NURS2105 Case study Essay Example
Conclusive diagnosis of a patient’s illness is often carried out through conducting physical examinations, various laboratory tests, analysis of patient’s symptoms and from information gathered from the patient’s history (Provan, 2010, 129). Based on the historical information and symptoms experienced by Martine, physical examination and tests including urinalysis, blood culture tests, full blood count and serum electrolytes among other tests, the medical practitioner diagnosed complicated recurrent urinary tract infection but failed to diagnose diabetes. Such failure would impact on the management of the illness thereby providing room for improvement in the management of Martine’s illness. Such improvements cover aspects such as diagnosis, emergency treatment, and choice of medication, discharge, patient education and management of Martine’s illness.
Critique of the nursing management for Martine
Use of patient’s history and symptoms in making correct provisional diagnosis
Martine’s immediate history is reflected in the recent symptoms that include feeling fatigued, hot and very thirsty, frequently passing large amounts of urine, which are suggestive of type 2 diabetes mellitus (Provan , 2010, p. 130).
Other symptoms experienced by Martine such as frequent and smaller amounts of urine with burning on mitricution (dysuria) and suprapubic pain, fatigue and anorexia, and cloudy urine with a distinct fishy odour, indicative of urinary tract infection with the additional of more serious symptoms of flank and back pain, nausea, and castes in her urine suggestive of urinary tract infection of the kidney (pyelonephritis) (Schrier, 2007, p. 285).
Laboratory investigations are essential for confirmation of UTI diagnosis since clinical features alone are not adequate in making diagnosis (Schrier, 2007, p. 289). Such tests aid in ascertainment of whether Martine suffered from multiple illnesses considering similarity of symptoms evident in differential diagnosis leading to more precise of diagnosis of illness and proper management of Martine’s health needs. This is especially crucial given the fact that diabetes is a major predisposing factor to complicated urinary tract infections.
Tests for confirmation of diagnosis
A general physical examination and tests include urinalysis, blood culture, Mid Stream Specimen of urine (MSSU) culture and assessment of vital signs such as body temperature, blood pressure, pulse and respiratory rate among other signs conducted on Martine to aid in confirmation of UTI diagnosis and to provide additional information of her health status.
Blood culture is useful where a patient displays symptoms that indicate possibility of infection such a fever (greater than 38.5o c) due to risk of sepsis and in identification of the type of infection causing microorganism (Petersen, 2006, 142). Susceptibility testing is carried out to determine the most effective antibiotic. A series of a minimum of three cultures are recommended for collection, with four bring the optimal number of cultures since bacterial infection sometimes comes and goes. The culture collected should consist of at least one aerobic and one anaerobic culture. Use of more blood cultures increase chances of detection considering that studies have indicated that pathogens only grow in 20% of cultures (Petersen, 2006, 143). The blood culture is incubated for 8 hours before transfer to an agar plate and the results take a minimum of 20 hours.
In Martines case, three cultures were ordered, which satisfied the minimum criteria. The blood culture was supposed to identify the type of microorganism responsible for Martine’s infection. From this, it was possible to identify the causative bacteria as Escheria coli and therefore aiding in determining ciproflaxin as the best medication for the type of bacteria through susceptibility testing.
Urinalysis shows the presence of bacteria in most urinary tract infections thereby it is crucial in diagnosis. Urinalysis in Martine’s case indicated pyuria, which is presence of white blood cells indicative of inflammation of urothelium, which could be caused by pathology such as tumour, stones, foreign body or tuberculosis. In case of Martine, bacterial infection considering other symptoms pointing to urinary tract infection is possible cause (Schrier, 2007, p. 289). False positive may also occur in contaminated specimens and with calvulanic acid.
Presence of red blood cells in urine (hemeturia) is suggestive of urinary tract infection (Schrier, 2007, p. 289). Red blood cells are detected in analysis using a dipstick and presence of red blood cells is indicated by colour change resulting from the catalytic action of haemoglobin on ortho-toluidine and organic peroxidise (Schier, 2007, p. 287). Microscopic urinalysis showing presence of casts in urine also indicates presence of red blood cells and this also occurs in urinary tract infection. The presence of casts and red blood cells further lend support to diagnosis of existence of an infection, with blood indicating infection of upper tract.
