Author: Claire

Claire Galea is the Owner and Director of Mariposa Holistic Care, through which she provides holistic care services tailored to her clients' personal needs. She is also in her final year following a Degree in Nursing at the Faculty of Health Sciences, University of Malta. Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading positivity and awareness on various subjects through her blog Student Nurse Life.

Nursing Diagnosis

Nursing diagnosis is the nurse’s clinical judgment about a patient’s response to actual or potential health conditions or needs.

Medical Diagnosis vs Nursing Diagnosis

*Medical Diagnosis*…	Nursing Diagnosis…
points to a particular disease or medical condition	focuses on the patient’s needs
is based on the physiological or medical condition	focuses on the patient’s physiological and/or psychological response to changes in health
is also concerned with the aetiology of the disease	addresses potential problems

Types of diagnosis include:

Actual Diagnosis – diagnosis of the problem/s present at the time of patient assessment
Potential Diagnosis – diagnosis of a potential problem which may arise from the patient’s actual diagnosis
Health Promotion Diagnosis – diagnosis in relation to altered behaviours towards healthy living

NANDA’s Nursing Diagnoses

NANDA International, officially founded in 1982 and previously known as the North American Nursing Diagnosis Association, is a professional organisation of nurses aiming to standardise nursing terminology.

The current structure of NANDA’s nursing diagnoses is referred to as Taxonomy II and has three levels: Domains (13), Classes (47) and Diagnoses (237) (Herdman & Kamitsuru, 2018).

NANDA nursing diagnosis — Retrieved from https://en.wikipedia.org/wiki/NANDA_International on 1st June 2022

Models of Nursing Care

Activities of Daily Living
Adaptation
Self Care
Goal Attainment

Activities of Daily Living

nursing diagnosis adl's — Retrieved from https://info.eugeria.ca/en/have-you-heard-of-adls/ on 1st June 2022

Roy’s Adaptation Model

nursing diagnosis — Retrieved from https://schoolworkhelper.net/the-roy-adaptation-model-health-environmentsociety-nursing/ on 1st June 2022

Orem’s Theory of Self Care

Retrieved from https://www.pinterest.com/pin/443886107007181690/ on 1st June 2022

King’s Goal Attainment Model

Retrieved from https://pmhealthnp.com/kings-goal-attainment/ on 1st June 2022

Nursing Diagnosis Care Plan – Based on the ADL

Activities of Daily Living	Assessment	Diagnosis	Implementation	Evaluation
Maintaining a safe environment
Communication
Breathing
Eating & Drinking
Elimination
Washing & Dressing
Controlling Temperature
Mobilisation
Working & Playing
Sexuality
Sleeping
Death
Education
Discharge

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Patient Hospital Admission

Patient hospital admission refers to the admission and acceptance of a patient into a health facility with the aim of staying under observation, undergoing necessary diagnostic investigations, and receiving required medical or surgical treatment. Patient hospital admission can be either elective – where a procedure is planned beforehand, or an emergency.

Elective Admission

In an elective patient hospital admission, a healthcare professional agrees with the patient on a convenient date for admission. This enables the patient to prepare in advance for the procedure.

Emergency Admission

In an emergency patient hospital admission, the patient is usually brought in by relatives or friends in a critical condition. In such an admission, the patient is usually transported by a wheelchair or a stretcher to an adequate ward for immediate evaluation and treatment.

Elective Patient Hospital Admission Procedure

Welcome the patient and any accompanying relatives to the ward and introduce yourself and any other present HCPs
Gather all required documents such as admission papers and other important information or documentation from the accompanying nurse
Confirm patient identity through given details
Ensure that the patient and accompanying relatives feel welcomed and comfortable
Gather any additional required information by the patient and/or the accompanying relatives
Provide a hospital bed located at an ideal room for the patient in question, based on the patient’s health requirements and condition
Provide assistance to the patient to change into pyjamas or hospital gown and ensure identification bracelet and any other required tags eg. allergy bracelet is provided
Take baseline vital signs and document
Collect any required specimens if needed
Administer any urgent medications
Ensure patient valuables are taken care of
Ensure informed consent is obtained, signed by the patient
Inform relatives about visiting hours and about anything that they may need to bring in for the patient on their next visit
Following relatives’ departure from the ward, orient patient to the ward and to the surrounding environment
Provide nursing care based on The Nursing Process
Input the patient’s particulars in the admission and discharge book
Document admission into the patient’s nursing documentation sheet
Input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system

