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Case Studies: Ms. Connie Chen, Mrs. Amy Adams, Robert and Julie, Mr. David Dixon

Discuss about the Perform a Random Blood Glucose Measurement.

Ms Connie Chen is 52 years old. She is currently single and has two adult children. Ms Chen reports that she has been feeling rather fidgety lately, as if she can’t sit still. She has also been feeling unusually hot. Her sleep is interrupted at night by the urgent need to pass urine and have a drink. She is always thirsty and is wondering if it is due to feeling so warm. Recently, she noticed that there is a large lump in her neck, just below her ‘voice box’ and her eyes seem to be ‘popping out’ more than normal.
She has come to the clinic in which you work because she is concerned about her symptoms.

As part of Mrs Chen’s assessment, you perform a random blood glucose measurement, which provides a reading of 13.8 mmol/L.

  1. Make a list of the cues from Connie’s case study and provide an interpretation of, or explanation for, each of these.The cues from Connie’s case study include, feeling hot, frequent urination, thirst, large lump in the neck, blood glucose level of 13.8 mmol/L.The first cue is a blood glucose of 13.8 mmol/L.A normal blood glucose level should be between 3.9 mmol/L and 5.5 mmol/L.A blood glucose of 13.8 mmol/L is by far the maximum threshold and this therefore indicates that Connie is diabetic. A large lump on the neck is the thyroid which has become inflamed due to its overstimulation to produce insulin by the beta cells of the pancreas. Unusual hot feeling is as a result of the breakdown of excess glucose in the body to release energy. Frequent urination on the other hand is as a result of the kidney striving to release excess sugar in the body. Finally, the thirst is as a result of the body striving to maintain a homeostatic state in the body since excess glucose leads to a hypertonic state of the cells. There should be intake of more water to correct the hypertonic state.
  2. Explain the difference between Diabetes Mellitus types 1 and 2. Describe the treatment options for each condition. Diabetes Mellitus are both conditions in which there is excess glucose or sugar levels in the body. However, the difference between the two conditions is that in Diabetes Mellitus type 1, the immune system attacks beta cells of the pancreases therefore rendering or impairing its ability to produce a hormone called insulin that breaks down excess sugar in the body. Diabetes Mellitus type on the other hand is a condition in which the insulin hormone is produced either in very small quantities that are not significant in the breakdown of excess sugar in the body or but the body does not respond to it. The treatment option of Diabetes Mellitus type 1 is through injection of the insulin under the fatty tissue while the Diabetes Mellitus type 2 is not treatable but only manageable through actions like weight management, dietary practices as well as exercise.
  3. State the hormones that can affect blood glucose levels. Describe where each is produced, what its target is, and how it alters blood glucose. Basically, there are two major hormones in the human body that alter the level of glucose in the body. They include insulin and glucagon hormones. Insulin is produced by the beta cells of the pancreas while glucagon hormone is produced by the alpha cells of the pancreas. Insulin is produced when the level of glucose is high and its target is blood where it breaks it down into less harmful substance like glycogen. Glucagon on the other hand is produced when the level of glucose is low. The target organ of the glucagon on the other hand is the liver where it stimulates it to release the stored glucose so that the body has enough glucose.

Mrs Amy Adams is 74 and has been brought to the hospital for a suspected broken Neck of Femur (NoF). According to her daughter, who arrived with her in the ambulance, Mrs Adams has a five-day history of vomiting due to a ‘stomach bug’. This morning her mother rose from her bed to let her cat out, experienced about of dizziness and lost her balance. She fell over and now has severe pain in her right hip and leg. You notice that she looks pale and her lips are dry. Her daughter reported that her mother had told her that she has hardly urinated in over 24 hours.

