Professional Practice Case Study of PP treating Diabetes

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Permission to put the resident as the subject of my case study was affirmed verbally after thorough explanation that every data collected would be kept confidential and be used only as an academic requirement to gain nursing registration in Queensland and that her name would be initialed only as, PP, as to protect her privacy.

II. Introduction

The first time I was able to interact with PP gave me an opportunity to put into test my communication and assessment skills as well as put into practice what I have learned in nursing. PP was very polite and slightly apprehensive as I first interacted with her, and even though there was slight communication difficulty because of a certain degree of hearing and visual impairment, the interest of which I wanted to determine what brought her to the facility struck me to choose her to be my case study.

PP has multiple medical conditions of which wound management in diabetics and diabetes per se would be the main focus of my case study. Diabetes is a chronic disease that affects 7.5% of Australian over 25 and 16.8% over 65 years (Dunstan et al 2000). In the 2004-05 National Health Survey, 699,600 Australians (3.5% of the population) reported having diabetes. Based on the 1999-2000 Australian Diabetes, Obesity and Lifestyle study, around one million Australians are estimated to have diabetes with the number expecting to increase over the coming decade. Rates of Type 2 diabetes in some Aboriginal and Torres Strait Islander communities are among the highest in the world. In some Indigenous communities as many as one third of the population may have diabetes (AIHW 2008).

The risk of developing Type 2 diabetes increases with age. Nearly 1 in 4 people aged 75 and over have Type 2 diabetes compared to less than 1 in 1,000 people in their 20s. However, rates of diabetes are increasing in all age groups currently affecting an estimated 1.5 million Australians (Diabetes Australia 2008).

PP who has an acute traumatic wound on her right anterior leg and long standing diabetes would be the main focus of my discussion. The natural wound healing process would be discussed and related to PP's diabetic condition. A nursing care plan would be presented which would include an overall assessment of PP status from which I would derive my nursing diagnosis, plan of care and nursing intervention and later on, evaluation of the care given. Ethical principles utilized in the care of PP as well as the multidisciplinary team approach will also be discussed in the study.

III. Brief client profile

PP is a lovely lady who spent most of her years in North Rockhampton and she really enjoys reminiscing about what she had been through all her life. She told me that she used to work as a domestic in private homes while studying at park avenue state school. PP narrated that she was a war bride in the 1940's, with husband serving the PNG, and described her wedding as simple yet memorable because most of her relatives were present. She stated that one of the most precious achievements that she had was having 4 lovely children. PP likes to listen to music but she actually does not know how to play any instrument. She also stated that because of her cataracts, she does not usually read a lot of books and poetry but like listening to it.

IV. Summary health history - medical, surgical, mental

PP was diagnosed to have type 2 diabetes mellitus in 1980 and was initially managed with anti-diabetic medicines under the sulfunyl urea class, gliclazide 80mg 3x/day and biguanide class, metformin 500mg 3x/day. She was shifted to insulin therapy by her doctor due to inadequate acceptable response in decreasing her blood sugar levels after maximizing the dose of her tablets to an accepted therapeutic level. Presently, PP is on insulin (Protaphane Innolet) 100u/ml, 12 units given subcutaneously mane before breakfast.

V. Outline of reason/s for current assessment / episode of care

PP has been diabetic for 30 years and strict blood glucose control should always be mandated to prevent further insult resulting from the chronic complications of this condition.

PP had a right anterior leg wound after accidentally hitting the side of her bed while ambulating. Initial assessment of the wound is that it is associated with swelling, redness, warmth, and pain hindering PP's mobility which could result in health risk if not attended to appropriately.

The impaired natural healing process in diabetics with erratic blood sugar control would present as a challenge to ensure that healing would take place and that initial signs of would infection be managed collaboratively with the interdisciplinary health care team.

VI. Brief overview of the related anatomy and physiology

The human body needs energy in order to function properly. Glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches) is the body's primary source of energy. This monosaccharide from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone produced by the beta cells in the pancreas, an organ located behind the stomach which aside from its hormonal function also performs enzymatic digestive function. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Excess glucose can be converted to concentrated energy sources like glycogen in the liver or fatty acids and saved for later use. When there is not enough insulin produced by the pancreas for some reasons or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells. (Guyton and Hall 2006)

In dealing with wound care and management, it is important to know that there are 2 main types of wounds: Acute wounds wherein normal healing process follows the normal phases of wound healing at an expected time frame and Chronic wounds defined as one in which the normal process of healing is disrupted at one or more points of the phases of wound healing. Listed below are the phases of wound healing (NSW Health 2008).

