My Nursing Education

By Nancy Lydia Kimmel, R.N. Ph.D. C.H.M.M.

Immigration to the United States has never ceased. It is a continual process that brings a variety of rich cultures and knowledge this great country. Health care workers experience the vastness of cultural diversity more so than any other profession. Therefore, more than any other profession, health care workers, nurses and physicians in particular must be culturally sensitive to the patients needs.

As the population of the United States continues to increase, hospitals are more likely to see more patients that have cultural needs. Meeting the cultural needs of a patient is essential in treating the whole person. Enhancing a client’s mental and physical wellness is the responsibility of the nurse. The nurse must attempt to use all of the resources at their disposal to see that the client receives the care that they need.

Nurses are faced with a great challenge when treating clients of various ethnicities. Hospital rules are not always congruent with the requests of patient’s families. Hospitals with set visiting hours may pose a problem for the nurse who recognizes that the patient needs family members around them at all hours. Hospitals do not always cater to the patient’s diet. Hospitals in Dearborn Michigan now carry Halal food for the patients who are of the Islamic faith. The city of Dearborn has one of the highest populations of Arabic speaking peoples in the nation. Hospitals had to recognize that to give quality care, they had to be sensitive to the client’s needs.

Nurses may not be able to change hospital protocol, but they can make a significant difference in how the patient views his or her health care. Therefore the nurse must make every effort to ensure that the patient’s needs are met. It may be to allow family to visit on off hours, or to have a plate of food brought in from home. Many cultures have a theory about sickness. In this theory, there are cold foods and hot foods. Each of these foods is used to treat a particular sickness.

Preventing families from taking a integral role in their loved ones care could possibly impede the healing process, by adding additional stress. Stress has been known to cause numerous illnesses. The nurse must attempt to balance the care that the family gives while in the hospital with the rules and regulations of hospital protocol. This can be a fine line. However, the patient comes first. To facilitate an atmosphere where the client feels most comfortable is the goal of the nurse as well as the other medical staff. Of course one would not encourage food from home if the client had leukopenia, or their immune system was compromised.

A nurse must possess the skill and compassion to facilitate the healing process from the first meeting. When the client cannot speak English the nurse should do their best to enlist an interpreter. Using a family member is not a wise choice, due to the fact that the family member may not know how to translate medical terms or may be selective in translating so as not to worry their loved one. Interpreters are usually employed by hospitals to assist medical personnel. Some hospitals have what is known as the “Blue Phone”. The Blue Phone is a direct line to an interpreter of choice for a specific language. The nurse merely has to hand the phone to the patient after explaining to the interpreter what the patient needs to know.

Being a culturally sensitive nurse can bring about positive change and improve the healing process. The client will want to return to that hospital if they find it necessary, and will recommend other family members as well.

In these troubled times in which we live, there exists a constant threat of disaster. Whether the disaster is man made, such as war or terrorism, or from nature, nursing has always been at the forefront. In the past, nurses were on the battlefield dressing the soldier’s wounds and giving emotional support to those whose time was at hand.

Formally, the occupation of nursing began with Florence Nightingale during the Crimean war. Even prior to that time there were those caring individuals who were first responders to disaster situations. Now more than ever, there is a need for nurses to become educated in the field of disaster nursing. The destruction unleashed by Hurricane Katrina tested the immediate response and mobilization of many doctors and nurses, as well as the merit of government response, to which in the final analysis the general consensus was one of “we could have done better.”

In spite of the many critics that abounded after the destruction, there stood those individuals who shined so brightly with their selflessness and compassion. These are nurses and doctors working around the clock in unsanitary conditions not unlike a battlefield hundreds of years ago.

One has to ask, “How is this possible in today’s world, with all of the state of the art technology that abounds in medicine and communications.” And yet, there it was in black and white, people were dying from lack of medical supplies and unsanitary conditions. The brave and caring souls who stood by and could perhaps only hold a hand, give a comforting touch, and say some kind word to someone who was taking their few last breaths were the ones that made the difference. Here was a case of disaster nursing like no other. These are men and women who stayed behind to care for the sick and dying, not knowing when or if any supplies would arrive.

In classes that are now taught currently in nursing schools on disaster nursing, the pervading theme for every new nurse to remember is to treat the walking wounded first. One would not think that this should be the case when someone is dying from blood loss or is badly wounded. Shouldn’t those who are so badly wounded be treated first? The experienced nursing instructor will nod her head and ask the student, “O.K., what happens when you exhaust all of your blood supplies on a patient that perhaps won’t last a few hours? What will you do when a patient who needs only minor care and does not get it due to your time expended on someone who is dying, goes into complications that could have been prevented? Now what kind of situation do you have?” The student nurse will not know what to reply. However the nursing instructor will reply the following, “Treat your walking wounded first. They will be your help.”