  1. Make a list of the cues from Amy’s case study and provide an interpretation of, or explanation for, each of these. No urination in over 24 hours might indicate impairment of the kidneys or fluid imbalance in the body. Pale and dry lips indicate dehydration in the body. Dizziness is as a result of ear disorders that arise due to impaired fluid balance regulating systems in the ear.
  2. What changes are happening in Amy’s kidneys as a result of her current fluid balance status? Explain what you would expect in terms of her eGFR, blood results, urinalysis and hormonal responses. Since Amy is dehydrated, the kidney will retain a lot of water and there will be very little urination. The rate of glomerular infiltration will increase and the ADH will increase permeability of the renal tubules to absorb more water.
  3. For Amy’s IV therapy, state the equipment required, the procedure for establishing her IV line, any precautions that you will take and suggest any indications for concern after the line has been established. There are different equipment but the basic equipment include gloves and protective equipment, IV bag that has solution set or the saline lock, non-sterile 2 by 2 gauze,6 by 7cm of Tegaderm Transparent dressing, alcohol swabs, non-latex tourniquet and appropriate size catheter 14-25G IV catheter. The procedure for establishing the IV line is as follows: The equipment are assembled and then donning of good size non-latex examination gloves. The tourniquet is then applied to the IV arm just above the site. The vein is then visualized and palpate. The site is then cleansed using the chlorhexidine swab in an expanding circular motion. The catheter is then inspected and the vein stabilized. Counter tension of the skin is then applied and then the stylet is inserted through the skin while reducing the angle as one advances to the vein. The flashback is observed as the blood slowly fills the flash back chamber. The needle is then advanced 1cm up the vein. The needle is then pulled back 1 cm with the middle finger while holding the end of the catheter with the thumb and the index finger. The catheter is then advanced into the vein slowly while keeping tension on the vein and the skin. The tourniquet is then removed. The catheter is then secured by placing the tegaderm on the lower half of the catheter hub while taking care not to cover the IV tubing connection. The distal end of the catheter is then occluded with the 3rd, 4th, and 5thfingers of the dominant hand. The catheter hub is then secured and the index finger and the needle is carefully removed. The needle is then placed in the sharps container. The cover from the end of the IV tubing is removed and inserted into the hub of the catheter. The tubing is then secured through screwing the Luer Lock tight and the IV roller clamp is opened up and the drips forming in the drip chamber are observed. The IV is checked if it is infusing into the vein through occluding the vein distal to the catheter and observed. The IV drop is then adjusted so as to keep the vein open rate of approximately 30-60 ml/hr. The piece of tape is then placed over the catheter hub. A small loop is then made in the IV tubing and place the second piece of tape over the first so as to secure the loop. The 3rd piece is then placed over the IV tubing above the site. The IV is then properly securely by infusion. All the sharps are then placed in the sharps container. The indications in this case is that IV access is crucial when it comes to managing problems in all patients with critical conditions.
  4. Amy is at risk of acute kidney injury (AKI). Explain why. Explain how AKI differs from chronic kidney disease (CKD). Amy is at risk of acute kidney injury due to the trauma after falling off. Acute kidney Injury is different from chronic kidney injury in the sense that acute kidney injury is sudden impairment in the glomerular filtration rate due to different reasons while chronic kidney injury is the loss of glomerular filtration due to underlying diseases like diabetes. Acute Kidney injury is also reversible while the chronic kidney injury is irreversible.
  5. Amy also has benign prostatic hyperplasia (BPH). Explain how BPH poses a risk to her kidneys. After problems with urethral obstruction, an indwelling catheter (IDC) is inserted. Explain the procedure, and your precautions and nursing considerations. Benign prostatic hyperplasia is an enlarged prostrate that pressurize the urethra. The pressure on the urethra in return cause obstruction to the outflow of urine. Since anything that obstructs urine from the kidney leads to acute renal failure, the pressure on the urethra by the enlarged prostrate due to BPH cause renal failure and subsequent kidney damage. The procedure for inserting an indwelling catheter is as follows, first the nurse has to gather the necessary equipment and explain to the patient in details how the procedure will be carried out. After that, the patients is assisted into a supine position with the legs spread apart while the feets are together. The catheterization kit is then opened and a sterile field is prepared. Gloves are the applied and the balloon is checked for patency. After that, the distal portion of the catheter is generously coated with a lubricant and a sterile drape is then applied. If the patient is female, the labia is separated using a non-dominant hand but if it is a male, the penis is held with the dominant hand and the hand position is maintained until when preparing to inflate the balloon. Using the gloved dominant hand, the catheter is then picked. The catheter is then held while it is loosely coiled in the palm of the dominant hand. If the patient is male, the penis is lifted higher in a perpendicular position relative to the patient’s body and light upward traction is then applied. The urinary meatus is identified and the catheter is inserted gently up to 1 to 2 inches beyond which urine can be posted. The balloon is then inflated using the right amount of the sterile liquid. The catheter is then pulled gently until the inflated balloon is snug against the bladder neck. The catheter is then connected to the drainage system and secured to either the abdomen or thigh with no tension on the tubing. The drainage bag is then placed below level of the bladder. After that, evaluation of the catheter function as well as amount color, odor and quality of urine is carried out. The nurse then removes the gloves and dispose the equipment correctly and washing hands. The size of the catheter is documented, the amount of water in the balloon as well as the patients response to procedure and assessment of the urine. The precautionary measures and nursing consideration include protecting potential contact with the blood as well as body fluids of the patients and therefore the nurse has to ensure that gloves are worn appropriately when starting the Foley.