Phases of Wound Healing (Crisp and Taylor 2005)

Phase 1 - INFLAMMATORY PHASE (0-3 Days) This is your body's

normal response to injury. This phase activates protective measures

through chemical activity causing HEAT, REDNESS, PAIN, SWELLING,

LOSS OF FUNCTION (e.g. arm swells and cannot bend). Wound ooze

may be present and this is also a normal body response.

Phase 2 - PROLIFERATIVE PHASE (3-24 Days) This is the time

when your wound is healing. Your body makes new blood vessels,

which cover the surface of the wound. The result is that your wound

will become smaller as it heals.

Phase 3 - MATURATION PHASE (24-365 Days) This is the final

phase of healing, when scar tissue is formed.

The patient's general health has important implications for wound healing. Many medical conditions adversely affect wound healing rates and some cause specific wound healing problems. For example, wounds in patients with diabetes have a poor inflammatory response and a higher rate of infection (MacLellan 2000)

There are studies that relate impaired wound healing in people with diabetes because hyperglycemia affects collagen synthesis and the capacity of phagocytes to travel to the wound site and engulf bacteria. Very poor blood sugar control results in tissue dehydration which in turn affects the transport of healing mediators and waste products to and from the wound with associate increase in fibrinogen levels in the blood which slows down inflammatory cell transport resulting to poor wound healing. Persistent elevation of blood sugar also results to macrocytic red blood cells because of excessive glycosylation with difficulty moving into the microcirculation thereby limiting transport of oxygen into the wound. People with diabetes were also found out to have increase levels of free radicals which allows the macrophage to destroy a larger area of the wound during reconstructive phase further delaying wound healing (Dunning 2008)











ï‚· PP says " I think my sugar level is not controlled very well that's why my leg hurts and my wound is not improving"


ï‚· ambulates slowly using wheelie walker as walking aide

10 point pain rating scale:


ï‚· Anterior right leg wound with swelling, redness, serous drainage, warmth, and tenderness

ï‚· Right leg circumference: 40cm

ï‚· (-) Homan's sign, Right leg

ï‚· Wears protection stockings on both legs

ï‚· OBS taken as follows:

BP: 130/80 mmHg

PR: 92 beats/min

RR: 19 cycles/min

Temp: 37.2 C

Weight: 66.7 kg


ï‚· Pain, Acute related to tissue injury as evidenced by actual tissue trauma

ï‚· Pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli

ï‚· PP will verbalize an acceptable reduction in pain and improvement in comfort

ï‚· Reduction of 10 point pain rating scale to 1/10


ï‚· Employ non-pharmacologic methods of decreasing pain like breathing exercises, watching television, knitting trauma bears, playing cards

ï‚· Assess PP's pain using the 10 point pain rating scale as needed

ï‚· Allow PP to verbalize expressions about pain

ï‚· Daily wound check with review of wound care plan plus appropriate dressing change to promote healing


ï‚· Ensure that PP continue receiving attentive analgesic care as per doctor's order

ï‚· To help client focus on non-pain-related matters

ï‚· The resident's report of pain is the single most reliable indicator of pain

ï‚· Verbalization allows outlet for emotions and may enhance coping mechanism

ï‚· Maintaining a clean and moist environment would facilitate non-disruption of our body's natural healing process

ï‚· To alleviate and ensure adequate pain relief

ï‚· PP verbalizes reduction in pain to a much comfortable level; 10 point pain rating scale: 1/10







ï‚· Alteration in peripheral tissue perfusion as evidenced by poor wound healing and edema

ï‚· Chronic condition like diabetes damages the endothelial lining of the vascular wall which impairs blood circulation resulting to poor tissue perfusion and decrease cellular function affecting the natural healing process

ï‚· To increase PP's awareness regarding ways to improve circulation to lower extremities to facilitate healing

ï‚· PP reports noticeable decrease in peripheral edema as evidenced by decrease in leg circumference

ï‚· Suggest frequent position changes and leg exercises when lying down to facilitate venous blood flow and encourage ambulation as possible

ï‚· Elevate edematous legs as ordered and ensure that there is no pressure under the knee

ï‚· Decreases peripheral venous pooling that may be potentiated by prolonged sitting or standing position.