This statement may seem harsh at best. It is however the rule of the disaster scenario. There will be those that you cannot help, and that is a fact. Therefore, you must treat those that can be of help to the nurse. Once you have treated these people, they can then proceed to follow your instructions. They will be the ones to give CPR, wrap tourniquets and do whatever it is that the nurse thinks that they can handle. How many of us can actually imagine a situation like this? The nurses who assisted the wounded during Hurricane Katrina lived it day after day.

No one knows where or when a disaster may occur. We are constantly being bombarded by the news informing us of elevated terror threats using colors. The fact is that most people are never prepared for a disaster. This does not mean that we should not try. This is the reason for teaching disaster nursing in nursing schools. Nurses have to learn about how to be a leader, how to mobilize teams, and organize people. Not a small task. This is why that nurses should constantly update their knowledge.

With the advent of new types of biological and chemical warfare, scenarios such as Hurricane Katrina could pale in comparison. First of all, every nurse should register themselves with a local emergency response team in their area. Secondly, every nurse should begin to read and obtain various continuing education credits in the field of disaster nursing. Hopefully they will never have to use their new found knowledge. However, if the time were to arrive that their nursing experience was required, then they would have some idea what to do. For it is their decision making and leadership skills that will facilitate saving the most people, and it is very possible that they will be alone in making such decisions.

Diagnosis Bipolar Disorder: Bipolar disorder is a severe biologic illness characterized by recurrent fluctuations in mood. Typically, patients experience alternating episodes in which mood is abnormally elevated or abnormally depressed-separated by periods in which mood is relatively normal. (Lehne, 2004, p. 321)

The following is a short synopsis according to the DSM-IV-TR, Criteria for Bipolar Disorder includes a distinct period of abnormality and persistently elevated, expansive, or irritable mood for at least:
- 4 days for hypomania
- week for mania

During the period of mood disturbance, at least three or more of the following symptoms have persisted and have been present to a significant degree:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual or pressure to keep talking
- Excessive involvement in pleasurable activities that have a high potential for painful consequences. (American Psychiatric Association [APA], 2000).

Psychodynamics of the Disease The onset of the disease usually occurs during late adolescence or in the mid twenties. However, the disease has been known to occur up into the fifth decade of life. The mood swings that accompany this disorder are of several types. They are as follows: the Pure Manic Episode, evidenced by hyperactivity, excessive enthusiasm, and flight of ideas, constant wakefulness without sleep,

Impairment in normal social functioning usually requiring hospitalization; Hypomanic Episode, evidenced by a milder form of the Pure Mania, without the loss of normal functioning that would require hospitalization; Major Depressive Episode, characterized by depressed mood consisting of symptoms such as anhedonia, avolition, alogia, affective flattening and thoughts of suicide and death; the last episode associated with Bipolar disorders is the Mixed Episode in which, patients experience symptoms of mania and depression simultaneously. The combination of high energy and depression puts them at significant risk of suicide. (Lehne, 2004, p. 321)

Case Presentation
A Caucasian woman in her mid twenties presented signs and symptoms of self mutilation with a straight edge razor inflicted gash across her lower abdomen approximately six inches below the umbilicus. The depth of the gash just stopped at the abdominal fascia. The patient was sent from the emergency room to the psychiatric floor. Upon meeting the patient one day after her admission to E.R., she appeared dressed in pajama bottoms and a t-shirt, shuffling down the hall in her socks. She was holding her abdomen with one hand and appeared in some discomfort. Her black hair was short and disheveled. When the patient arrived at her room she sat down on her bed. She acknowledged with blunted affect that she cannot stop self mutilation, and described how she cut herself through the muscles in her abdomen almost down to the fascia. Her voice was tremulous and fast paced. This could be due to the fact that she had just been given her first dose of Clozaril. She stated that her mouth was dry and that she needed to drink some water. She then went on to say that she was getting very sleepy. The client felt comfortable with the interview.

She shared personal information in regards to being sexually abused by her bother beginning at the age of seven until the age of fifteen. Her brother was two years older than her and died in an automobile accident at the age of eighteen. She went on to say that her mother never knew or acknowledged the sexual abuse and that she could not tell her because the mother idolized the son. The client was receptive to cognitive reframing; however she was very critical of herself and stated that she felt worthless and ashamed. She appeared very tired and stated that she wanted to sleep.