Nitrite in urine is one of the indirect indicators of urinary tract infection. Nitrate in the body is reduced to nitrite through action of organisms such as Escherichia coli, Proteus among other organisms (Lee, 2009, p. 174). Absence of nitrites (negative test) does not rule out infection since the test is only positive misses some gram-negative organisms such as enterococcus. Martine’s urine contained traces of nitrites indicating likelihood of infection.
Glucose is generally absent in urine. While glucose is filtered in glomerulus, it is completely reabsorbed in proximal tubule (Lee, 2009, p. 174). However, when glucose concentrations exceed 180mg/dl, the capacity for reabsoption of glucose is exceeded and glucose seeps through and is detected in urine (glycosura). Among the conditions that glycosuria may indicate include diabetes mellitus. Glucose levels above 10mmo/l (180 mg/dl) are indicative of hyperglycaemia.
Martine’s random glucose levels in urine are 20mmo/l, way higher than the 10mmo/l for diagnosis of hyperglycemia. Other symptoms experienced by Martine point to the classic symptoms of type 2 diabetes mellitus such as passage of large volumes of urine (polyuria), increased thirst (polydipsia), polythagia (excess hunger) and weight loss. The presence of hyperglycaemia poses risk for Martine as when unattended can lead to complications such as kidney damage, cardiovascular damage, neuropathy, neurological damage and damage to retina.
Mid Stream Specimen of urine (MSSU)
Urinalysis does not identify the type of bacteria.Mid stream specimen of urine (MSSU) culture test is used to test presence of microorganisms in the urine. It involves collecting urine midstream where the first part of urine is voided and next 10-20ml is collected since the first part of urine may contain bacteria from skin (Hayden, 2009, p. 366). The urine collected results are obtained after 2 to 3 days for bacteria. Besides identifying presence of bacteria, the MSSU test assists in management of infection by identifying the best type of antibiotics to use by testing the bacteria against various antibiotics thus avoiding using antibiotics that bacterium are resistant (Hayden, 2009, p. 365). False negative results can be caused by soaps while washing perineal area.
In Martines, case MSSU lead to the identification of Escheria coli bacteria, which was resistant to the trimethoprim leading to the recommendation for change of drug to Ciprofloxin.The change was a reflection of the findings from the urine culture tests.
Full blood count and serum electrolytes
Full blood count is a thorough examination of blood components to ascertain the number, size, type and other features of blood cells. It is used in diagnosis of abnormalities such as infections manifested by very high number of particular blood cells, or very low number of cells as occurs in anaemia among other abnormalities (Wizorek & Whinney, 2005, p.245). In a patient with urinary tract infection, a full blood count should show elevated number of white blood cells.
Martine’s blood may reveal higher number of white blood cells.
Martines blood tests however may reveal abnormal increased levels in the packed cell concentration (PCV), the mean corpuscular haemoglobin (MCV) and mean corpuscular haemoglobin concentration due to volume contraction caused by dehydration (Sarma 1990, p. 720).
Kidney function is measured through urea, electrolyte and creatinine blood tests. Due to Martines symptoms of anorexia and nausea, her urea, electrolyte and creatinine profie may indicate her reveal more about her general health status. Wizorek & Whinney (2005, p. 246) indicate that elevated levels of urea and creatinine, which are waste products of cell protein metabolism that are normally excreted by kidneys occur in dehydrated individuals and in renal impairment. Martines level of urea and creatinines are therefore expected to be high due to her high evident dehydration levels.
Electrolytes are chemical substances including potassium, chloride, sodium and bi-carbinate which disassociate into ions and can conduct an electrical current when dissolved in water (Lewis’s p. 346). They are essential in the normal functioning of all cells and in maintaining intracellular and extracellular homeostasis (Lewis’s p. 346). Due to Martines evident volume depletion, she may be experiencing Hypokalaemic and hypochloraemic metabolic alkalosis. The hypokalaemia reflects the potassium-hydrogen exchange occurring at a cellular level in an effort to correct alkalosis (Wizorek & Whinney 2005, p. 246).
In people with diabetes elevated blood sugar levels cause sugar to spill into the urine and water then follows, causing significant dehydration. Initially polyuria (osmotic diuresis) caused by fluid drawn away from the tissues and into the blood to offset the high sugar concentration occurs. Urination increases to aid in excreting excess sugar in the urine. Fluid deficit causes decreased plasma osmolarity sensed by osmoreceptors in the hypothalamus triggering thirst.