Emergency Patient Hospital Admission Procedure

Perform hand hygiene
Gather emergency equipment– vital signs apparatus, resuscitation trolley, oxygen, venepuncture equipment, suction apparatus, and an adequate bed in a suitable location based on the patient’s condition
Welcome the patient and accompanying relatives to the ward and introduce yourself and any other present HCPs
Gather all required documents such as admission papers and other important information or documentation from the accompanying nurse
Confirm patient identity through given details
Assess patient’s overall condition efficiently
Receive patient into a previously prepared bed, keeping the patient’s current condition in mind
Provide assistance to the patient to change into pyjamas or hospital gown and ensure identification bracelet and any other required tags eg. allergy bracelet is provided
Take baseline vital signs and observe further the patient’s overall appearance and reaction, level of consciousness, skin integrity, pain, breathing pattern, and any other complaints, and document
Collect relevant history from the patient or accompanying relatives
Ensure informed consent is obtained, signed by the patient (include detailed information about required emergency procedures is given to ensure informed consent)
Ensure patient valuables are taken care of
Inform relatives about visiting hours and about anything that they may need to bring in for the patient on their next visit
Following relatives’ departure from the ward, orient patient to the ward and to the surrounding environment
Collect any required specimens if needed
Administer prescribed medications
Input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system
Document admission into the patient’s nursing documentation sheet

The Nurse’s Role in the Admission Process

Ensure the patient’s physical and emotional needs are met
Ensure the patient is assigned to a bed adequate to his/her personal needs and condition
Ensure that the patient’s admission report is completed
Ensure the patient is assessed using The Nursing Process
Provide a holistic approach to patient care based on the Activities of Daily Living guide whilst considering the patient’s psychological, social, spiritual, and cultural needs
Ensure the patient’s comfort and aim to reduce anxiety in both the patient and accompanying relatives

Patient Hospital Admission — Retrieved from https://nurseslabs.com/nursing-diagnosis/ on 7th November 2021

Retrieved from https://nurseslabs.com/nursing-diagnosis/ on 7th November 2021

Transferring the Patient

During a hospital stay, the patient may require transferring from one ward to another within the same healthcare facility.

Transfer in

In a Transfer-In, a patient is moved from one unit to another, eg. from a medical to a surgical ward.

When a patient is being transferred in:

ensure a suitable bed is available to receive the patient
ensure all necessary equipment depending on the patient’s condition is readily available
ensure the patient, accompanying nurse, and any accompanying relatives are received warmly
ensure correct handover, transfer of notes, and any patient personal belongings are received from the accompanying nurse
confirm patient identity with accompanying nurse
clarify any queries pertaining to the patient’s condition
introduce yourself and other present HCPs to the patient and accompanying relatives
assess patient’s overall condition efficiently
ensure the patient is assessed using The Nursing Process
orient patient and relatives to the ward and to the surrounding environment
input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system, including time of admission
document transfer into the patient’s nursing documentation sheet

Transfer Out

In a Transfer-Out, the patient can be transferred from one ward to another, or from one facility to another.

When transferring a patient out:

confirm transfer with receiving unit
assess the patient’s condition
arrange for a nurse to accompany the patient
plan for an appropriate transferring vehicle if required
collect all patient data
reduce the patient’s and accompanying relatives’ anxiety by explaining reason for transfer
obtain informed written consent for transfer
assist in the packing of the patient’s personal belongings
ensure patient’s medication, diagnostic results, and transfer notes, are all compiled as required
assist patient in dressing up adequately for the transfer
assist patient into a wheelchair or stretcher, and into an ambulance, if required
ensure patient’s notes and belongings are handed over to the accompanying nurse
input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system, including time of transfer
document transfer into the patient’s nursing documentation sheet

Discharging the Patient from the Hospital

Discharge planning should start shortly after the patient is admitted, and is usually done at the discretion of the medical team, based on the patient’s overall health condition, or if the patient requests to be discharged. The patient and his/her relatives should always be informed about intended discharge plans.

