Holistic Care Nurse Essay

The name and other revealing information about the tolerant embarrassd within this piece of work have been changed to protect confidentiality, as learnd by The command of Professional Conduct ( treat and Midwifery Council, 2008). For this reason, the patient included in this case study give be given the pseudonym of Sam Jones.The purpose of this assignment is to identify one client bother and raise an evidence-based political platform of concern for the respective(prenominal). The purpose of carry on envisionning is to show a logical and systematic while period of ideas through from the initial assessment to the final evaluation (Mooney and OBrien, 2006).The treat model that pass on be incorpo directd in this care plan will be the Roper, Logan and Tierneys model (2000). This model was elect be attempt is it extremely prevalent in the United Kingdom and is the most widely used model old(prenominal) to nurses. The model of nursing specifies 12 activities of daily don jon which are related to basic human call for and incorpo points five dimensions of holistic care, physiological, psychological, sociocultural, politicoeconomical and environmental (Roper, Logan and Tierneys model, 2000).Care plans are based on evidence-based practice, allowing the nurse to determine the better(p) possible care and rationale for the chosen nursing interjections (Roper, Logan and Tierney, 2000). They take into account the psychological, biological and sociological unavoidably of the person and therefore provide a holistic approach to care (Roper, Logan and Tierney, 2000). The main activity of living that will be affected within this care plan will be maintaining a arctic environment as Mr. Jones may have a potential worry of death, due to hypovolemic and/or metabolic traumatise caused by ketoacidosis.Diabetic ketoacidosis (DKA) usually occurs in people with type 1 diabetes mellitus, merely diabetic ketoacidosis suffer set in any person with diabetes (Diabet es UK, 2013). DKA results from evaporation during a call down of relative insulin deficiency, associated with high parentage deals of sugar level and ketones (Diabetes UK, 2013). This pass ons because there is not enough insulin to allow glucose to sneak in the cells where it can be used as energy so the form begins to use stores of fat as an alternative source of energy, and this in turn draws an acidic by-product known as ketones (Diabetes UK, 2013). It is evident that DKA is associated with real disturbances of the bodys chemistry, which should resolve with appropriatetherapy (Diabetes UK, 2013).Severe metabolic acidosis can lead to shock or death (Dugdale, 2011). The precise problem was chosen because there are measures that can significantly shorten the risk of metabolic and hypovolemic shock which can be caused by severe metabolic acidosis (Dugdale, 2011). Within the care plan relevant care interventions will be set to prevent the possible development of shock for Mr. Jones. In practice the interventions would happen contemporaneously.The interventions involve identifying the potential risk factors for the development of shock by using specific assessments. This will be done by come abouting an assessment which includes planning, assessing, implementing and evaluating the care that will be provided to Mr Jones and to evaluate its effectuality (Mooney & OBrien, 2006).Once the diagnosing was make, specific, achievable, measurable, realistic and time limited goals of care for Mr. Jones were made. The NHS fixation trust specific guidelines for adult diabetic ketoacidosis suggest a series of immediate actions and assessments for suspected DKA which will allow for appropriate interventions to be made and will provide a service line which will provide a measure of the effectiveness of the discussion (The Joint British Diabetes Societies Inpatient Care Group, JBDS, 2012).Mr Jones will need eloquent and electrolyte management to pull ahead ketone s and correct electrolyte imbalance (Nazario, 2011). He will also require pharmacological involvement which will include administrating medication that is postulate to reverse gear the acidosis, raised melodic line glucose and pH levels (Nazario, 2011).Psychological intervention is also necessary to reduce his solicitude and therefore reduce potential shock (Nazario, 2011). The goal of manipulation for Mr Jones is to lower his high snag sugar level with insulin an hour after the insulin infusion is administ judged with the expected outcome of maintaining a phone line glucose level in the range of 8.3mmol/l 10.0mmol/l within 72 hours (JBDS, 2012). Due to this it is vital that Mr Joness blood sugar is monitored and regulated frequently (JBDS, 2012).Another goal is to replace his lost body fluids endovenous fluids will be given to treat dehydration and dehydration situation will be assessed every hour by observe intake and output, skin turgor and vital signs (JBDS, 2012). Mr. Jones will be able to understand the care that is universe given