Physiological Diagnosis
Blood sugar and electrolyte imbalance related to type 2 diabetes as evidenced by lack of energy, fatigue, weakness, blurry vision, dehydration, and impaired cognition.
Rationale: Type 2 diabetes mellitus is a condition caused by a combination of factors, i.e., inadequate insulin secretion by the pancreatic beta cells, increased secretion of glucagon, and resistance of the peripheral cells to insulin. This often results in fluctuations in the blood glucose levels, although the levels may predominantly be high, leading to metabolic and macrovascular derangements manifested by the aforementioned symptoms (DeFronzo et al., 2015).
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Safety Diagnosis
Risks for fall and susceptibility to injury and physical harm secondary to hypothyroidism, manifested by Braden score of 17, fall risk Morse tool score of 80 Weakness, impaired walking, gait and balance, and self-care deficit.
Rationale: Hypothyroidism is an endocrine disorder caused by deficient thyroid hormone resulting in slowed physical and mental activity. Ataxia is one of the primary effects of hypothyroidism, manifested as impaired gait, and walking (Pashkovska, 2016). Consequently, the patient is at high risk of falling and sustaining physical injuries.
Psychosocial Diagnosis
Impaired social interactions and coping due to hypothyroidism that increases the propensity of ineffective assessment of physical stressors and positive interactions. This diagnosis is evidenced by self-care deficit and impaired cognition characterized by confusion and dementia.
Rationale: Social interactions and coping are contingent on an individual’s cognitive functions. Impaired cognitive functions make it difficult for an individual to engage positively social functions (Anandkumar & Venkatesh, 2019). The individual’s ability to assess their environment is also affected.
Plan/Goals
Blood Sugar and Electrolyte Imbalance
STG: The patient will achieve the required electrolyte and fluid balance within 12 hours, i.e., total body water (TBW) 60% of body weight, Na + 135-145 mmol/l, K + 3.5 -5 mmol/l, and Cl - 95-105 mmol/l.
LTG: The patient will attain stable blood sugar levels on assessment at after one month of initiation of therapy. The desired levels are random blood sugar below 11.1 mmol/l, fasting blood sugar below 5.5 mmol/l, and post-prandial blood sugar below 7.8 mmol/l.
Risks for Fall and Susceptibility to Injury and Physical Harm
STG: By the end of my shift, the patient will demonstrate two changes in self-care procedures such as being cautious of their environment, and readiness to participate in activities that enhance their safety and wellness. This involves looking out for slippery floor/surfaces and using support objects while walking.
LTG: After 2 months of the therapy, the patient will be able to walk with the correct gait and posture for 500 meters without being supported.
Impaired Social Interactions and Coping
STG: By the end of my shift, the patient will be able to respond positively and demonstrate social cues such as greetings and casual talk with their caregivers.
LTG: The patient will demonstrate improved cognitive functions and enhanced memory within three months of initiation of the therapy. Enhanced cognitive functions will enable the patient to perform their social functions as desired. They will also be able to assess their environment and positively interact with those around them, thereby improving their prognosis.
Nursing Interventions
Physiological Interventions
Oral rehydration therapy will be provided every 3 hours to restore the fluid and electrolyte balance. This intervention may be a collaborative initiative of the nurse and physician. This may include using ORS salts, dextrose, electrolytes, and rice syrup solids in different combinations. The effective concentration and combination for Na + and K + absorption is 5 gm/L casein hydrolysate and 30gm/L rice syrup solids. Rationale: Oral rehydration therapy is effective in rehydrating the cells. The therapy should be administered continuously and the patient be closely monitored. Given that severe and prolonged dehydration may be fatal, it is important to initiate the therapy promptly (DeFronzo et al., 2015). This will help to restore electrolyte balance to the desired levels and prevent further complications.
Initiation of glycemic therapy and diet monitoring to lower the blood glucose to the desired levels. This intervention is physician initiated and delegated to the nurse. The therapy includes insulin administration, sulfonylureas, alpha-glucosinade inhibitors, biguanides, and thiazolidinediones (TZDs). The dosage varies with the patient’s physiology. Blood glucose levels will be monitored every 8 hours within the first week of therapy initiation to determine prognosis. Diet modification involves providing diets with low glucose levels such as whole fruits and non-starchy vegetables. Rationale: Regulation of blood glucose is dependent on insulin activity and intake of glucose in the diet. Type 2 diabetes is largely insulin non-dependent and therefore requires additional glycemic therapy, besides insulin administration, to ensure optimum effectiveness (DeFronzo et al., 2015).
Developing a physical exercise and aerobic schedule for the patient. This intervention is nurse-initiated. The schedule will involve regular exercises within the patient’s physiological capabilities. Exercises that do not exert too much pressure on the joints will be recommended, e.g., swimming. These will be conducted twice a week within the first three weeks of initiation of therapy. Each session will last for about 30 minutes to 1 hour. Rationale: Exercising increases the cells’ uptake of glucose, enhancing glucose metabolism, and thus reducing the levels in circulation (DeFronzo et al., 2015). The patient is likely to have had a sedentary lifestyle prior to the assessment. An exercise schedule will, therefore, important to bolster the outcomes of glycemic therapy.
