Question

You are a new graduate registered nurse working in the paediatric ward of your local hospital.

Sam Nicolaides is a nine-year-old boy who until recently has been in good health. Sam lives with his mother and father and two siblings. Following a respiratory virus a few weeks ago he has been slow to recover, lacking in his usual energy. He has been hungry and thirsty all the time, and has recently begun wetting the bed, which he has not done for many years.

Sam presented to the Accident and Emergency department two day ago with nausea, abdominal pain and feeling generally unwell. His observations taken on admission were:

Blood pressure 80/50mmHG, pulse 140, respiratory rate 28 deep and sighing with an unusual sweet smell to the breath, oxygen saturation 100%, temperature 37.2 degrees Celsius. Urinalysis SG1025, pH 5, sugar++++ ketones+++ no other abnormalities. BGL 28mmol/L.

A medical diagnosis of Diabetes type 1 with keto-acidosis was made.

Question 6. Maximum word limit 120 words (approximately 30 words per section)

Briefly explain the pathophysiology causing the following symptoms Sam was experiencing on admission:

1. Glycosuria
2. Thirst
3. Ketonuria
4. Kussmaul breathing

Question 7. Maximum word limit 50 words.

List four (4) ongoing nursing assessments, other than vital signs, that will be required to monitor Sam’s fluid status and ensure safe fluid replacement therapy over the next 48 hours.

Question 8. Maximum word limit 150 words.

Explain the concept of family centred care and why this is important to the physical and psychological care for Sam.

Question 9. Maximum word limit 150.

For the ongoing management of type 1 diabetes, current best practice recommends an intensive insulin therapy regime called multiple dose insulin (MDI) or basal/bolus regime. Explain:

1. What this insulin regime involves and
2. Discuss why this is considered best practice management for type 1 diabetes.

Question 10. Maximum word limit 150 words

Explain what the HbA1c test is and why it is important in the management of patients with diabetes.

Answer 1

6a. Hyperglycemia in DKA causes an osmotic diuresis, which results in severe fluid and electrolyte deficit. If left untreated, fluid deficit can be sufficiently severe to cause acute renal failure. FIG 2. Osmotic diuresis in DKA causes polyuria, glycosuria and electrolyte depletion.

b.Thirst, which arises due to dehydration. Excessive urination, which occurs because the kidneys try to rid the body of excess glucose, and water is excreted along with the glucose.

c. Ketonuria occurs when high levels of ketone bodies which occur when cells are broken down for energy are present in the urine.

d. In hyperglycemia metabolic acidosis soon produces hyperventilation, but at first it will tend to be rapid and relatively shallow. Kussmaul breathing develops as the acidosis grows more severe.

7. The four (4) ongoing nursing assessments, other than vital signs, that will be required to monitor Sam’s fluid status and ensure safe fluid replacement therapy over the next 48 hours are :-

- Assess skin turgor, mucous membranes, and thirst.To provide baseline data for further comparison. Skin turgor will decrease and tenting may occur. The oral mucous membranes will become dry, and the client may experience extreme thirst.

- Monitor hourly intake and output. Oliguria or anuria results from reduced glomerular filtration and renal blood flow.

- Monitor BP especially for orthostatic hypotension.Decreased blood volume may be manifested by a drop in systolic blood pressure and orthostatic hypotension.

- Weigh client daily.Provides baseline data of current fluid status and adequacy of fluid replacement. A weight loss of 2.2 lbs over 24 hours indicates a 1 liter of fluid loss.

8) Family centered care is an approach to health care that shapes healthcare policies , programs , facility designs, day to day interactions among patients , families , physician and other healthcare workers .

It is important to the physical and psychological care for Sam because it can improve patient and family outcomes, increase patient and family satisfaction, build on child and family strengths, increase professional satisfaction.

9) Multiple dose injection (MDI) therapy, also known as multiple daily injections, is an alternative term for the basal/ bolus regime of injecting insulin.

The therapy involves injecting a long acting insulin once or twice daily as a background (basal) dose and having further injections of rapid acting insulin at each meal time.

Multiple daily injection therapy will usually involve at least four injections a day.

It is best for the management of Diabetes type 1 because of its advantages :-

- greater flexibility of meal time ,carbohydrate quantities , physical activity and better glycemic control to prevent the complications of Diabetes type 1