and why it is being given within 30 minutes of diagnosing and he will also be able to express his fears and discuss his needs with nursing staff, whichcombined with improvements in his blood sugar levels will reduce his anxiety.Intervention one Fluid and Electrolyte ManagementAccording to The Joint British Diabetes Society (2012) the usual cause of shock in DKA is severe fluid depletion secondary to osmotic diuresis leading to intravascular volume depletion. Diabetes Daily (2013) rid this by stating that dehydration can become severe enough to cause shock. So once a diagnosis of DKA has been established, fluid replacement should be commenced immediately (Park, 2006).According to Oaks and Cole (2007) the development of total body dehydration and atomic number 11 depletion is the result of increased urinary output and electrolyte losses. They pass on that insulin deficiency can also institute to renal losses of wa ter and electrolytes (Oaks and Cole, 2007). The Joint British Diabetes Society (2012) suggests that the most important initial remediation intervention when treating a patient with DKA is fluid replacement followed by insulin initiation. They also state an adult calculation 70kg or above puting with DKA may be up to 7 litres in fluid deficit with associated electrolyte disturbances (JBDS, 2012).Rhoda, gatekeeper and Quintini (2011) propose that a fluid and electrolyte management plan developed by a multidisciplinary team is discriminatory in promoting continuity of care and producing safe outcomes. The development of a plan for managing fluid and electrolyte abnormalities should start with correcting the implicit in(p) condition (Rhoda, door guard and Quintini, 2011).In most cases, this is followed by an assessment of fluid balance with the goal of achieving euvolemia (state of normal body fluid volume) (Rhoda, Porter and Quintini, 2011). The Joint British Diabetes Society (20 12) propose the main aims for the set-back few litres of fluid replacement are to clear ketones and correct electrolyte imbalance.The Joint British Diabetes Society (2012) has issued guidelines on the management of adults with DKA to each(prenominal) NHS foundation trust. The guidelines state that intravenous fluids should be commenced via an intravenous cannula (JBDS, 2012). It is recommended that 9% Sodium chloride 1000mls should be infused initially everyplace one hour (JBDS, 2012).Park (2006) clarifies this by stating that slower outranks have been associated with a more(prenominal) rapid field of blood plasma hydrogen carbonate and it is recommended that 1000mls is to be infused in the first hour. Rhoda, Porter and Quintini (2011) propose that after fluid status is corrected,electrolyte imbalances are simplified.To correct dehydration and achieve the goal of rehydrating Mr Jones, several assessments will need to be completed. Rhoda, Porter and Quintini (2011) suggest th at after a plan is developed, frequent monitoring is vital to regain homeostasis. Mr Joness water output, heart rate, blood pressure, respiratory rate and pulse oximetry will be monitored hourly to ensure the treatment being given is working effectively (JBDS, 2012).Also, to assess the degree of dehydration a variety of specific observations will need to be carried out including observing neck veins, skin turgor, mucous membranes, tachycardia, hypotension, capillary tubing fill again and water system output (JBDS, 2012). A strict fluid balance chart will need to be in place to monitor input and output (Mooney, 2007).To continue with gradual rehydration and restoration of depleted electrolytes after the first 1000ml bag of 0.9% sodium chloride has been administered to Mr Jones over one hour a second 1000ml bag of 0.9% sodium chloride will be commenced over two hours and a third bag will then follow over another two hours (JBDS, 2012) . Following these two hourly bags of fluid ano ther two bags of sodium chloride will follow at a rate of four hours and then another two bags will be commenced over six hours consecutively to ensure complete rehydration (JBDS, 2012).Pharmacology InterventionThe medication that was needed to resolve Mr. Joness acidosis and to prevent metabolic shock will be discussed in this intervention. A fixed rate intravenous insulin infusion is recommended by The Joint British Diabetes Society (2012) and declared on the NHS foundation trust DKA guidelines to reverse DKA.An intravenous insulin infusion via a pump should contain 50 units of actrapid insulin in 50mls 0.9% sodium chloride at a continuous fixed rate of 0.1 units/kg/hour (JBDS, 2012). If you are unable to weigh the patient an estimated incubus will need to be made to calculate the units per kg per hour (JBDS, 2012).Whilst the infusion is running ketones and capillary blood glucose will be monitored hourly to screen for improvement (JBDS, 2012). Preedy (2010) and guidelines to DKA both state that if the patient unremarkably takes long acting insulin (e.g. Lantus, Levemir) this should be continued at their