg ulceration is the length of time a person is diabetic.Chronicity of the disease process is an independent variable for legulceration. (Simon P et al 2004)
A number of authorities haveestimated the burden of cost of Diabetes Mellitus to the NHS. A recent study byNewrick (et al 2000) considered 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 complications and the commonestclinically relevant complication is that of venous ulceration(Ellison et al2002)
We can start by considering thepathophysiology of Diabetes Mellitus
Pathophysiology
This is a huge subject in its ownright and we shall therefore present a brief overview as far as it is relevantto Mrs Singh.
In broad terms Diabetes Mellitus isa condition where the body looses the ability to metabolise carbohydrates ingeneral and glucose in particular.
Glucose is absorbed from the gut,transported to the liver where is can be stored as glycogen, and thentransported through the bloodstream to the cells in the periphery of the body,where it is one of the main metabolic substrates. It is absorbed from the bloodinto the cells by a specific molecular carrier system and this is totallyinsulin dependant.
If there is a failure of insulinproduction, then the circulating level of insulin falls and the glucose is nottransported into the cells. This leads, initially to hyperglycaemia and finallyto ketosis and metabolic failure. This is the situation of Type I diabetesmellitus.
The alternative is Type II diabetesmellitus where the cells loose the ability to respond to the circulatinginsulin levels. This also results in hyperglycaemia and eventual metabolicfailure but is characterised by high levels of circulating insulin. In generalterms, Type I diabetes mellitus is a comparatively acute illness whereas TypeII diabetes mellitus tends to be far more chronic, sometimes taking many monthsor even years to become 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 to the process of atherosclerosis and present with either degrees of myocardialischaemia or as peripheral impairment such as intermittent claudication orulceration. In general terms the incidence of this type of complication isdirectly associated with the average levels of HbA1 (which is a long termindicator of diabetic control) (HSG 1997)
Nursing interventions
The major nursing intervention todiscuss here is the management of the leg ulcer. In any medical intervention itis important to establish a sound evidence base (Sackett, 1996). We shalltherefore quote the literature relevant to each point.
The first, and arguably mostimportant consideration is whether the ulcer is primarily venous, arterial or(more rarely) neuropathic in origin. This is comparatively easily determined byan assessment of the ankle/brachial pressure ratio. This is measured by meansof a Doppler measure and the ratio is easily calculated. If it is less than thecritical level of 0.8 it is likely that an significant arterial element is present.(Partsch H. 2003)
Mrs Singh was treated with a 4layer bandage. He ratio was significantly above the 0.8 threshold and the mainaetiology of her ulcer was therefore judged to be venous.
The composition and construction ofa 4-layer bandage is very specific but it can be individually modified to suitthe demands of the individual patient. The first layer is a cotton wool basedbandage with the primary purpose of absorbing the copious amounts of exudatesthat are common with this type of ulcer. It also has the secondary purpose ofspreading the pressure evenly across the underlying tissues the second layer isa crepe bandage which has the prime function of holding the lower layer inplace. The third layer is a compressive layer, usually an elastic type ofbandage is then applied and this is covered by a final binding layer. (Nelsonet al. 2004).
The rationale behind the bandage isthat in the typical diabetic venous ulcer there is an increased pressure atthe venous end of the capillary bed which translates into stagnation in thecapillary blood flow which renders the tissues less viable because of pooroxygenation. By exerting physical pressure of about 40 mm Hg on the tissues,this increase of venous pressure is negated and the circulation improved.(Thomas S. 2003)
Clearly it follows that in anarterial ulcer, as there is a reduction in the arterial pressure at thearterial end of the capillary bed, any increase in physical pressure couldfurther reduce the blood flow across the capillary bed, which is why it isvital to differentiate between the two types before applying the bandage.(Marston W et al. 2003)
The second main nursingintervention, and possibly more beneficial in the longer term, would be theHealth Promotion aspects of the nursing relationship. Mrs Singh is overweight.Her BMI is about 29 which means that her weight is not only contributing to thereduction in venous return, and thereby contributing to both the aetiology andthe persistence of her ulcer, but the obesity is also a major factor in theaetiology of her Type II diabetes mellitus. If Mrs Singh can be persuaded toreduce her weight, her need for hypoglycaemic medication may well lessen. Itis possible that it may reduce to the point that she could manage her conditionon diet alone. (Terry T-K et al 2003)
Smoking is not only an independentrisk factor for Type II diabetes mellitus, but it is also a risk factor forcardiovascular disease. A major health promotion measure would therefore be tohelp Mrs Singh to give up smoking. This is not a short term 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 seen by, the smoking cessation nurse at the local primary healthcare team.
The whole concept of patientempowerment and education is most important in this field. If a patientunderstands why they are being asked to do something, they are much more likelyto comply with the request from the healthcare professional (Marinker M.1997).
The weight reduction needs to becarefully managed if it is to be successful. She was refered to the dieticianwho prescribed a low fat, carbohydrate regulated, 1,200 cal. per day diet.Because this is clearly going to be a long term intervention, arrangements weremade for Mrs Singh to be followed up in the community dietetic clinic.
Mrs Singh was in hospital for sevendays when the multidisciplinary discharge team were able to arrange herdischarge. This involved the assistance of an occupational therapist to assistwith minor home modifications and the community nurses who continued thetreatment with the 4 layer bandage.
(Harrison, I. D et al 2005) Thediabetic specialist nurse was also involved. As Mrs Singh's weight slowlyreduced she was able to reduce and finally come off her hypoglycaemicmedication
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