CLINICAL VIGNETTE ESSAY: PATIENT HANDOVER TO HDU
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Introduction
Sophia Jane Wilson, a 76- year old woman, presented to the hospital 24 hours ago, accompanied by her husband. At the time, she was complaining of flu-like symptoms, including a dry cough, fever, malaise, and a loss of appetite. The patient, who has diabetes 2, also has a heel ulcer, reportedly caused by something she stepped on in her garden a month ago, and which has still not healed. The patient also has hypertension and hypercholesterolemia, for which she has been treated before. Her husband also says the patient was irritable, and confused before he presented her to the hospital. This vignette essay seeks to discuss the patient’s pathophysiology, as part of the handover process to a multidisciplinary team at the HDU. This handover document will aim to discuss the main health issues of the patient and in the process, hand over the professional responsibility and accountability to the multidisciplinary team.
Patient assessment
In initiating and executing the handover of the patient to the High Dependency Unit (HDU), the nurse in charge has ascertained, together with the multidisciplinary team, that the patient’s condition warrants a transfer. This is evidenced by the gradual deterioration of the patient’s vital signs, as well as the certainty that in the HDU, the patient will be monitored better, and the necessary interventions prescribed. Among other reasons, Yazdanpanah, Nasiri, and Adarvishi (2015), in their article on foot ulcers in patients with diabetes, refer to the injury as one of the most devastating, and one that, if not dealt with properly, could result in an amputation of the lower limb. At the same time, research by Penckofer et al (2012) shows that glycemic variations in diabetic patients, and particularly women, has a significant impact on their mood variations, and general quality of life.
Sophie is suffering from an abnormally fast heartbeat, which has worsened over the last two hours. The patient is Hypoglycemic. This may help explain the fast heartbeat experienced by the patient. Additionally, the patient is at risk of suffering an irregular heartbeat. According to Chow et al (2014), one of the interventions to control glycemic is intensive glycemic therapy, which increases the chances of cardiovascular mortality in patients.
The patient has an abnormally low blood pressure, which has also decreased since the last measure. The hypotension is a common feature in diabetic patients who have a fast heartbeat. However, the lowering of the blood pressure needs a more careful monitoring and intervention. As Abisheganaden et al (2012) show in their work on the issue, low blood pressure causes dizziness, confusion, and irritability. The patient’s struggle to understand where she is and the other symptoms are consistent with low blood pressure. Low blood pressure is dangerous, especially in older people. It is therefore important to have the patient under closer observation to ensure that she recovers well enough.
Normal people have a respiratory rate of between 12-16 per minute. However, Sophie’s rate is 22, having come up from 18 a couple of hours back. This is another concerning observation. The fast respiratory rate points to cardiovascular or respiratory health issue. Abisheganaden et al (2012) show that the unusually fast rate of respiration could be tied to community – acquired pneumonia, or other forms of pneumonia. This is especially so in older patients, who may have underlying issues. In the case of Sophie, the underlying issue is diabetes. However, at the same time, the patient has been treated for hypertension in the past. This demands an additional examination of the patient’s respiratory system to rule out pneumonia.
Sophie has abnormally high levels of hematocrit. Normal levels for women peak at 0.48, but her levels are currently at 0.52, and going up. The high levels signify an infection, in either the lungs or the heart. The patient has been treated before for hypercholesterolemia, which would suggest the high level of red blood cells in her blood. At the same time, however, the patient has a dry cough, and malaise that is yet to be identified. This could suggest a lung infection, independent of the diabetes that already afflicts her. As Wagener et al (2018) show in their work on the subject, the other considitons assessed here, in addition to the blood measures in this passage indicate the presence of a lung infection. Hwang et al (2017) also link the abnormally high measures of hematocrit to diabetic foot, which the patient suffers from as well.
The patient’s platelets count is normal, and well within the expected range. This is despite the fact that the patient is currently battling an ulcer to the foot, and a possible infection in the ling, as well as other health issues. With such a disease burden, it would be expected that the patient would have higher than usual levels of platelets, which would be used to fight off infections. After a while at the HDU, the patient’s platelets count has stabilized, and even dropped. This could be the result of pharmacological intervention. However, it may also signal the patient’s inability to respond to issues affecting her, partly due to diabetes, but also due to a serious, if non-chronic, medical condition.