usual dose and time. According to The Joint British Diabetes Society (2012) it is no longer advised to administer abolus dose of insulin at the time of diagnosis of DKA to allow rapid correction of blood sugar. Intravenous fluid resuscitation alone will reduce plasma glucose levels by two methods it will dilute the blood glucose and also the levels of counter-regulatory hormones (JBDS, 2012).If the blood glucose locomote too slowly, the insulin rate should be doubled every hour until the target decrease is met (JBDS, 2012). If the blood glucose falls too quickly, the insulin rate can be halved to 0.05unit/kg/hour, but for a short time only, as a rate of 0.1 units/kg/hour is needed to switch off ketone production (JBDS, 2012).If hypoglycaemia occurs prior to complete steadiness of DKA, the insulin infusion should not be stopped, but extra glucose should b e added to the IV fluids instead (JBDS, 2012). Diabetes Daily (2013) inform that if necessary, potassium should be administered to correct for hypokalemia (low blood potassium concentration), and sodium bicarbonate to correct for metabolic acidosis, if the pH is less(prenominal) than 7.0.For Mr. Jones neither of these was needed to correct his acidosis. JBDS (2012) can justify this as they clarify that intravenous bicarbonate is very rarely necessary. Similarly, Diabetes Care (2004) proposes the use of bicarbonate in DKA remains controversial. At a pH 7.0, insulin activity blocks lipolysis and resolves ketoacidosis without any added bicarbonate. Potassium is often high on admission but falls precipitously upon treatment with insulin (JBDS, 2012).Potassium levels can fluctuate severely during the treatment of DKA, because insulin decreases potassium levels in the blood by redistributing it into cells (JBDS, 2012). A large part of the shifted extracellular potassium would have been l ost in Mr. Joness peeing because of osmotic diuresis (Dugdale, 2012). Hypokalemia increases the risk of dangerous irregularities in the heart rate (Dugdale, 2012).Therefore, continuous observation of the heart rate is recommended as well as repeated measurement of Mr. Joness potassium levels and addition of potassium to the intravenous fluids once levels fall under 5.3 mmol/l (JBDS, 2012). By 24 hours Mr. Jones had improved and was able to eat and drink. The guidelines state that by 24 hours the ketonaemia and acidosis should have resolved but you should continue intravenous fluids if the patient is not further drinking as per clinical judgement (JBDS, 2012).The guidelines also suggest if blood glucose becomes lower than 14 mmol/L then 10% glucose should be prescribed to run alongside the sodium chloride (JBDS, 2012). Also, if Mr Jonesspotassium had of dropped below 3.5mmol/L in the first 24 hours of treatment then additional potassium would have needed to be given (JBDS, 2012).P sychological InterventionA third intervention would be communicating needs to reduce patient anxiety and keep the patient feeling secure. Communication plays an important part in the holistic care plan and biopsychosocial approach to care. Anxiety can be a barrier to communication therefore, it is important to communicate with Mr. Jones intelligibly and supportively in order to make him feel free to discuss his fears and to allow him to participate in the decisions made in his care. According to Sarafino (2008) anxiety appears to be caused by an interaction of biopsychosocial factors, including vulnerability, which interact with situations, stress, or trauma to produce added anxieties for the patient.The nurse should take a step by step approach to build a plan of care and voice the plan of care to Mr. Jones so he does not become overwhelmed by the extensiveness of the treatment (Sarafino, 2008). Communication is identified as one of the all important(p) skills that health care pr ofessionals must acquire (NMC, 2010). The Nursing and Midwifery Council (2010) stipulate that, within the domain for communication and interpersonal skills, all nurses must do the succeeding(a) communicate safely and effectively, build therapeutic relationships and take individual differences, capabilities, and needs into account, be able to maneuver in, maintain, and disengage from therapeutic relationships, use a range of communication skills and technologies, use verbal, non-verbal, and written communication, address communication in diversity, promote well-being and personal safety, and identify ways to communicate.Communicating with Mr. Jones relatives is also important so that they develop an understanding of his condition and the care he is receiving (Webb, 2011) According to Webb (2011) health professionals who can communicate at an stirred level are seen as warm, caring, and empathetic, and engender trust in their patients, which encourages disclosure of worries and conc erns that patients might otherwise not reveal. Additionally, informative and useful communication between the practitioner and the patient is shown to encourage patients to take