ï‚· Elevation increases venous return and decreases edema

ï‚· PP's aware to regularly do leg exercises when sitting for prolonged periods

ï‚· PP was observed to regularly elevate legs with 1 pillow underneath when sleeping; Right leg circumference decreased to 37.5cm







ï‚· Mobility, Impaired Physical related to musculoskeletal impairment and limited strength as evidenced by use of walking aide

ï‚· Alteration in mobility may be a temporary or permanent problem. It is also related to body changes as a result of ageing like loss of muscle mass, decrease in muscle strength, stiffer and less mobile joints as seen in medical conditions like osteoarthritis

ï‚· PP would understand the importance of regularly using her walking aide for mobilization

ï‚·Ensure environment always remain safe for PP

ï‚· Encourage PP to begin early ambulation and other ADL's

ï‚· Encourage PP to always use her wheelie walker when ambulating

ï‚· Regularly checks PP's room and bathroom for clutters, rugs and things that could be hazardous when PP is ambulating

ï‚· The longer the resident becomes immobile the greater the level of debilitation that will occur

ï‚· Mobility aides can increase level of activity

ï‚· Reducing hazards in the environment decreases incidence of injuries from falls

ï‚· PP now uses her wheelie walker even for short distances verbalizing its importance in reducing her risk of falls

ï‚· PP's room and bathroom is well-organized, clutter free during my 3 days of nursing care







ï‚· Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care

ï‚· Inadequate information and misinterpretation of facts could result to false assumptions which could lead unnecessary anxiety and psychological effects

ï‚· After 3 days of nursing intervention, PP would verbalize decrease anxiety thru understanding of the disease process, complications, and treatment regimen and the importance of having a well-balanced diet

ï‚· Explain to PP what the acceptable blood sugar level and its detrimental effects in the body it could cause if left uncontrolled.

ï‚· Assist PP identify modifiable risk factor like avoiding foods with high glycemic index like carbohydrate rich foods and saturated fats


ï‚· Administer prescribed insulin medication as per doctor's order

ï‚· Provides basis for understanding elevations in blood sugar and misconception about the disease process

ï‚· These risk factors have been shown to contribute to difficult to control diabetes

ï‚· Insulin promotes glucose clearance from the blood by facilitating entry of glucose into muscle, adipose and several other tissues and stimulating the liver to store excess blood glucose in the form of glycogen

ï‚· PP verbalizes understanding of diabetes and the need for maintaining optimum blood sugar levels by having a well balanced diet and adequate insulin coverage








ï‚· Risk for infection related to inadequate primary defenses: injured tissue, broken skin, high glucose levels, decrease leukocyte function

ï‚· Alteration in skin integrity bypasses the body's most important defense barrier which is the skin increasing risk for contamination and microbial growth

ï‚· After 3 days of nursing interventions, PP will identify interventions to prevent or reduce risk for infection

ï‚· Wound to remain uninfected during course of intervention

ï‚· Teach PP and caregiver the signs and symptoms of infection like redness, swelling, increased pain and purulent drainage and when to report these to the physician or nurse

ï‚· Keep wound clean and free from contaminants

ï‚· Early detection of infection could lead to early management decreasing risk for further complications

ï‚· PP verbalizes potential signs and symptoms of infection like increase in pain, purulent drainage, foul smelling discharge and redness

ï‚· Wound remained uninfected during 3 days of nursing intervention

ï‚· Risk for falls/injury related to impaired physical mobility and visual impairment

ï‚· Falls in the elderly population could result in fractures increasing morbidity and mortality in these population

ï‚· To ensure that PP has no episodes of fall and remain free from injury and that she always use her wheelie walker during my 3 days of nursing care

ï‚· Remind PP to always keep room and toilet dry and free from hazard like wet rugs lying on the floor and to always wear flat shoes with good traction to prevent from slips

ï‚· Always remind PP to use her wheelie walker when mobilizing from one place to another

ï‚· Evaluate PP's medication prior to administration to determine whether it would increase risk of her falling

ï‚· Supportive shoes provide better balance and protect the client from instability

ï‚· Assistive devices helps maintain balance during transfer and during mobilization

ï‚· Cocktail of medications increase risks of elderly from having adverse reaction like dizziness and balance disturbance

ï‚· PP did not have any episodes of fall and was consistent in using her wheelie walker when mobilizing from one place to another

VIII. Identify patient education opportunities and the strategies used to address these with the client and significant others