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Pathophysiology
The most physically visible issue facing the patient is the heel ulcer. The patient has had this ulcer for a month, and from the examination conducted on the patient, there are no signs that it is getting better. The levels of hematocrit seen in the lab examinations may be a response to this problem.
Sophie has had a fever, which has not abated over the last three days. The fever has been accompanied by a dry cough, though results of the x-ray to the chest are not conclusive. The presence of the fever accompanied by a fever is usually a sign of viral pneumonia. Pneumonia is a leading cause of mortality and morbidity in the world. The disease is an infection of the respiratory organs.
People with diabetes also have a low immunity against illnesses that they would otherwise deal with comfortably. Pneumonia is one of those opportunistic diseases that infect people with a low immunity. Sophie, after some time with diabetes, is especially prone to pneumonia. The initial symptoms of pneumonia, namely a dry cough, and a fever, are consistent with this. The pathophysiology of the dry cough and fever can therefore be concluded to be pneumonia (Berbudi et al, 2020).
For many wounds, the body, and some pharmacological interventions, are enough to ensure the wound heals within a reasonably short time. Having diabetes, however, may have different outcomes. A patient with diabetes will see their wound fester, in some cases even occasioning the amputation of the lower limb Hwang et al (2017).
One of the other signs of pneumonia, especially in older adults, is delirium, confusion, and irritability. Patients with pneumonia undergo severe swings in their moods, and can appear confused, sometimes even failing to gather where they are. These symptoms are clear in the patient. Her husband has reported that Sophie has become increasingly irritable, a condition that has increasingly worsened over the last three days. This can also be attributed to pneumonia.
The patient’s leg is swollen, when compared to the other. This is down to the ulcer, which has occasioned an edema as the body tries to fight off the infection, albeit with little success.
Pharmacology
The drugs currently being taken by the patient after admission to the hospital all paint the picture of a medical care that wants to manage the patient’s high blood pressure, and diabetes. There is also a painkiller, to minimize the pain the patient has because of the ulcer. There is no medication currently prescribed for pneumonia or a flu-like condition.
The patient is currently being treated with Cartia, 100mg. This is a common medication for hypertension. It works to regularize the condition. The patient takes a relatively low dosage, meaning that her condition has not been acute before the hospitalization.
The patient is also taking glibenclamide. The drug works to improve the pancreas’ release of insulin, which in turn regularizes the blood sugar levels in the patient. The drug reduces the production of insulin by the liver, while simultaneously increasing the production of insulin by the pancreas.
Another drug taken by the patient after medication is cardizem cd. The drug works by relaxing heart muscles, and in the process, easing hypertension. It is also important in regularizing the heartbeat. Another drug taken by Sophie is enoxaparin, which acts by reducing high blood pressure, particularly when such pressure is caused by artery clogging.
Paracetamol is another drug being taken by the patient. The drug is a common painkiller. The patient has been experiencing a low level of pain (1/10). The painkiller can comfortably minimize this.
Critique of monitoring and diagnostics
Fever is an important symptom that the onset of a serious illness has occurred. Fever may be extremely high, or relatively low. In all circumstances, it needs to be monitored closely, since it will call attention to areas that might have been ignored. A more important reason for monitoring fever in the patient is that the patient, with preexisting conditions, has several issues that could potentially result in a fever. For instance, the diabetic foot may cause fever, as may the incidence of pneumonia. In some instances, a flu would also manifest itself in a fever (Xiao, Wu, & Liu, 2020). It is therefore critical to ensure that the issue is monitored more closely, in the HDU.
A diabetic foot is a dangerous proposition for any diabetic patient. An ulcer to the foot can easily go unnoticed, especially if it is originally small. A patient may not notice the issue until it is too late. The patient in this case seems to have ignored the issue for around one month. In fact, the reasons for seeking medical intervention are not related in any way to the diabetic foot. The additional monitoring is justified by the fact that it could lead to an amputation of the foot, or even a fatality of the patient (Dalla Paola et al, 2015).