Table 1
Textbook characteristics of Bipolar disorder versus client characteristics observed

Textbook Characteristics:
Pure Manic Episode
Hypomanic Episode
Major Depressive Episode-
Affective Flattening
Alogia
Avolition-apathy
Anhedonia
Mixed Episode
Rapid-Cycling Bipolar Disorder- Patients experience four or Client

Characteristics Observed:
No current symptoms
Rapid breathing, rapid speech, however due to medication a client was concurrently exhibiting lethargy
Client acknowledged sadness/ worthlessness
Facial expression flat
Thoughts of dying, hard to focus
Hair/clothes unkempt
Expressed no interest in children or own

Client’s Symptoms
1. Hypomania
2. Depression
a.) Affective Flattening
b.) Alogia
c.) Avolition & Apathy
d.) Anhedonia
3. Mixed Episode
4. Rapid Cycling
(Varcarolis, 2004, p. 485)

Nursing Interventions
1. Observe the client every 15 minutes while suicidal, remove all dangerous, sharp objects from room.
2. Reinforce that she is worth while,
a.) Assist the client in evaluating the positive as well as the negative aspects of her life
b.) Encourage the appropriate expression of angry feelings.
c.) Schedule regular periods of time throughout the day for recreational/occupational therapy, encourage client to groom self, offer praise for completing grooming.
d.) Ensure client’s participation in taking mood stabilizing medications. Watch client swallow medication.
3. Engage client in interpersonal therapies, cognitive-behavioral therapy,
4. Encourage client to attend group therapy, and journal episodes.

Table 2
Medical Interventions, Bipolar Disorder
Drug therapy using
Mood stabilizer
Antidepressants
Antipsychotics
Education and Psychotherapy
ECT
(Varcarolis, 2002, p. 483)

Clients Medical Interventions
Drug therapy includes
Lithium 300mg every h.s.
Not taking any Clozaril
Client is receiving psychotherapy, family counseling, group therapy while in hospital, and cognitive restructuring.
None

References
Lehne, R. (2004). Pharmacology for Nursing Care. Missouri: Saunders
Varcarolis, E. (2002). Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. Pennsylvania: Saunders

By Nancy Kimmel R.N., Ph.D., C.H.M.M.

The quality of life and health are greatly increased when those who are diabetic control their blood glucose levels consistently throughout the day. Tight glycemic control can prevent many of the illnesses associated with diabetes such as peripheral neuropathy, glaucoma, cardiovascular disease and hypertension. A good predictor of careful blood glucose monitoring is the Hemoglobin A1C test. This test can measure the amount of glucose that has bound to blood cells over ninety to a one hundred and twenty day period, which is the approximate life of a red blood cell. As it happens, glucose, once bound to a red blood cell, stays bound to it for the course of the blood cells life. The acceptable level that indicates good glycemic control is 7.0% or less. (1). Levels greater than this indicate that the diabetic individual needs to exert greater control over their blood sugar levels. Many times, diabetics will insist that they are doing a successful job at monitoring their blood glucose levels, until their hemoglobin A1C results come back with results greater than 7.0%.

It is not unusual for diabetics to become frustrated, or overwhelmed with the task of managing their blood glucose, administering insulin and eating a well balanced diet. Those diabetics, who have led a sedentary life style, are over weight, drink and or smoke, are placing their health in jeopardy by not adhering to their blood glucose monitoring regime. Finger sticks two to four times a day are not pleasant. Combine that with the insulin injections, and it is no wonder that many diabetics continue to ignore their medical problem. Also, many diabetics will say that they feel good, so there is no reason to monitor their blood glucose carefully. What the diabetic needs to understand is that although they may feel well, their blood glucose can still be at a level that is physiologically destructive. A blood glucose level of 160mg/dl may not make the diabetic notice any physical symptoms, but internally that extra sugar can break down muscle tissue, affect their kidneys and start plaque build up in their arteries by raising their LDL’s (low density lipoproteins). Family, friends and visiting nurses can help the diabetic manage their blood glucose consistently. Those members of the family who buy the groceries should keep healthy foods on hand for snack time such as yogurts, carrots, fruit, nuts, and whole grain cereals. Family members should try to eat the same foods as their diabetic member. Limiting carbonated beverages, cakes, cookies and processed sweets in the household will help the diabetic family member realize that they are important and help them to adhere to a well balanced diet. It is important for the diabetic family member to know that they are not alone.

Friends can help in a similar fashion by suggesting a healthy restaurant when dinning out, such as Mediterranean or sea food cuisine. The visiting nurse can help by meeting with the diabetic client and the rest of the family, offering praise, support and knowledge. Praise and encouragement from the nurse can help renew the clients hope and the family’s commitment to the health of their loved one. The visiting nurse can bring new knowledge about treatments and tests, verify that the client is using the equipment properly and assess the injection sites. They can also bring supplies to the home, such as syringes, alcohol wipes and brochures.

Diabetic support groups are also very helpful. Family members should encourage their loved one to attend and accompany them. The more knowledgeable a family is about their loved ones illness the better they will be at helping them manage their condition successfully.