Robert and Julie have been together for four years. They have been trying to conceive for the past two years. Robert is 52 and Julie has just turned 40. They attend your clinic to discuss their fertility issues.

You conduct sexual and reproductive health interviews with both Robert and Julie.

Robert informs you that he had a vasectomy at the age of 42, followed by reversal surgery at the age of 50 when he and Julie decided that they wanted a baby together.

During the sexual and reproductive health interview, Julie informs you that she had been taking the oral contraceptive pill for 20 years prior to their decision to conceive. Julie also reveals that she was diagnosed with Chlamydia in her early 20’s despite having no initial symptoms. It then developed into pelvic inflammatory disease (PID).

  1. Make a list of the cues from given case study and provide an interpretation of, or explanation for, each of these. History of vasectomy. This is a birth control mechanism that means Robert could not be able to fertilize the ovum from Julie. Chlamydia that developed into PID means that Julie has an STD in the name of chlamydia.
  2. Julie has two STIs. From the cues provided, what are they likely to be? What nursing considerations do you have for managing each condition? What is the likely long-term prognosis for each condition? From the cues, Julie is likely to be suffering from chlamydia and Lymphogranuloma venereum STIs. The long term prognosis include permanent damage to the reproductive system and lead to infertility as well as ectopic pregnancies in female. The considerations in this case include encouraging them to use male condoms as well being monogamous.
  3. Julie has acquired an STI due to infected semen from early age. Describe the pathway of sperm from its site of production to the site of deposition in the vagina. Name five circumstances under which successful transfer of sperm from the male into the female may be impaired/impeded. Production of the sperms occur in the testes. The epididymis receives the sperm from the testes and it stores it for quite some days. During ejaculation, it is released from the tail of the epididymis into the ductus deferens. It then moves through the ductus deferens up to the spermatic cord into the pelvic cavity that is situated over the ureter to the prostrate just behind the gall bladder. It is at this juncture that the vas deferens joins the seminal vesicle to result into what is called the ejaculatory duct. It is the ejaculatory duct through which the sperm move through the prostrate and finally empties into the urethra. It is the urethra that opens up in the vagina then the sperms are deposited.
  4. When taking a blood sample from Julie, what equipment will you use and what will the procedure be? If you accidentally stick yourself with the needle, what steps will you take? When taking blood from Julie, the equipment to be used is needle and syringes as well as alcohol swabs and the vacutainer and finally the tourniquet. The procedure is first tying the upper arm with the tourniquet so as to locate the vein. Once the vein is located, I will sterilize the point with the alcohol swabs and then puncture the vein using the needle. The blood is then drawn into the syringe and transferred to the vacutainer. If I accidentally stick myself with a needle when drawing blood from Julie, I will straight away subscribe to post exposure prophylaxis to protect myself against HIV/AIDS.