The most common symptoms of Diabettes Mellitus are those of hyperglycemia: an osmotic diuresis caused by glycosuria leading to urinary frequency, polyuria, and polydipsia that may progress to orthostatic hypotension and dehydration. Hunger and fatigue increase because the body’s cells cannot utilize sugar for energy. The body’s stores of fat and protein are used as an alternative energy source, leading to weight loss. A risk of renal failure due to dehydration and UTI infection exists.
Physical examination, symptoms interpretation and relevance to management of Martine’s illness
Physical examination of Martine vital signs include blood pressure, respiration rate, temperature and pulse are supposed to show the general condition of the body and provides the direction for immediate interventions. Martine’s respiratory rate of 24 breaths per minute is higher than the average in adults of between 12-20 and these is indicative of illness or fever (Folley, 2004, p 135 ).
In diabetes, hyperglycaemia is a culprit in resulting to the increased respiratory rate and depth (kussmaul respirations) and it occurs through a physiological process triggered by a fall in body pH in most body fluids resulting from ketogenesis (Folley,2004, p135 ). The increased respiration aims at blowing off carbon dioxide to restore pH through the process. Since ketogenis results from insulin deficiency and excess glucagon, placing Martine on insulin therapy is a measure that should be adopted to restore pH and respiratory rate to normal. Restoration of body water and electrolyte balance is also crucial. After start of treatment, through IV normal saline and ural satchel administration, the rate returned to 20, which is within the normal range.
Before start of treatment, blood pressure BP for Martine was 94/75mmHg against the recommended range for persons of Martines age that range from 109/76 to 133/84 ( ). This is indicative of low blood pressure and these improved to BP 110/70 after initiation of treatment. The low blood pressure is caused by dehydration resulting to low volumes of blood in the arteries (Wilburta, 2009, p 576 ). Administration of IV normal saline and daily fluid intake was crucial in restoring blood pressure to near average for Martine’s age.
Martine had a high fever reflected in her temperature readings of 39.5’C and thus was recommended to be put under paracetamol treatment. After two days, the temperature had reduced to 38.4 oC, which is still high. Failure of the drug trimethropin to work would have been responsible for the continued fever due to continued presence of bacteria in Martine’s body.
Physical examination further indicates capillary refill >2sec, tenting over sternum, and dry tongue, and the body weight loss which are suggestive of dehydration (Wolfson, 2009, 245) thereby indicating that Martine is highly dehydrated. Dehydration, leading to the medical emergency of hypovolemia that is manifested in Martines symptoms in this case is caused by multiple factors including decreased fluid intake, elevated temperature and elevated blood glucose. Martine decreased her daily fluid intake which has led to oliguria (frequent small amounts urine) caused by fever and a simultaneous lack of adequate fluid intake with initial symptoms including fatigue, hot and very thirsty (polydispia).
Recommendations by medical practitioner on management of illness
The medical practitioner made various recommendations as first line of medication for Martine. These include
IV Normal saline at 84mL/hr
The recommendation by the medical practitioner for administration of IV normal saline at 84ml/hr was intended to restore fluid and electrolyte balance through fluid replacement (Jones et al, 2002). Fluid imbalance in Martines was caused by dehydration caused by loss of body water and electrolytes through urine loss, heat and low replacement of water in body. The amount to be administered is calculated based on the patients body weight. Martines response to the IV should be assessed continuously and continued where there is no sufficient improvement. Martine should also be checked for shock. If she shows no signs of shock, she should be recommended for oral rehydration through free fluids aimed for daily intake of 2000mL/day with combined oral/IV fluids which nurse’s state is the amount of maintenance fluids expected for Martine’s weight.
Oral trimethropin was recommended as the first line of drugs for martine but this was changes after failure of the patient to respond and after sensitivity tests indicating that Martines urinary tract infection was caused by escheria coli, which ciproloxin was recommended. The patient was put on observation after every hour to avoid emergency complications and to ensure that she is responding appropriately to treatment. This is important especially since some patients may react negatively to some drugs. Daily weight is also taken to identify the rate at which she is responding to treatment. Identification of possibility of adverse reactions due to combination of various drugs such as use of progesterone and asthma drugs that she has been taking with the new drugs been administered is also taken into consideration.
Recommendations short term nursing management specific to patient using appropriate cues and appropriate evidence
According to Martine’s condition, it is recommended that various short term nursing management measures be taken based on various cues from the patient and research evidence to improve patient care.