Family members need to encourage their diabetic loved one to express their feelings. Let them weep, cry, yell and or scream. Give them the freedom to express their emotions in an accepting and loving environment. Whether the diabetic is six or sixty, diabetes can make one feel all alone, and this can lead to apathy towards their illness. Family and friends can play a crucial role in helping the diabetic manage their blood sugar so that they can live a long, healthy and happy life.

Below is a list of some of the diabetic support groups.

References:
1. Lewis, Heiitkemper, Dirkesen, Medical Surgical Nursing 6th ed., Copyright 2006, Mosby, St. Louis., pages 1273 -1278.
2. www.defeatdiabetes.org/support_groups
3. www.accu-chek.com
4. www.Type2Diabetes-Info.com
5. www.ChildrensDiabetesFdn.org
6. www.diabetesinmichigan.org
7. www.diabetesmonitor.com

By Nancy Lydia Kimmel R.N., Ph.D., C.H.M.M.

Proper foot care is very important for people who are diabetic. People spend a great amount of time on their feet. Knowledge of proper foot care can save the diabetic individual from many future complications that can arise from foot care neglect, such as open wounds, infection, and loss of toe nails, poor circulation, peripheral neuropathy, septicemia and gangrene. Diabetes causes poor circulation, which in turn causes the diabetic individual a loss of sensation. The feet are the farthest away from the heart and are therefore the most susceptible to complications from injury.

Using common sense and taking some simple precautions will go a long way to promoting healthy feet. Here is a list of some of some healthy tips for diabetics regarding their foot care.
- Water should be tested with the person’s hand, and should be tepid not hot. Due to peripheral neuropathy, it is possible to use water that is too hot and can cause injury to the tissue.
- Use soap that is gentle on the skin, such as Ivory. or Dove.. Antibacterial soaps can be harsh on the skin, cause allergic reactions in some people.
- Instead of clipping the toe nails, use an emery board. Clipping the toe nails can lead to breaking the skin or ingrown toe nails.
- See a podiatrist on a regular basis, at least monthly. The podiatrist can clip the toe nails and determine if there are any areas of concern.
- Wear foot coverings at all times. Going barefoot can lead to unexpected injury from foreign objects as well as bacterial infection. Sandals that are open toed should be avoided. Always try to cover the entire foot. Use slippers while in the home.

Be sure to have comfortable shoes. Choose shoes that are a half size bigger and wide enough to accommodate cotton socks. Leather shoes are better than vinyl man made materials. The type of activity that someone engages in usually dictates the type of shoes to be worn. Comfort should be their priority. A diabetic may choose not to wear socks with their tennis shoes while engaging in an activity. If they are wearing shoes made of vinyl or leather, their feet will sweat profusely. Sweat from feet, especially in a slightly anaerobic environment (without oxygen) can become acidic, rather than alkaline. The acid sweat can irritate the skin and excoriate areas where there are sores beginning to form.
- Always use cotton socks. Cotton absorbs sweat more than any other material. Avoid nylon socks if possible.
- Avoid shoes that have high heels. High heels will push the toes forward and can easily cause ingrown toe nails and loss of feeling.
- Try to elevate the feet during the day. Schedule daily rest periods. When elevating the feet, try to keep the feet higher than the heart. This position allows blood to flow easier and enhances circulation.
- Avoid perfumed lotions on the feet. If dryness is a problem, use alcohol and perfumed free lotions. Be sure to thoroughly massage all of lotion into the foot, or dry off excess lotion.
- Dry feet thoroughly after each washing and air out feet if possible during the day.
- Avoid standing for long periods of time. Blood has a tendency to pool in the foot and ankle area, making it harder to circulate back to the heart.
- Avoid activities that can cause injury to the foot, such as soccer and football. If those games cannot be avoided, then choose good foot protection.

Using proper foot care sense with good hygiene can make living with diabetes easier and prevent unnecessary complications that could affect the quality of ones life.

References:
1. www.diabetes.org
2. www.diabetes-exercise.org
3. www.diabetesnet.com/diabetes_resources
4. www.ChildrensDiabetesFdn.org
5. Dudek, Susan G., Nutrition Essentials for Nursing Practice, 5th ed., Publisher: Lippincott Williams & Wilkins, copyright 2006

By Nancy Kimmel R.N. Ph.D. C.H.M.M.

So, you are a diabetic. If you have just been recently diagnosed, then there is much to learn. Be careful where you get your information. The doctor should be your first source. Your doctor should prepare you with literature and other teaching material, as well as give you referrals to help groups. Being a diabetic doesn’t mean your life is going to change. It does mean that you will have to make important decisions about your health maintenance. If your diagnoses requires that you take oral hypoglycemics then you need to know how they work, when to take them, and the signs and symptoms of hypoglycemia and hyperglycemia. For those who are required to take injections of insulin, they must learn how to give themselves injections, and take their blood glucose level. The best idea is to take it slow. All of this information may seem overwhelming at the beginning. No one expects you to know everything. Most of all be patient with yourself.

