Case Study Nursing
Introduction
The case scenario selected for discussion is about Jeremy Kayton, 18 year old male student who moved to America when he was 17 year old. He was recently diagnosed with a case of type I diabetes mellitus, went through a break up and he had to work long hours to support himself. He was probably under a lot of psychological and emotional stress, suffering from 'tension headache' and took an over dose of Panadol or acetaminophen with alcohol. According to food and drug agency (2009), a combination of these can cause acute liver failure, something that needs to be worked on in this case.
Jeremy is taking insulin aspart (NovoRapid) which is rapidly acting insulin and insulin galargine (Lantus) which is long acting insulin. According …show more content…
to NHS (2014), both these types of insulin react with alcohol. Normal level of blood glucose is 4.4-6.6 mmol/L (Webmed 2012). Our patient has a value of 12mmol. Although clinical presentation is not given here but at a level above 11mmol of blood sugar level in a patient with type 1 diabetes, diabetic keto-acidosis should be ruled out (Savage 2011).
Therefore, we need to make a plan on medical grounds considering his type 1 diabetes mellitus and acetaminophen over dose. A psychiatric evaluation and plan of management will also be of prime importance for him. Social services or other volunteer organization working around can also be contacted to help him psychology or if possible, financially. Various aspects will be discussed below.
Critical Questions
Few clinical questions that we should look into from here onwards would be
" Is the interaction of acetaminophen and alcohol strong enough to cause acute liver failure?
" Does the high level of glucose show non compliance of therapy?
" Is the patient having any signs of diabetic ketoacidosis?
" What are various psychiatric evaluations and interventions that can be done for this patient?
Investigate
According to the clinical information we are given so far, there are certain investigations we need to do in diagnosis of this patient. First of all we need to look for acetaminophen toxicity because most patients are asymptomatic and end organ failure starts after 24-48 hours of taking high dose of medication (Farrell 2014). Such patients complain of malaise and fatigue in first 24 hours and hepatic phase or liver failure is seen after 72 hours. Our patient has been in emergency department for only four hours. Minimum dose for toxicity in adult patients is 7.5-10 g. According to family health guide of Harvard School (2006), it is still controversial if toxicity of acetaminophen is increased after a single episode of excessive alcohol consumption. However, we are still clear if he was a chronic alcoholic or had a single excessive alcohol intake. Therefore, immediate acetaminophen levels should be monitored to decide if we need to start therapy.
Suspicion of Diabetic ketoacidosis is the other issue at hand here. Clinical signs for it usually are dehydration, vomiting, deep breathing and loss of consciousness. It seems to be a little unlikely in our patient but since it is a life threatening condition, we need to rule it out as soon as possible. Ketones in blood and urine, arterial blood cases, serum electrolyte levels and blood glucose levels should be monitored for this (Craig 2009).
Our patient has a lot in his plate at this moment. He has moved to a new place last year and is working very hard to earn a decent living and to meet both ends. According to his friend, he also had a break up and is not doing so well in his university. Moreover, his diagnosis of type 1 diabetes adds to the list of stress factors he has. Such life events in young age are a major cause of depression and can cause drug and alcohol overdose (Smith 2004). The continuous 'headache that never goes away' also points towards that. Therefore, he should be immediately evaluated by psychiatrist for depression and for any possible suicide intentions.
Pathophysiology
The pathophysiology of acetaminophen causing liver toxicity is very complication. There are serious of events. Drug in excessive dose, is converted into a reactive metabolite which depletes glutathione and form a strong bond with several proteins. Decrease glutathione increase reactive oxygen and nitrogen products which are hepatotoxic. This starts a cycle of necrosis which also causes calcium haemostasis leading to mitochondrial injury. Mitochondrial injury will decrease level of ATP leading to necrosis. There are certain inflammatory mediators which further potentiate the whole process (Hinson 2010).
Erikson's Psychosocial Stage and its coorelation
Another important requirement of this discussion is to explain Erikson's psychosocial stages and see its correlation with our clinical scenario. He proposed 8 stages of lifespan developmental model from infancy to maturity. He called 5th stage in this model as, Identity vs. Confusion. (McLeod S 2008). During adolescence, a child is exploring his level of independence and a sense of self. Those children, who receive proper training and encouragement at this stage, come out as strong independent personalities and are able to move with their head held high. However, those who are not sure about their plans and future have a high risk of developing depression, get confused and also feel insecure (Cherry 2010).
Our patient is at the 5th stage of Erikson's Psychosocial Model. He is suffering from depression because he doesn't feel himself to be at a strong position in future and he is not sure who he can be. He also has problems with social relationships which is a very important aspect of this stage.