Mr David Dixon is 63 years of age and a retired bank manager. He is married and has 6 grandchildren. Mr Dixon’s father died of colorectal cancer and Mr Dixon has had several colonoscopies in the past to remove polyps from his colon, all of which have turned out to be benign. Unfortunately, his most recently removed polyps have come back as cancerous and he has been diagnosed with adenocarcinoma of the colon.

Mr Dixon has been recommended surgical resection followed by adjuvant therapy. He has also been told that the staging and grading of his cancer can only be performed post-operatively.

His blood tests demonstrate that he is severely anaemic as a result of blood loss caused by the cancer.

  1. Explain the meaning of Dixon’s blood test results. What are the risks to Dixon for each finding? From Dixons blood test results, it indicates that he is severely anemic. By this it means that he has low levels of red blood cells in his body. Due to anemia, Dixon has risks which include hypoxia. Hypoxia is a condition where tissues and organs in the body are devoid of oxygen. This is because hemoglobin is a pigment found in the red blood cells and it is responsible for transporting oxygen to various parts of the body. The fact that Dixon has few red blood cells means there will be limited transportation of oxygen to the tissues and that is why hypoxia is likely to occur. Suffocation therefore is the end result of anemia.
  2. Explain what chemotherapy is, how it works to treat cancer, and what precautions should be taken around administration. Chemotherapy has two words, chemo and therapy. Therapy generally refers to treatment of a condition while chemo is chemicals. Chemotherapy therefore means the treatment of cancer using medications. Chemotherapy treats cancer by the chemical composition of the medicines that interfere with process of cancerous cells division ultimately causing their death. The kind of medicines used during chemotherapy are very strong and therefore the need for safety during administration. Some of the precautions during administration include the use of protective clothing like gloves and glass as well as masks to prevent contact with the body. After, their use, they are disposed in special bags or tins that are labelled red for easy identification. Some medicine like the 5-fluorouracil can cause sensitivity to the sun or heat and therefore the patients should be warned to minimize exposure to the sun.
  3. Name 4 potential side effects of adjuvant therapies including chemo- and radio-therapy. Choose one side effect and discuss the goals of care and management options for that side effect. Just like all other therapies for neoplasms, adjuvant therapy is associated with different side effects like vomiting, nausea, alopecia and finally the myelosuppression especially neutropenia. One particular side effect is vomiting and it is due to a combination of different muscles within the body. The goals of care for this side effect is to prevent vomiting. There are several management options for vomiting and they include drinking a lot of fluids, avoiding unpleasant smells, use of relaxation techniques, eating what appeals to the patient, eating small meals and finally the use of complimentary therapies like acupuncture and aromatherapy are the best management options of vomiting as a side effect of adjuvant therapies.
  4. Dixon requires a blood transfusion. Explain the process and checks that need to occur for this type of therapy. If Dixon is of blood type B+, what blood types can she be transfused with? Blood transfusion therapy involves the introduction of blood through the intravenous lines. Conditions that need blood therapy include cancer and hemophilia .However, before the blood transfusion therapy, there should be different processes and checks that need to take place. The first process is laboratory tests to ensure that the blood from the donor is compatible with that of the recipient. There are different types of blood groups depending on the Antigen present. The blood groups are O, A, B and AB. Other people have Rhesus factor in their blood and are therefore referred to as rhesus positive. After compatibility tests have taken place. Screening of the blood is then done to ensure that it is free from different infections like viruses. After screening, there is transfusion through the intravenous route. Since Dixon has blood group B+,it means he has the rhesus factor and is only eligible to receive blood types O both positive and negative and blood type B+ as well.
  5. Name three nursing considerations for Mr. Dixon relating to her a) Anemic, b) blood transfusion.The three basic considerations for anemia and blood transfusion include managing fatigue through exercise as well as physical activities. Maintain adequate nutrition by prescribing a good diet and teach on how to avoid alcoholism. Finally, it is maintaining of adequate perfusion by monitoring the blood transfusion.
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