Every time I went to PP's room and assist with her ADL, I see to it that I educate her on ways to go about her daily routines properly. I asked PP to always use her wheelie walker when moving from the bed to the bathroom to do her toileting and showering explaining that it would help her with her balance and would decrease risk of injury from fall. It is also of utmost importance that I remind and tell her not to immediately stand up after lying from bed but instead to sit for a few minutes before actually standing preventing her from becoming dizzy and losing her balance. I also told PP the importance of keeping her environment clean and hazard free further reducing her risk of fall and trauma related injuries. As I do her BGL's, I explain to her its importance because this simple test determines if her diabetes is being adequately controlled by her current dietary and drug regime thus reducing the likelihood of micro- and macro-vascular complications that may arise from uncontrolled blood sugar levels. I reiterate that the insulin given to her everyday acts to replace the insulin that her pancreas wasn't able to produce naturally so that her blood sugar could be absorbed by the body to be used as energy. I pointed out that keeping a well-balanced diet is also important in keeping her blood sugar in check. I then explained the importance of keeping her right leg wound as clean as possible to prevent contamination and educated her on things to watch out for like increasing pain, greenish purulent discharge, redness and warmth around the area which indicates the possibility of an infection and that she must report it immediately to the health care staff if she thinks something is not right (NSW Health 2008).

IX. Write a narrative report on the client's progressive response to care (over a period of 3 days)

PP was initially apprehensive as I told her of the care I would be providing and she was asking a lot of questions. I've used effective communication techniques like talking slowly and in short sentences for her to understand clearly what my goals were so that her apprehension and anxiety would lessen. I've explained to PP in simple ways that her body was not producing enough insulin and as a result, her body cannot utilise the sugar as a source of energy and so I told PP why it was important for her to have regular insulin injections. The pain that PP was experiencing as a result of a trauma on her right leg decreased to a comfortable level as I have ensured that she gets round the clock analgesics as per doctor's order. I also did regular checks daily of her right leg wound ensuring that healing was taking effect and that there was no sign of infection that may result in wound deterioration. I did the care plan in collaboration with the staff to ensure that all are well aware of my interventions. PP was very appreciative that I took the time to look after her at the end of my 3 day nursing care as I conclude the nurse-resident therapeutic relationship.

X. Discuss and give an example of the multi-disciplinary team approach in relation to the care of this client

PP's care plan was thoroughly discussed with other health care staff especially on how to go about her wound care pathway because of the vast amount of available dressing it comes to a consensus that we follow the Australian standard guideline in wound management. Assistant in Nursing has a definite role of assisting with PP's ADL and the Endorsed Enrolled Nurse assists with medication management while the RN makes all the daily assessment of PP's condition, also doing the medication round and ensures that all documentation in relation to the care provided is written accordingly. The dietician ensures that PP has a well-balanced diet rich in fibre and fruits and only low glycaemic index foods be given to her to prevent rapid rise in her blood sugar. The clinical pharmacist does a regular drug review every 3 months making recommendations to the medical officer and RN's for any changes that she deemed necessary to further benefit PP. The RN also regularly updates PP's GP regarding assessments that needs to be reported and acted upon as per doctor's order.

XI. Describe the category of infection control practices implemented in the care of the client and justify why this was necessary.

Skin is one of our bodies natural defences against infection and anything that would bypass the skin would result in risks of infection. I have used standard precaution when handling body and bodily fluids ensuring that I wear proper protective personal equipment (PPE) like gloves and disposable aprons after thorough hand washing using sterile aseptic technique in managing and attending to PP's wound dressing ensuring that the risk of the wound getting infected because of improper procedure is reduced (Tollefson 2005). PP has diabetes which makes it more important to maintain asepsis because of the multi-factorial risks that may result from inadequate care and the alteration in wound healing process that comes with diabetes. According to Crisp and Taylor (2005, p.771), the skin of a person cannot be made sterile by using plain soap and water but washing of the skin can reduce the number of resident microbes and that use of sterile gloves can further prevent microbial transfer. Irrigation with normal saline would remove the wound of any debris that may impair healing and manual removal of slough and necrotic tissue starting from the inside of the wound going out in one motion reduces contaminating the clean wound with the normal skin flora.

XII. Identify and discuss at least one ethical principle that was considered in relation to care of the client. Show evidence of how you involved the client in the planning and implementation of care in relation to this principle.