It is important to understand why you have diabetes. Diabetes whether Type I or Type II has been determined to have certain genetic links. Genetically speaking, Type I Diabetes risk to offspring from the mother is 1%-3%, risk to offspring of diabetic fathers is 4 %-6%, with identical twin concordance between 30%-50%. (1) In regards to Type II Diabetes the genetic predisposition of risk to first degree relatives is 10%-15% and identical twin concordance can exceed 90%. (1)

In Type I Diabetes the autoimmune system of the individual gradually destroys the beta cells within the pancreas. Signs and symptoms of diabetes do not begin to manifest until 80%-90% of the beta cells are destroyed. Beta cells are important because they are responsible for the production of insulin. Insulin is a hormone that controls the amount of glucose in the blood stream at any particular time. For instance, when a person indulges in a meal that is high in sugar content, there will be large amounts ofo circulating glucose in the blood. To protect the body from excessive amounts of glucose, there is cascade of hormonal signals that stimulate the pancreas to produce insulin and put the unused glucose back into the cell where it will stay until the body requires it. High glucose levels can put the person in danger of diabetic ketoacidosis. Excessively low levels of blood glucose can be just as dangerous as in hypoglycemia. The acceptable range of blood glucose levels considered optimum range between 90-120 mg/dl. The diagnoses of diabetes require blood tests for confirmation. Usually one of the following blood tests are done;

1. Fasting Plasma glucose level exceeding 126 mg/dl

2. Random, or casual, plasma glucose exceeding 200mg/dl, with the inclusion of the signs and symptoms of Type I Diabetes.

3. Two hour Oral Glucose Tolerance Test level exceeding 200mg/dl using a glucose load of 75mg.

Type II Diabetes is by far the most prevalent in those people diagnosed with diabetes. Also, certain populations have a predisposition to diabetes more so than others. Native Americans, Hispanics and African Americans appear to have higher rates of Type II diabetes than their non-Hispanic white counterparts.

The signs and symptoms of diabetes can differ depending on whether the person is Type I or Type II. For Type I diabetics, the symptoms include, polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger) as well as weight loss, weakness and fatigue. The signs and symptoms of Type II Diabetes are not as obvious as Type I. In Type II Diabetics, the onset is later in life. Also, their pancreas is still producing some endogenous insulin. Therefore, their symptoms are not as detectable. Symptoms include, delayed wound healing, peripheral neuropathy (decreased sensation or pain in extremities), fatigue and visual changes. or Diabetes, just like hypertension is a disease that must be treated for life. Diabetics who take proper care of themselves can live long healthy lives into their nineties.

References:

1. http://en.wikipedia.org/wiki/Beta_cell

2. Lewis, Heitkemper, Dirksen, Medical surgical Nursing 6^th ed., Mosby, copyright 2004, pg. 1270-1273.

Nancy Lydia Kimmel R.N., Ph.D., C.H.M.M.

Diabetes is an illness that the patient must live with the rest of their lives. The key to living with diabetes successfully is managing tight glycemic control, or controlling blood sugar levels. Blood sugar levels can vary from time to time depending on several factors such as stress levels, amount of food consumed, type of food consumed, amount of insulin used or insufficient insulin coverage and the time of day.

The human being responds to Circadian Rhythms. These are regular changes in mental and physical characteristics that occur in the course of a day. This term may be more familiar as the, “biological clock”. A good example is that of someone working midnights for the first time. They find it very difficult to sleep during the day and stay awake all through the night. It is as if their body has a mind of its own. In fact, there is some truth to that statement. Bears hibernate because of their biological clock.

Circadian Rhythms combined with the above mentioned factors can produce wide fluctuations in the blood glucose levels of diabetics while they sleep. A diabetic’s blood glucose level may be at 135 mg/dL prior to bedtime and at two A.M. may drop to 40 mg/dL, causing a severe state of hypoglycemia. The body responds to such a drop by producing glucose from alternate sources, since there is no source of ingested food. The only sources of glucose come from the liver via gluconeogenesis, lipolysis (break down of lipids) and glycogenolysis.

The body’s hormones stimulate this cascading response to dangerously low blood sugar. The results of such a response, is that of high blood sugar. This rebound hyperglycemia can in turn causes ketosis. Ketosis occurs because the body is fooled into thinking that there is not enough glucose, since the cells are starved, and the glucose is floating in the blood stream instead of being utilized within the cells. The body then begins to break down proteins which in turn cause the release of ketones. The release of ketones causes the pH of the system to drop. If the pH of the body drops below 7.35, a state of Diabetic Ketoacidosis occurs, which can cause a diabetic coma.