more relate in their condition, ask questions, and develop greater understanding and self-care (Webb, 2011).Webb (2011) explains that this isparticularly so when the patient is given time and encouragement to ask questions and be involved in their treatment decisions. By using the Roper, Logan and Tierneys nursing model (2000) a holistic approach to care was able to be implemented for Mr. Jones by victorious into account his biological, psychological and social needs. By establishing a holistic care plan three interventions were identified that were equally vital in treating Mr. Joness DKA to prevent hypovolemic and metabolic shock caused by his acidosis.The first intervention was the management of fluid and electrolytes put in place to achieve the goal of rehydrating Mr. Jones in aim to correct his electr olyte imbalance and clear ketones to prevent hypovolemic and metabolic shock caused by his DKA. The second intervention included pharmacological input which included the administration of relevant medication to achieve the goal of reversing Mr. Joness raised blood glucose and acidosis. Lastly the third intervention within the holistic care plan communicate Mr. Jones psychological needs by resolving his anxiety by utilising effective communication and interpersonal skills.It can be concluded that the care plan and treatment for Mr. Jones was successful therefore he did not require escalation to the high dependency unit and additional treatment was not necessary. Therefore it is evident from the success of Mr Jones care care planning provides a structured and holistic method which in turn addresses all elements of an individuals health and well being.AppendixThe individual chosen for this care plan is Mr. Sam Jones (a pseudonym, as explained in the confidentiality statement). This ge ntleman was chosen for the care plan as caring for diabetic individuals is becoming a more common activity within health care today. Mr. Jones is a 58-year-old builder who was admitted after being found collapsed at his home by his brother.He is 5ft 9 tall and weighs 88 kilograms. Mr. Jones lives alone in a centrally heated two bedroom semi detached house he sleeps on the pep pill floor and is very independent and does not require a package of care. He has a female child aged 22 who has two small children and also has a brother aged 64 who lives nearby with his wife.Mr. Jones has been diagnosed with type 1 diabetes since the age of 18 and has struggled with the management of his conditionresulting in numerous hospital admissions. Mr Jones stated he did not smoke but admitted to having an increased intake of alcohol. On arrival blood monitoring was performed which revealed un-recordable blood sugar levels which gave the clerking impression of diabetic ketoacidosis.The health care t eam then had the problem of potential death due to hypovolemic and metabolic shock caused by ketoacidosis. On admission to the checkup assessment unit (MAU) numerous assessments needed to be completed to discover the extensiveness of the condition and to provide baseline levels.Firstly, rapid ABC was performed with measurement of pulse, blood pressure, Glasgow coma scale, respiratory rate and pulse oximetry. Urinalysis was performed which indicated the social movement of ketones, and glucose and samples were sent for microscopy, culture and sensitivity. The patients full blood count was taken as part of the septic screen.The patients capillary blood glucose was taken and venous blood samples were be sent to the lab for U&Es which is essential in order to assess the baseline potassium as well as giving a biochemical indication of dehydration and renal function. Laboratory glucose is also an essential baseline investigation to identify glucose and evaluate blood sugar concentrations (Association for Clinical Chemistry, 2011).A baseline ECG is a mandatory investigation for a patient with DKA (Turner 2012). Blood gas measurements were used to evaluate Mr. Joness oxygenation and acid/base status and from the blood gas a pH result was obtained as well as a bicarbonate levels and PC02 (the numerate of carbon dioxide released into the blood) levels (ACC, 2011).The results of the numerous tests confirmed the diagnosis of metabolic acidosis. Metabolic acidosis is characterised by a lower pH and decreased bicarbonate, the blood is too acidic on a metabolic/kidney level. A pH less than 7.4, low bicarbonate and low PC02 will indicate metabolic shock and DKA (ACC, 2011). The assessments that were undertaken on Mr Jones revealed that he fitted the criteria for diagnosis of diabetic ketoacidosis.According to The Joint British Diabetes Society (2012) to diagnose DKA the three of the following must be present blood glucose over 11mmol/l or known diabetic, blood ketones above 3mmol/l or urine ketone ++ or more and venous pH less than 7.3 and/or bicarbonate below 15mmol/l. Once the diagnosis was made, specific, achievable, measurable, realistic and time limited goals of care for Mr. Jones were made.