The patient’s heart rhythm is too fast, while her blood pressure is unusually low. Among other reasons, it could signify the inability of drugs being taken right now to manage the situation effectively. It could be that the patient’s condition has recently worsened, or a new condition is developing. When taken together with the other serious symptoms scrutinized here, further, and more intensive monitoring and diagnosis is necessary.
The comprehensive blood tests undertaken on the patient are all geared towards ensuring that a proper diagnosis is reached. By all necessary measures, the patient has been adhering to medication already prescribed. Therefore, the additional tests are meant to definitively diagnose what the patient ails from, and therefore, come up with a comprehensive, and correct, intervention, both from a nursing and pharmacological point of view.
Individualized nursing care plan
The nursing diagnosis for Sophie’s case is hyperthermia, evidenced by temperatures hovering around 38.5 degrees Celsius, flushed skin, rapid respiratory rate, and a fast heartbeat. The signs the patient is experiencing have thoroughly destabilized her. It is necessary to manage this before embarking on further treatment options.
Goals
The goal of any intervention will be to significantly reduce the fever, such that the patient’s temperature is within the normal values. The success of this nursing care plan will help the multidisciplinary team in further monitoring and diagnostics, and ultimately, provide better care to the patient.
Intervention and evaluation
The interventions will be multifaceted, since no single intervention can reliably achieve the desired result. The first of these will be a regular monitoring of the patient’s temperature, in this case every four hours. This will buttress the case of a proper diagnosis, while assessing the efficacy of existing medication designed to reduce the fever.
Excess clothing will be removed from the patient. The room’s temperature will be regulated to ensure it is not uncomfortable, and that it does not lead to a deterioration in the patient’s condition. The patient will also be offered a tepid sponge bath. The bath is expected to have a significant effect in cooling down the patient. It will also add to the comfort the patient feels in the new environment. This may result in reduced confusion. The headrest of the bed will also be elevated, improving the positioning of the lungs, while making the patient more comfortable.
Drug interventions will also be administered. The patient will take antibiotic and fever-reducing (anti-pyretic) medications. The antibiotic medication will be used to treat the pneumonia, while the antipyretic medications will help manage the patient’s hyperthermia. They do this by stimulating the hypothalamus and thereby enabling the body control its own temperature. Throughout the nursing care plan, the patient and her husband will be involved, thereby serving to decrease their anxiety and distress about Sophie’s health status.
Critique of management
Alongside other interventions (such as Chinese herbs as explained by Deng et al (2014), sponge baths’ efficacy has been well documented. It helps the patient reduce their body temperature. Nevertheless, perhaps more importantly, it enables the patient to have an enhanced sense of comfort, enabling them overcome delirium and confusion. This will be a key deliverable of this intervention.
Antipyretic drugs and their efficacy on treating fever in diabetics has long been discussed. A recent article by Grosser et al (2011) determined that the drugs were highly effective, with tangible, measurable results being apparent a few hours after administration the side effects can be safely managed within the setting of a HDU, where observation is well done.
The use of antibiotics such as lefamulin is effective in treating pneumonia. The treatment of the disease will also result in a reduction in the patient’s body temperature. This is therefore an intervention whose effects will be effective in both the long term and short term (File et al, 2019).
Conclusion
The patient has an existing chronic ailment, which has had significant health implications on the patient. For instance, diabetes has arguably weakened Sophie’s immune system. This has made her susceptible to different ailments, including the current pneumonia that she is battling. Wounds, especially those to the foot, are notoriously difficult to treat in diabetes patients. As a result, the management of the diabetic foot is an extremely important necessity in this case. The fever’s reduction will ensure the patient is more comfortable to undertake further medication. Her placement in the HDU will have important, and positive, benefits for her health. Without an effective nursing care plan that takes care of her needs as illustrated in this paper, this may not be very efficient, since the interventions may be overly pharmacological, and neglect the other equally important aspects of her treatment that will ensure a short and successful hospital stay.
References
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