This rebound hyperglycemia known to occur in response to hypoglycemia in the early hours of the morning between two and four A.M., is called, the Somogyi Effect. A good way of detecting the Somogyi Effect is to have the diabetic test their blood sugar during those hours. If their blood sugar is low, then they can correct it by eating a snack, before going back to sleep.

The Somogyi Effect can occur at anytime during the day, but is most often equated with the early hours of the morning. Symptoms include headache, nightmares and night sweats. The treatment of this phenomenon usually involves lowering insulin dosage prior to sleep.

Another disorder similar to the Somogyi Effect is known as the Dawn Phenomenon. Although most diabetics are affected by this disorder, it seems to occur more often in pubescent adolescents. Adolescents’ blood sugar is affected adversely by their body releasing counter regulatory hormones. These counter regulatory hormones produce precipitously high blood sugar levels. It is thought that the growth hormone has some impact in relation to the production of counter regulatory hormones. Usually upon waking, the diabetic’s blood sugar is excessively high. Correction of the Dawn Phenomenon requires an increase in insulin coverage prior to bedtime.

It is easy to see how both of these disorders can be mistakenly diagnosed for the other. That is why it is important for the diabetic to test their own sugar on several early morning intervals and present the results to their doctor. Correct determination of which disorder is occurring is crucial to continued health of the diabetic.

References:

1. Lewis, Sharon., Heiitkemper, Margaret., Dirkesen, Shannon., Medical Surgical Nursing 6^th ed., Copyright 2006, Mosby, St. Louis., pages 1273 -1278.
2. www.defeatdiabetes.org/support_groups
3. www.accu-chek.com
4. www.Type2Diabetes-Info.com
5. www.ChildrensDiabetesFdn.org
6. www.diabetesinmichigan.org

7. http://healthlink.mcw.edu/article/922567322.html

Once a patient is diagnosed as having diabetes, their world suddenly changes. Now they must monitor their glucose before meals and at bedtime, they must watch the sugars that they consume and be aware of the signs and symptoms of hypoglycemia and hyperglycemia and know what actions to take. This is a lot of information to process for a diabetic of any age. Type 1 diabetics tend to develop diabetes during adolescence. Type 1 indicates that they are dependent upon insulin to control their blood sugar. Type II diabetics usually develop diabetes later on in life and they are prescribed oral hypoglycemic agents to control their blood sugar. A healthy diet can make a positive impact on the diabetic’s life expectancy. Knowing what foods to eat and what foods to avoid is the cornerstone of managing diabetes, as well as tight glycemic control. Therefore nutritional intervention is the responsibility of the nurse, to help promote the health and well being of the patient. Nutritional recommendations for diabetic’s is similar to that of the National Cholesterol Education Program.

In the diabetic patient, their production of insulin (a necessary enzyme produced by the beta cells on the Islets of Langerhan within the pancreas) is insufficient. In type I diabetes, insulin deficit occurs at an early age, whereas in type II diabetes this insulin deficiency takes years to deplete. Lack of insulin allows proliferation of large amounts of glucose to travel freely throughout the blood stream. Insulin administered subcutaneously or via pill form, helps to move glucose from the blood stream back into the cells. Levels of normal blood glucose levels range from 70 -120 mg/dl, although some literature suggests levels up to 145mg/dl as normal. Excessive amounts of glucose in the blood stream can cause numerous health problems. Diabetes has been directly related to some of the following illnesses; kidney disease, high blood pressure, peripheral neuropathy, glaucoma and heart disease. Therefore it is essential for the diabetic patient to have a good understanding of the foods that will benefit them. Recommendations include choosing carbohydrates from grains, fruit and vegetables. Consistency of carbohydrates eaten regularly for snack and at meal time is a crucial factor in glycemic control, more than the type of carbohydrate eaten. Diabetics who receive either insulin or Lantus® (a long lasting insulin) at night should be instructed to eat a snack in the middle of the night to prevent a dramatic drop in blood sugar in the dawn hours. Hypoglycemia can be just a dangerous as hyperglycemia. The signs and symptoms of each state mimic the other. The rule of thumb is to treat the onset of either with a source of fast acting glucose source, such as a hard candy or fruit juice, and then check the blood sugar. Hypoglycemia can cause a coma. The brain is the only organ in the body that utilizes pure glucose. Therefore, by depleting the brains only source of food, the brain will cease to function. So, it is better to treat with fast acting sugar first. This is not going to raise the blood sugar appreciably if the blood sugar is already high. However, if the persons blood sugar is very low, then the addition of a fast acting sugar can save their life immediately. Of course, in a hospital setting, the nurse would immediately check the client’s blood sugar with a glucometer. Sucrose can replace starch without effecting blood sugar levels dramatically. The client should make a list of the foods that they are used to eating on a regular basis and with the help of the nurse re-structure their diet with choices from the food pyramid. Allow the client to choose the foods that they want to substitute. This is going to be their life diet, and it is very important that they be the one to structure how and what they eat. The patient should verbalize the benefits of the foods and what type of sugar source the foods represent. Once the patient can express their dietary plan, and the type of foods that are beneficial as opposed to those foods that are merely empty calories, the patient will feel encouraged and become more involved in their blood glucose monitoring.