Safety Interventions
Explaining to the patient the need for and the importance of ensuring their safety and wellness is imperative in their management program. During this patient education program, the client will be guided on safety measures to undertake within and outside the care facility. This involves identifying the triggers of accidents and objects or situations that might increase the possibility of falls, such as slippery surfaces and objects along the path. Rationale: The patient assessment indicates that they may have ataxia and high probability of falls during movement. It is, therefore, important to make them aware of the factors that might increase the possibility of accidents and prevent their occurrence (Fonteyn, 2016).
Providing support for movement within the care facility precincts. These include crutches and rails along the paths. The NP will ensure that the client has access to these support devices and are aware of how and when to use them. Rationale: Given that the patient experiences impaired walking and impaired gait balance, it is important to provide them with support to facilitate their locomotion (Fonteyn, 2016).
Developing a regular exercise and physiotherapy management program. The physical exercise and aerobics schedule for the physiological intervention will also be used for this intervention. Physiotherapy will be provided 3 – 5 time a week, preferably in the morning or evening. Rationale: Muscle strength depends on the rate of physical activity. Although the derangement of muscle function is due to the patient’s etiological condition, adopting a regular physical exercise schedule will help to restore muscle function and strength, thereby gradually restoring normal walking gait and posture. This is important in preventing falls and physical injury. Physiotherapy is a rehabilitative procedure for muscular-skeletal functions (Pashkovska, 2016).
Psychosocial Interventions
Engaging the patient in dialogue and talking to them about their condition will be the first step in creating a rapport and developing positive interactions with them. Rationale: Socializing and talking to the patient about the condition helps to develop trust between the patient and the caregiver (Pashkovska, 2016). The patient will thus open up to the caregiver about their psychosocial concerns, making it easy for the nurse to administer the appropriate care.
Incorporating memory and cognitive functional therapy into the patient management program. This will involve disseminating basic information and assessing the patient’s synthesis and memory of the information. Rationale: Cognitive functions and memory assessment is essential in determining the patient’s cognitive development (Anandkumar & Venkatesh, 2019).
Initiating counseling and peer group therapy sessions for the patient. This is important in creating and strengthening the social interactions, and enhancing the patient’s understanding of their condition and how it influences their social functions. Rationale: Exacerbation of the patient’s physiological and neurological symptoms may impede their social functions. Through counseling and peer group sessions, the patient will get a better understanding of their condition and how to effectively manage their symptoms. Also, their social function will be enhanced, making it easy for them to resume their social duties after prognosis (Anandkumar & Venkatesh, 2019).
Evaluation of Goals
Physiological Interventions
STG: The goal was partially met due to the severity of the dehydration. More electrolytes were required to achieve the electrolyte/fluid balance.
LTG: The goal was met evidenced by the significant reduction of the patient’s blood sugar levels. After three months of the therapy, the patient’s RBS was 10.8 mmol/l.
Safety Interventions
STG: The goal was partially achieved. This was mainly because of the patient’s cognitive impairment, i.e., memory loss and confusion. The intervention required a longer time to achieve the goal.
LTG: The goal was achieved a, manifested by the patient’s improved gait and walking. The patient’s muscular-skeletal functions had been enhanced by the therapy.
Psychosocial Interventions
STG: The goal was achieved. The patient became open to social conversations with the caregivers.
LTG: The goal was partially achieved as manifested by the improved memory and cognitive functions. The assessment, however, indicated that a longer duration of cognitive functions therapy was required to achieve optimum performance. Six months would result in better cognitive performance.
Evaluation of Implementation
Physiological Interventions
The intervention worked through a collaboration of the nurses and physicians. The physician ordered the concentrations of the electrolytes and prescribed the dosages for glycemic therapy. These were then administered and closely monitored by the NP. Adjustments were made to the concentration of electrolytes because the STG was partially met.
Safety Intervention
The physical exercise and aerobics schedule was designed and fully implemented by the NP. Revisions were made on the schedule, depending on the patient’s conditions. If the patient was unable to participate in an exercise on a particular day; the activity had to be rescheduled. Patient education and awareness on their safety and environment were also exclusively done by the NP. No revisions were made to this intervention.
Psychosocial Intervention
Cognitive functions therapy, engaging the patient in conversations, counselling, and peer group therapy were all designed and administered by the NP. The physician occasionally monitored the patient’s progress and would make recommendations on possible changes, especially on the cognitive functions therapy. The cognitive function therapy was revised from three to six months because the LTG was partially met. The patient would need more time to demonstrate considerable improvement.
References
Anandkumar, S., & Venkatesh, S. (2019). Clinical assessment of cognitive impairment in various conditions of hypothyroidism patients.
DeFronzo, R. A., Ferrannini, E., Groop, L., Henry, R. R., Herman, W. H., Holst, J. J., ... & Simonson, D. C. (2015). Type 2 diabetes mellitus. Nature reviews Disease primers , 1 , 15019.
Fonteyn, E. M. R. (2016). Falls, physiotherapy, and training in patients with cerebellar degeneration . [Sl: sn].
Pashkovska, N. V. (2016). Treatment of hypothyroidism according to modern clinical guidelines. International journal of endocrinology , (6.78), 48-58.
