Care of deteriorating patient
Scenario
After three days on the ward Joel’s condition has deteriorated and he is now confirmed as having stage 3 acute kidney injury (AKI) with serum creatinine of 403µmol/L and no urine output for 18 hours. He needs renal replacement therapy.
Problem 3: What evidence-based treatment options may be employed to maintain Joel whilst he is in the ICU. Assuming Joel recovers from this acute episode discuss the ongoing care he may need to help him rehabilitate and in relation to the management of potential ongoing chronic kidney disease, including any multi-disciplinary team involvement.
Scenario
A urine specimen taken at the surgery is positive for ketones. Raymond vomits whilst in the clinic and the nurse immediately calls for an ambulance to take Raymond to A&E. On arrival Raymond’s condition has deteriorated and he is barely conscious.
Problem 3:
Discuss the management of Raymond once her arrives at Hospital.
Consider any further evidence-based tests and treatment that may be required.
Any special considerations related to Raymond’s age.
Ongoing support that can be available to Raymond and his family to help him manage his condition.
Raymond Williams
Raymond is a 16-year-old student who attends the GP surgery at 9am to see the diabetic nurse accompanied by his mother Alice. Raymond has type-one diabetes which was diagnosed when he was three and this has been poorly controlled recently.
Raymond is studying A-Levels at a local college and is keen to go on to university and study engineering. He likes socialising with friends and finds the restrictions imposed by his condition very difficult. Alice is worried because Raymond’s college work has been deteriorating and she is worried that he will not get the grades he needs to go on to further study.
Raymond appears quite drowsy and is complaining of thirst and keeps asking for a cup of water. Alice tells you that he never seems to be out of the loo.
OBSERVATIONS TAKEN IN CLINIC
AIRWAY: Raymond can talk in full sentences.
BREATHING: RR 30 breathing appears deep and laboured and his breath carried a slight smell of nail polish remover. SpO2 95% on air.
CIRCULATION: HR 100bpm, BP 98/50mmHg.
DISABILITY: AVPU: Alert but drowsy and rather distressed. Blood glucose just reads as HIGH on the Practice Monitor.
EXPOSURE: Temperature 36.2C, no wounds visible, no IV access, Raymond appears quite drawn and has reduced tissue turgor.
Problem 1:
Using the A-E approach identify the nursing priorities for Raymond’s care whilst he is in the clinic.
Consider both his current presentation and the potential for any further deterioration and how this could be managed.
Treat Raymond as a whole person, considering everything we know about him and not just his presenting condition.
Problem 2: Provide a rationale for the care you have suggested in Problem 1
Use the pathophysiology of type 1 diabetes mellitus and an understanding of Raymond’s overall condition.
Remember to refer to relevant pharmacology
Refer to appropriate national guidelines