Negative health attributes
Patient has several negative attributes that have caused detrimental effects on his health. First is non compliance to medication and not taking his insulin properly. Second would be not taking medical or psychological helpful for the issues going on in his life. He should have taken medical help for his headache rather than taking an over dose of paracetamol. There is also no mention of his family and it seems that he is not attached to them either. All these modifiable factors have a negative influence on his disease.
After the discussion so far, a very important clinical question is about the various treatment dimensions that need to be considered for this patient keeping in view the holistic framework.
Construct
ANMAC's applicable Domains
National competency standards for registered nurses (2010) are set of rules that are devised by Australian Nursing and Midwifery Accreditation Council (ANMAC).
These rules ensure safe and appropriate nursing practice and registered nurses are directed to follow these guidelines in their practice. In the case scenario under discussion, four competency standards given by ANMAC are relevant i.e. Professional practice, Critical thinking and analysis, Provision and coordination of care and Collaborative and therapeutic practice. Professional practice would require nurses to consider their ethical and moral responsibilities, ensure high level of care and integrate nursing knowledge, skills to give safe nursing care for our patient. Critical thinking would require them to look for latest literature review and treat type I diabetes's mellitus and paracetamol over dose on the basis of 'evidence based practice' and latest guidelines. Provision and coordination of nursing care signifies working in a multidisciplinary team and coordinating with medical and psychiatric team about the treatment options and further management plan, doing proper documentation of intervention, collecting relevant data and monitoring patient's treatment outcome. Collaborative approach means they should communicate properly with our patient, inform him about his disease and how he can control it. It also means that a nurse should track Jeremy's family or friends. Nurse should also facilitate our patient by catering to his psychological, physical, cultural and social needs. Nurses can truly work effectively only when she keeps in consideration the various aspects of these
guidelines.
Person Centric Approach
There are three different management objectives for our patient, treatment of the primary cause which is acetaminophen overdose, depression and informational care for type I diabetes mellitus. Various nursing interventions can be done for these problems based on person centered and holistic approach. Person centre approach has four pillars i.e. prerequisites, care environment, person-centred processes, and expected outcomes (McCormack B 2006). Prerequisites and care environment have already been discussed above. Person-centred processes would require several interventions and some of them are
" Treatment should be started with in eight hours of over does. Treatment for our patient can be started even after four hours since the exact time of over dose in known (Ferner 2011).
" If the level of timed paracetamol level is above 100 mg/L at 4 hours, N-acetylcysteine should be started immediately (Willacy 2013).
" The initial dose of acetylcysteine should be given as an infusion over 60 minutes. It is given in 5% glucose or in 0.9% sodium chloride infusion. Three doses should be administered.
" For treatment of type I diabetes (after ruling out diabetic ketoacidosis for this patient), he should be given 2 or more injections per day with adjustment of dose depending on insulin level. Insulin is given by basal insulin and a preprandial/premeal insulin. Basal insulin is a long acting insulin like glargine or intermediate acting insulin. Preprandial should be insulin lispro, aspart or regular short acting
" Patient needs to be fully educated about the disease, management, monitoring of glucose level. This is very important in our patient since this could have been one of the primary causes for triggering all these problems.
Expected outcome would be significant improvement in pain and disease process.
Holistic Nursing Approach
Holistic approach would require nurse to act as a healer and consider patients emotional and psychological needs. It would also require nurse interaction with patient himself, involve psychiatric team and try to connect with his family. His depression should especially be considered during management of these interventions. Some of these holistic interventions would include
" For depression, psychotherapy and counselling, social support, proper sleep, company of his friends as short term intervention and proper healthy diet, physical exercise and regular restful sleep as long term intervention (Meyer B 2008).
" Spiritual intervention by asking patient about his religious, believe his perception of illness and if there is any religious intervention which keeps him strong during the difficult times.
" Involve social services and volunteer groups who can help our patient with the social problems or through financial support like paying his university fee etc.
After treatment patient should be discharged with proper advice of follow up, education about disease process and treatments done and how she can improve her quality of life by all the interventions discussed.
Conclusion
Our case discussion was about a patient who was diagnosed with type I diabetes and has now presented with paracetamol overdose. He is a young man who is under a lot of stress because of certain factors in his life. After detail discussion of important clinical issues and possible diagnosis, we mentioned several investigations that can be done at this stage. Treatment plan should be based upon the diagnosis. Pathophysiology of type I diabetes was discussed. Various treatment options were discussed in detail keeping in view the holistic and person centric approach. A multidisciplinary team needs to be formed for his medical as well as psychiatric evaluation.