Considering the role of diabetes in contributing to complicated urinary tract infections, short term measures in nursing management should aim to manage the blood glucose levels.
Fluid imbalance is potentially life threatening (Jones et al, 2002). Initial goal of therapy for Martine is to establish intravenous access and to start fluid and electrolyte replacement. Once it is established that Martine’s fluid resuscitation is underway, insulin administration to contain the high glucose levels can be initiated since insulin allows water to enter cells.
Monitoring of vital signs and oxygen saturation is crucial in IV fluid replacement (Jones et al, 2002). The nursing practitioner should therefore monitor these signs for any abnormalities to avoid complications and increase success of treatment outcome.
Assessment of Martine should be a continuous and dynamic process rather than a singular event. This would enable capturing of subtle cues that may indicate deterioration of her illness.
Any overall changes to the nursing management of Martine, in relation to interdisciplinary care
Overall changes to the nursing management of Martine in relation to interdisciplinary care is based on the expected benefits of using integrated care team as a model for treatment of diabetes and its associated complications such as urinary tract infection. Adoption of interdisciplinary care, while relatively new to managing some chronic illness such as diabetes, portend some benefits to the patient thus requiring some changes on how the providers view their roles and relationships, with professionals in other disciplines and with patients (Porta, 2009, 34).
An integrated team in management of Martine’s diabetes may include nurses, dieticians, physicians, pharmacists and even behavioural scientists (Porta, 2009, p. 35). In some cases specialised professionals such as gerontologist may assist in meeting patients special or specific needs such as Martine’s added complication of urinary tract infection and they should be included in a diabetes care team. Such teams provide integrated care, which is goal directed and patient centred with equal emphasis given to medical treatment, counselling and education (Porta, 2009, p. 35). Martines interdisciplinary care in taking cognisance of these elements identify medical treatment of the diabetes and urinary tract infection as crucial as well as education of diabetes, possible complications, and self care to the patient and counselling of Martine on coping with the illnesses. This is attained through an interdisciplinary team with shared leadership
Besides the use of a diabetes care team, other changes in the overall care of Martine, would be the development of a comprehensive diabetes care program (Porta, 2009, p. 35). Such a program should be research-based and outcome focused with mutual support among team members encouraging ongoing professional development a
Other changes in Martines care related to interdisciplinary care regards the relationship between the team, with a shift towards a collaborative rather than a consultative relationship between the nurse, physician and other team members, and shared professional identity and leadership(Porta, 2009, p. 36). Such a change in team organization towards shared leadership has the roles performed by members shifting from roles being defined by physician towards a mutual problem solving, open communication and team cohesiveness model that should best meet Martines medical needs.
The roles played by the nurse clinician for Martine would include diabetes education, assistance in choice of insulin regimen, teaching problem-solving skills to patients, promoting patients self-image, adjusting dosage among other roles. The role of dietician would include working with Martine to identify the meals algorithm that are appropriate for Martine s condition, exercises goals, patient support and developing programs that meet specific motivational needs and lifestyle needs for Martine. Complications such as urinary tract infection would be addressed by the gerentologists with behaviouralist assisting Martine to adapt to new schedules. Counsellor may be required to ensure that Martine is able to cope with the new challenges that may suffice with the advent of the diabetes illness. These activities conducted through teams allow collaborative practice that would involves matching Martines goals and needs with the style of various experts. s
Range of education needs for Martine
Gurkova et al (2009) suggest that satisfaction with treatment regimen and quality of life among patients with diabetes is improved by use of multifaceted diabetes self-management education interventions. For Martine to continue experiencing quality life, and optimal treatment outcome for diabetes and urinary tract infection, a range of education needs for Martine include the need to understand the illness, treatment options, blood glucose self-monitoring, identification and recognition of potential complications, self empowerment and general management of illness. This is crucial for the success of treatment outcome and for the increased quality of life.
The need to understand the illness is a core education need for Martine especially due to the chronic nature of diabetes. Since the disease requires consistent management, Martine would be in a better position to identify what is happening with her body and thus fostering and reinforcing changes in behaviour to suit the illness resulting to better treatment outcome and resulting to increased satisfaction with quality of life.