References:

Dudek, Susan G., Nutrition Essentials for Nursing Practice 5^th Ed., Lippincott Williams & Wilkins, copyright 2006

When the individual’s blood sugar gets very high and they are profoundly deficient in insulin, the body becomes unable to utilize blood sugar efficiently. The body then begins to burn fat stores for food. As these fat stores are burned, a by product is released called Ketones. It is ketones that are responsible for lowering the body’s pH level below 7.35. Metabolic acidosis occurs when the pH of the body drops below 7.35. The body attempts to excrete the ketones via the kidneys, causing ketones to be released in the urine, a term called ketonuria. However along with the negative ketones, the body’s positively charged electrolytes are also excreted. This leads to an electrolyte imbalance. The body continues to burn other glucose stores in the body such as proteins, causing nitrogen losses.

Now the body has depletion in electrolytes. This can cause nausea and vomiting, depleting more electrolytes. The individual is now in a severe hyperglycemic state and is hypovolemic as well. If these conditions are left untreated, the person can go into hypovolemic shock, become comatose and die.

Outward signs and symptoms of DKA include the following; eyeballs are soft and appear sunken, skin turgor is poor, (Dehydration of tissues can be tested by pinching the skin fold on the sternum. If the skin stays in one place or does not loose its shape rapidly, then dehydration can be assumed.), the person is very pale, cold, clammy, and exhibits deep rapid respirations, an effort the body makes to eliminate excess carbon dioxide. The individual may also exhibit severe abdominal pain and tachycardia, (heart rate greater than 100 beats per minute.) Diagnostic laboratory findings from arterial blood gases would indicate a pH less than 7.35, blood glucose level greater than 250 mg/dL, serum bicarbonate level less than 15 mEq/L, as well as ketones in the urine.

Interventions must be immediate to prevent irreversible destruction to the body’s organs and prevent coma or death. Ensure a patent airway, and begin to administer oxygen via nasal cannula or mask. Establish an intravenous access with a large bore needle (18 to 20 gauge). Begin fluid stabilization with 0.9 Normal Saline. This is an isotonic fluid, compatible with the body’s pH. The purpose of using an isotonic infusion initially is to re-establish blood pressure which was low and to increase urinary out put to 30-60ml/hr. When urinary output is less than 30 ml/hr, kidney failure can rapidly occur. Fluids should continue for one hour or until stabilization occurs. Next begin insulin infusion with a drip rate or 0.1U/kg/hr. During this time it is important to monitor the person’s vital signs every fifteen minutes until stable or for at least one hours after treatment begins. If necessary, potassium should be administered to correct for hypokalemia, and sodium bicarbonate to correct for metabolic acidosis, if the pH is less than 7.0. The person should also have electrocardiogram leads placed on chest to monitor heart rhythms.

When the diabetic is at home and feels these bodily signs and symptoms beginning to occur, they should take the following steps; call 911, check their blood sugar, administer insulin per sliding scale, drink an electrolytic fluid, (i.e., sports fluids), breath into a paper bag, use oxygen if available, lie down, raise feet level with the heart and wait for the ambulance.

Preventative measures to avoid DKA include consistent control of blood sugar with administration of insulin per protocol. The diabetic should avoid too much food intake, and avoid taking too much or too little insulin. Stressful life situations can also cause elevations in glucose levels. Therefore the diabetic should prepare to check their blood sugar more often during times of stress and administer insulin as prescribed.

Understanding the complications of diabetes can help the diabetic take the necessary actions to prevent DKA from occurring and help them live a healthy life.

References:

1. Lewis, Heiitkemper, Dirkesen, Medical Surgical Nursing 6^th ed., Copyright 2006, Mosby, St. Louis., pages 1273 -1278.
2. www.defeatdiabetes.org/support_groups
3. www.accu-chek.com
4. www.Type2Diabetes-Info.com
5. www.ChildrensDiabetesFdn.org
6. www.diabetesinmichigan.org
7. www.diabetesmonitor.com

If you have the desire to go into nursing, then you must first get ready to take the N.E.T., the HESI or the TEAS entrance test. You can begin preparing for your career by practicing your skills using the online tutorials and tests at The Nurses Learning Center. There are over 1000 questions and answers. You will get unlimited internet access, 24/7. It is yours to keep. New questions are added daily. It’s like sitting for the N.E.T., The HESI or the TEAS in your home.