The case scenario selected for discussion is about Jeremy Kayton, 18 year old male student who moved to America when he was 17 year old. He was recently diagnosed with a case of type I diabetes mellitus, went through a break up and he had to work long hours to support himself. He was probably under a lot of psychological and emotional stress, suffering from 'tension headache' and took an over dose of Panadol or acetaminophen with alcohol. According to food and drug agency (2009), a combination of these can cause acute liver failure, something that needs to be worked on in this case.
Jeremy is taking insulin aspart (NovoRapid) which is rapidly acting insulin and insulin galargine (Lantus) which is long acting insulin. According …show more content…
to NHS (2014), both these types of insulin react with alcohol. Normal level of blood glucose is 4.4-6.6 mmol/L (Webmed 2012). Our patient has a value of 12mmol. Although clinical presentation is not given here but at a level above 11mmol of blood sugar level in a patient with type 1 diabetes, diabetic keto-acidosis should be ruled out (Savage 2011).
Therefore, we need to make a plan on medical grounds considering his type 1 diabetes mellitus and acetaminophen over dose. A psychiatric evaluation and plan of management will also be of prime importance for him. Social services or other volunteer organization working around can also be contacted to help him psychology or if possible, financially. Various aspects will be discussed below.
Critical Questions
Few clinical questions that we should look into from here onwards would be
" Is the interaction of acetaminophen and alcohol strong enough to cause acute liver failure?
" Does the high level of glucose show non compliance of therapy?
" Is the patient having any signs of diabetic ketoacidosis?
" What are various psychiatric evaluations and interventions that can be done for this patient?
Investigate
According to the clinical information we are given so far, there are certain investigations we need to do in diagnosis of this patient. First of all we need to look for acetaminophen toxicity because most patients are asymptomatic and end organ failure starts after 24-48 hours of taking high dose of medication (Farrell 2014). Such patients complain of malaise and fatigue in first 24 hours and hepatic phase or liver failure is seen after 72 hours. Our patient has been in emergency department for only four hours. Minimum dose for toxicity in adult patients is 7.5-10 g. According to family health guide of Harvard School (2006), it is still controversial if toxicity of acetaminophen is increased after a single episode of excessive alcohol consumption. However, we are still clear if he was a chronic alcoholic or had a single excessive alcohol intake. Therefore, immediate acetaminophen levels should be monitored to decide if we need to start therapy.
Suspicion of Diabetic ketoacidosis is the other issue at hand here. Clinical signs for it usually are dehydration, vomiting, deep breathing and loss of consciousness. It seems to be a little unlikely in our patient but since it is a life threatening condition, we need to rule it out as soon as possible. Ketones in blood and urine, arterial blood cases, serum electrolyte levels and blood glucose levels should be monitored for this (Craig 2009).
Our patient has a lot in his plate at this moment. He has moved to a new place last year and is working very hard to earn a decent living and to meet both ends. According to his friend, he also had a break up and is not doing so well in his university. Moreover, his diagnosis of type 1 diabetes adds to the list of stress factors he has. Such life events in young age are a major cause of depression and can cause drug and alcohol overdose (Smith 2004). The continuous 'headache that never goes away' also points towards that. Therefore, he should be immediately evaluated by psychiatrist for depression and for any possible suicide intentions.
Pathophysiology
The pathophysiology of acetaminophen causing liver toxicity is very complication. There are serious of events. Drug in excessive dose, is converted into a reactive metabolite which depletes glutathione and form a strong bond with several proteins. Decrease glutathione increase reactive oxygen and nitrogen products which are hepatotoxic. This starts a cycle of necrosis which also causes calcium haemostasis leading to mitochondrial injury. Mitochondrial injury will decrease level of ATP leading to necrosis. There are certain inflammatory mediators which further potentiate the whole process (Hinson 2010).
Erikson's Psychosocial Stage and its coorelation
Another important requirement of this discussion is to explain Erikson's psychosocial stages and see its correlation with our clinical scenario. He proposed 8 stages of lifespan developmental model from infancy to maturity. He called 5th stage in this model as, Identity vs. Confusion. (McLeod S 2008). During adolescence, a child is exploring his level of independence and a sense of self. Those children, who receive proper training and encouragement at this stage, come out as strong independent personalities and are able to move with their head held high. However, those who are not sure about their plans and future have a high risk of developing depression, get confused and also feel insecure (Cherry 2010).
Our patient is at the 5th stage of Erikson's Psychosocial Model. He is suffering from depression because he doesn't feel himself to be at a strong position in future and he is not sure who he can be. He also has problems with social relationships which is a very important aspect of this stage.