Gurkova e al (2009) posits that blood glucose self-monitoring is an integral component of self-care behaviour and an invaluable tool in aiding individuals with diabetes to understand the impact of medications, foods and activities on the glucose levels. Applying the evidence from research, Martine thus needs to understand not only how to carry out self-monitoring of glucose levels but also how to apply the data to realise the full potential that may accrue from appropriately applying the data to other components of overall plan of diabetes self care.
When changes occur to treatment plan, it is essential to change the teaching to reflect the changes (Falvo, 2010, p 52). The change of medication for Martine from trimethoprim to Ciprofloxin should be explained to the patient.
The education need on how Martine can identify and recognise potential complication is another need that should be met to ensure successful outcome of treatment. Porta, 2005, p. 51 posit that diabetes self management training programs should emphasize on the risk factors for macro and and microvascular disease thus requiring a multifaceted attack.
Management of diabetes and other complications such as urinary tract infection experienced by Martine provide another education need that must be met in the successful management of her illness. Martine should be taught how to take the medicines prescribed, when to take them and how they should be taken. She should also be informed on other aspects of managing the illness such as through recommendations on diet, lifestyle changes and the risks that may result from failure to adhere to the medication and recommendations (Falvo, 2010, p. 53). Martine should be informed on the importance of checking her glucose levels and what these portend for her health outcome.
Empowering independence is another aim of education that meets the need for patients to meet their own diabetes care goal (Porta, 2005, p. 41). The need to gain mastery over the illness is a crucial need among patients with diabetes and this is attained through education processes that assist in enhancing problem-solving skills and translating optimal diabetes care into daily practice. Martine may benefit from such empowerment that may assist her in discovering effective problem-solving strategies to aid in mastering diabetes and its accompanying complications such as urinary tract infection.
Discharge needs for Martine, including a range of strategies to assist in her discharge
Dunning, 2009, p. 468 posits that it is crucial to incorporate discharge planning into the initial assessment and patient care. Discharge needs vary depending on the illness and specific circumstances of a patient. In Martine’s case, discharge needs are dependent on certain factors that include her special circumstances of diabetes with complicated urinary tract infection and the fact that she is a tourist and not an Australian citizen thus denying her some of the benefits such as coverage by the Australian health system. Martine travel insurance need to be ascertained on whether it covers chronic illness such as diabetes.
Among Martines discharge needs include ensuring that she has adequate self-care knowledge to enable her deal with diabetes and associated complications such as microvasculra and macro vascular diseases. In order to meet this need, educational information on the disease, possible complications and self care such as insulin monitoring should be provided to the patient.
Martine also needs to be aware of where and how she can get emergency assistance in case of complications. To meet this need, the discharge planning should involve providing her with the telephone numbers for emergency care within the location that she would be located besides providing contacts where she can seek more information about the illness after the discharge if it is necessary.
Discharge planning needs brought about by diagnosis of diabetes further include access to equipments for self-monitoring and management of diabetes. Martine needs to be aware how to access such equipment such as glucose monitoring devices.
Educational needs for Martine must be identified and strategies for meeting this needs identified (Porta, 2005, p. 42). Education needs include provision of information on diabetes, potential complications and how to avoid them. Other information that may be provided include self empowerment information that aid her to make independent decision in self care management in line with the expected larger role that patients are expected to play in the management of diabetes.
Other discharge needs include follow up for the duration that she is in Australia. Martine should be provided with suitable follow up schedule in case she will be within the location to ascertain whether there are possible complications and to identify how well she is responding to medication.
The need for the patient to understand how and when to take medications is another crucial aspect that is met through discharge planning. Martines understanding of the medication schedule and risks in failure to follow such schedules is critical. For instance, the risk for resistance on failure to complete medication for antibiotics is an issue that the patient should be made aware.
A patient’s history is a very crucial component in diagnosis and management of a patient’s illness. Recurrent patterns in patients history is not only crucial in diagnosis but also in epidemiological context as it provides the medical practitioner with a line of investigation. Based on Martine’s history and some of her symptoms, provisional diagnosis of urinary tract infection was made by the medical practitioner but failed to make a diagnosis for diabetes. Such failure may affect the care that a patient receives increasing the risk of morbidity and mortality among patients. Proper diagnosis while is the first step in patient care influences patient care at all stages. With the shifts in the nursing field such as use of interdisciplinary teams, care for patients is evolving to best meet the needs of the patients and making it possible to identify such shortcomings in diagnosis.
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Urology: An Atlas of Investigation and Management
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