The ethical principle of beneficence and non-maleficence was considered in relation to the care of PP. By definition, beneficence entails to act for the benefit of others while non-maleficence means to avoid harm or hurt (Crisp and Taylor 2005). As I attended to PP, I have ensured to only provide evidence-based nursing care under the scope of nursing practice like the way I administer her insulin injections subcutaneously, making sure to rotate the site so that the likelihood of developing lipodystrophy would be reduced. I also strictly implemented aseptic technique in caring for her leg wound to prevent contamination that may delay healing. I see to it that all my implemented plan of care would benefit PP and not to worsen her condition like telling her how she could help in controlling her blood sugar by making sure that she eats a well-balanced diet, meaning high in fibre and fruits and eating only low glycaemic index foods.

XIII. Evaluate the outcome of the care delivered to the client

The outcome of my 3 day course of nursing care, PP verbalised increased in comfort as a result of reduction of pain on her right leg and was well aware of the importance of keeping the wound clean to reduce the risk of infection. The swelling of PP's right leg decreased from 40cm to 37cm as I taught PP the importance of elevating the leg to reduce swelling and to regularly do range of motion exercises to improve circulation. PP also had a better understanding of what diabetes is and the importance of keeping a well-balanced diet and strictly adhering to her medication regime for adequate control of her blood sugar. PP knows that a controlled blood sugar is an important factor which would enable the natural healing process for her wound to take place. PP now uses her walking aide (wheelie walker) every time she transfers and mobilises from one place to another as she was well aware of the consequences that may happen if she suffers a fall or injury.

XIV. Conclusion

PP's diabetes should be adequately controlled by ensuring that her insulin requirement be met constantly through collaboration with the interdisciplinary health care team implementing proper techniques in BGL measurement and insulin administration and to ensure that a well-balanced diet for PP should be strictly adhered to. PP's right anterior leg wound should remain free from infection and this would be achieved by daily wound check and thru proper application of wound dressing using aseptic technique. PP was also told to report any signs of possible infection as per care plan so that adequate treatment measures could be implemented. PP's nursing care plan achieved the expected outcome and may be used as needed for future references so that there would be continuity of care.

Appendix A: Laboratory Results and Diagnostic Tests (if relevant)

HbA1C: 6.5 (Normal Range: 4-6) Date: 24 Feb 2010

Fasting Blood Sugar: 8.4 mmol/l Date: 24 Feb 2010

Capillary Blood Glucose: 7.6 mmol/l Date: 16 May 2010; 7.2 mmol/l Date: 17 May 2010;

7.0 mmol/l Date: 18 May 2010

Appendix B: Information on Prescribed Medication (eMIMS Australia 2010)

Human Insulin (Protaphane Innolet) 100u/ml x 3ml

- An intermediate acting human insulin preparation. Its hypoglycaemic effect after subcutaneous administration begins after approximately 1.5hrs, is maximal between 4 and 12hrs and lasts up to approximately 24 hrs.

- used in insulin dependent type 2 DM; type 1 DM

Pantoprazole (Somac EC) 40mg tablets

- Proton Pump Inhibitor; inhibits specifically an dose proportionately H/K-ATPase, the enzyme which is responsible fro gastric acid secretion in the parietal cells of the stomach.

- used in gastroduodenal lesion, dyspeptic symptom prevention associated with non selective Non-Steroidal Anti-Inflammatory Drugs (NSAIDS).

Temazepam (Temaze) 10mg tablets

- benzodiazepine derivative which hastens the onset of sleep and increases the total sleeping time in short-term use.

- adjunct therapy for the short-term management of insomnia in adults.

Frusemide (Uremide) 40mg tablets

- loop diuretic; it acts by inhibiting sodium and chloride reabsorption, primarily in the ascending loop of Henle and in both the proximal and distal tubules.

- used in edema associated with CHF, hepatic cirrhosis, renal disease, hypertension, alone or in combination with other hypertensives.

Betaxolol 2.5mg/ml (Betoptic S Eye Drops 0.25%)

- have the action of reducing elevated as well as normal intraocular pressure, whether or not accompanied by glaucoma.

- mediated by reduction of aqueous production as demonstrated by tonography and has minimal effect on pulmonary and cardiovascular parameters.

Hydroxocobalamin Chloride (Neo-B12 Injection) 1000mcg/ml x 1ml

- prophylaxis, treatment of pernicious anemia; optic neuropathies.

- administer IMI only; prophylaxis of macrocytic anemia 1000mcg every 2-3 months.

Cholestyramine (Questran Lite) 4.7g sachet

- reduction of serum cholesterol levels and prevention of coronary heart disease.

- usual maintenance therapy is 12-16g daily.