Negative health attributes
Patient has several negative attributes that have caused detrimental effects on his health. First is non compliance to medication and not taking his insulin properly. Second would be not taking medical or psychological helpful for the issues going on in his life. He should have taken medical help for his headache rather than taking an over dose of paracetamol. There is also no mention of his family and it seems that he is not attached to them either. All these modifiable factors have a negative influence on his disease.
After the discussion so far, a very important clinical question is about the various treatment dimensions that need to be considered for this patient keeping in view the holistic framework.
Construct
ANMAC's applicable Domains
National competency standards for registered nurses (2010) are set of rules that are devised by Australian Nursing and Midwifery Accreditation Council (ANMAC).
These rules ensure safe and appropriate nursing practice and registered nurses are directed to follow these guidelines in their practice. In the case scenario under discussion, four competency standards given by ANMAC are relevant i.e. Professional practice, Critical thinking and analysis, Provision and coordination of care and Collaborative and therapeutic practice. Professional practice would require nurses to consider their ethical and moral responsibilities, ensure high level of care and integrate nursing knowledge, skills to give safe nursing care for our patient. Critical thinking would require them to look for latest literature review and treat type I diabetes's mellitus and paracetamol over dose on the basis of 'evidence based practice' and latest guidelines. Provision and coordination of nursing care signifies working in a multidisciplinary team and coordinating with medical and psychiatric team about the treatment options and further management plan, doing proper documentation of intervention, collecting relevant data and monitoring patient's treatment outcome. Collaborative approach means they should communicate properly with our patient, inform him about his disease and how he can control it. It also means that a nurse should track Jeremy's family or friends. Nurse should also facilitate our patient by catering to his psychological, physical, cultural and social needs. Nurses can truly work effectively only when she keeps in consideration the various aspects of these
guidelines.
Person Centric Approach
There are three different management objectives for our patient, treatment of the primary cause which is acetaminophen overdose, depression and informational care for type I diabetes mellitus. Various nursing interventions can be done for these problems based on person centered and holistic approach. Person centre approach has four pillars i.e. prerequisites, care environment, person-centred processes, and expected outcomes (McCormack B 2006). Prerequisites and care environment have already been discussed above. Person-centred processes would require several interventions and some of them are
" Treatment should be started with in eight hours of over does. Treatment for our patient can be started even after four hours since the exact time of over dose in known (Ferner 2011).
" If the level of timed paracetamol level is above 100 mg/L at 4 hours, N-acetylcysteine should be started immediately (Willacy 2013).
" The initial dose of acetylcysteine should be given as an infusion over 60 minutes. It is given in 5% glucose or in 0.9% sodium chloride infusion. Three doses should be administered.
" For treatment of type I diabetes (after ruling out diabetic ketoacidosis for this patient), he should be given 2 or more injections per day with adjustment of dose depending on insulin level. Insulin is given by basal insulin and a preprandial/premeal insulin. Basal insulin is a long acting insulin like glargine or intermediate acting insulin. Preprandial should be insulin lispro, aspart or regular short acting
" Patient needs to be fully educated about the disease, management, monitoring of glucose level. This is very important in our patient since this could have been one of the primary causes for triggering all these problems.
Expected outcome would be significant improvement in pain and disease process.
Holistic Nursing Approach
Holistic approach would require nurse to act as a healer and consider patients emotional and psychological needs. It would also require nurse interaction with patient himself, involve psychiatric team and try to connect with his family. His depression should especially be considered during management of these interventions. Some of these holistic interventions would include
" For depression, psychotherapy and counselling, social support, proper sleep, company of his friends as short term intervention and proper healthy diet, physical exercise and regular restful sleep as long term intervention (Meyer B 2008).
" Spiritual intervention by asking patient about his religious, believe his perception of illness and if there is any religious intervention which keeps him strong during the difficult times.
" Involve social services and volunteer groups who can help our patient with the social problems or through financial support like paying his university fee etc.
After treatment patient should be discharged with proper advice of follow up, education about disease process and treatments done and how she can improve her quality of life by all the interventions discussed.
Conclusion
Our case discussion was about a patient who was diagnosed with type I diabetes and has now presented with paracetamol overdose. He is a young man who is under a lot of stress because of certain factors in his life. After detail discussion of important clinical issues and possible diagnosis, we mentioned several investigations that can be done at this stage. Treatment plan should be based upon the diagnosis. Pathophysiology of type I diabetes was discussed. Various treatment options were discussed in detail keeping in view the holistic and person centric approach. A multidisciplinary team needs to be formed for his medical as well as psychiatric evaluation.