My Experience in E.R.

Nursing/Medical Surgical 222

By Nancy Taji

Upon arriving at the emergency room at 8:00 A.M., I was greeted by a nurse at the desk who asked me if they could be of service. I explained that I was there to a make up clinical day with a staff nurse who was also an instructor at Henry Ford Community College Nursing Department. They assigned me to Sam, short for Samantha. She was a very kind woman, who immediately began to show me the ropes. The first thing that she showed me was how the rooms were set up. As it turned out the rooms were arranged in a circle from one to seventeen. There were only a few rooms open at this hour. She explained that the midnight shift was very busy and that many of the patients currently have been there since late last night. She began to show me how the E.R. charts were put together and the trail of paperwork that had to be followed. It seemed rather confusing to me. I could immediately see how things could get quite crazy as more and more patients were to come in. The first patient we went to see was a young woman in her early thirties who had come in because of chest pain. Sam asked me to do an assessment on her. I greeted the patient and performed a complete assessment as taught in nursing school. Sam, then showed me the med room. What I found very interesting, was that the med cart was activated by fingerprint identification. “Wow”, I said. “This is definitely, high tech stuff.” Sam agreed. She said that this is the type of med cart that you would frequently come across when working in a E.R.. The cart was computerized so that it counted the meds each time one was programmed out of the cart. The E.R. doctor was very gracious in explaining to Sam and I the purpose in ordering a dose of magnesium for the patient. I have to say that I couldn’t understand all of what he said other than that magnesium helped women that were in labor as well as helping the heart muscle. Sam asked me to prepare the magnesium. I had to draw up the magnesium from two vials and then inject it into a I.V. fluid so that it could be given. Sam and I went back into the room where I hung the magnesium I.V. on a pump, while Sam gave her something for pain.
I soon found my self separated from Sam. Though, I am not sure how this exactly happened. I believe that it started when one of the other E.R. nurses asked Sam if she could show me how she wrapped a frost bite burn. So off I went with another nurse to see how this was done. She went into a room where a gentleman was lying on a stretcher, looking rather disheveled with his bare feet sticking out from the covers. The nurse pointed out several of his toes that were a dusky blue. “Not a good sign”, I thought to my self. The E.R. doctor came in just prior to the nurse wrapping his toes to evaluate his condition. “Not bad, you must have some good circulation”, the E.R. doctors said to the man. The man replied in a not so concerned voice as he sipped a cup of coffee, “do you think I’m going to loose them Doc?” The doctor replied, “We won’t know just yet, let’s wait a while and see how this warming blanket works.” After the doctor left the nurse began to wrap the mans toes by first applying Silvadine ointment and then wrapping them with gauze. When she left the room, I decided to say a while longer and talk to this gentleman. I asked him if he a place to stay, when he leaves the hospital. He replied that he did not have anywhere to go, that the last place that he was staying in, which was a shed was no longer an option. This was because someone called the police on him, and the police asked him to leave since there was no plumbing or heat. I thought to myself, “so it’s against the law to stay somewhere that provides shelter, but if it doesn’t have hot and cold running water, you have to live outside.”. I bent down to pick up his clothes that had fallen on the floor and put them back on the chair only to find they were wet to the touch and extremely dirty. Pity filled my heart for this man. He asked if he could have some more coffee, stating that he was a coffeeholic, and that he could sit here all day and drink the stuff. Funny, how something so small like a cup of hot coffee could make someone so happy. Realizing that I couldn’t change the world, I briskly walked over to the coffee pot that seemed to have a endless supply of coffee in it at all times and poured the man a cup. After that, I just kept the cups coming. I moved on to several other patients, completing assessments the best that I could, and passing my information to the nurses and E.R. doctor. I had a feeling of some autonomy while I was in the E.R.. I’m not sure if that was a good thing, seeing that I was there to work directly with Sam. However, I knew that she must have been keeping a close eye on me, of which I was glad. It made me feel secure. All in all it was a good experience for a student nurse. There were a couple of very intense and emotional moments that took place while I was there that day, but I feel that I cannot write about them since they are too fresh in my mind and elicit some very strong feelings. The emergency room is a place were an experienced nurse can apply her expertise and still gain knowledge. I felt very fortunate to have had the opportunity to work with Sam. She is a special individual.

If you have the desire to go into nursing, then you must first get ready to take the N.E.T., the HESI or the TEAS entrance test. You can begin preparing for your career by practicing your skills using the online tutorials and tests at The Nurses Learning Center. There are over 1000 questions and answers. You will get unlimited internet access, 24/7. It is yours to keep. New questions are added daily. It’s like sitting for the N.E.T., The HESI or the TEAS in your home.