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Haemostasis ~ The Blood Clotting Process

Haemostasis

Haemostasis is the process by which blood loss is prevented. This happens through three basic mechanisms:

Vascular Spasm – blood vessel damage stimulates pain receptors to cause immediate smooth muscle contraction within its wall; this reduces blood loss rate for up to 30 minutes, during which other haemostatic mechanisms are triggered.
Platelet Plug Formation – platelets which come into contact with damaged blood vessel parts begin to enlarge, become irregular, sticky, and start adhering to collagen fibres; ADP (adenosine diphosphate) and enzyme synthesis triggers the formation of other substances, activating more platelets to adhere to the original platelets, forming a platelet plug, which is then reinforced by fibrin threads.
Blood Coagulation a.k.a. Blood Clotting -whilst blood within the vessels maintains its liquid state, blood outside the vessels thickens and forms a gel (serum) which separates from the liquid. Blood serum is blood plasma without its clotting proteins, whilst the gel is the clot, which contains insoluble fibres that trap the cellular components of the blood.

Retrieved from https://quizlet.com/185065266/hemostasis-vs-anticoagulation-and-thrombolysis-flash-cards/ on 22nd May 2022

Blood Coagulation

Blood coagulation is the process of clot formation – a process which involves various chemicals referred to as coagulation factors.

haemostasis coagulation factors — Retrieved from https://www.vetfolio.com/learn/article/hemostasis on 22nd May 2022

There are 3 basic stages for coagulation…

Stage 1: Formation of Prothrombin Activator

Stage 1 involves the formation of prothrombin activator, initiated by the extrinsic and intrinsic pathway of blood clotting.

Stage 2: Conversion of Prothrombin into Thrombin

Following the formation of prothrombin activator, it binds to Ca²⁺ ions (Calcium Ions), causing the conversion of prothrombin into thrombin.

Stage 3: Conversion of Fibrinogen into Fibrin

Thrombin and Ca²⁺ ions trigger the conversion of Fibrinogen (soluble) to Fibrin (insoluble).

Thrombin activates Factor XIII (Antihemophilic Factor) which strengthens and stabilises the fibrin clot.

Through a positive feedback effect, Thrombin accelerates the formation of prothrombin activator through Factor V (Proaccelerin), which further accelerates the production of more Thrombin.

The formed clot plugs the ruptured area of the blood vessel, preventing haemorrhage. This is followed by permanent repair of the blood vessel.

Additional Factors related to Haemostasis

Vitamin K

Efficient clotting requires Calcium as well as Vitamin K, which is required for prothrombin formation and other coagulation factors by the liver. Vitamin K is formed by the human intestinal bacteria, and can also be found in foods such as spinach, cabbage, cauliflower, and liver.

Thrombosis

Thrombosis is the formation of a clot (thrombus) within an intact blood vessel. Thrombosis is caused within blood vessels containing sluggish blood flow, and when platelets stick to fatty deposits on the blood vessels’ inner surface. A thrombus can either dissolve or else grow and eventually block the blood vessel.

Embolism

Embolism happens when a part of the thrombus breaks off from its original site forming an embolus, moves along the blood stream until it reaches a small blood vessel and blocks it.

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Blood Disorders

Blood disorders have an impact on the main components of the blood – red blood cells, which carry oxygen throughout the body; white blood cells, which fight infection; and platelets, which help through their blood clotting mechanism. Some blood disorders are caused by genes. However, blood disorders can also result from other diseases, medications, or lack of nutritional intake.

Diagnostic Tests for Blood Disorders

CBC (Complete Blood Count) – haemoglobin, haematocrit, reticulocyte count, red blood cell indices, MCV (mean corpuscular volume i.e. RBC size), and RDW (RBC distribution width)
Blood Chemistry Tests – Electrolytes, Fats, Proteins, and Glucose
Blood Enzyme Tests – Myoglobin, Troponin, and Creatine-Kinase
Blood Clotting Tests – PT (Prothrombin Time), aPTT (activated partial thromboplastin time), TT (Thrombin Time)
Serum Vitamin B12 and folate levels, haptoglobin, erythropoietin levels
Bone Marrow aspiration

Anaemia

Anaemia is a blood disorder in which there is a deficiency in erythrocytes or haemoglobin, leading to tissue oxygen deprivation.

Causes

bleeding (eg. menstruation, childbirth, NSAIDs overuse [may cause ulcers and gastritis], GI conditions [ulcers, haemorrhoids, gastritis and cancer]
decreased or abnormal RBC production (eg. sickle-cell anaemia, iron-deficiency anaemia, vitamin deficiency, problems related to the bone marrow and/or stem cells)
premature RBC destruction (RBCs inability to withstand circulation stress, leading to premature rupture, causing haemolytic anaemia)

Possible complications

Confusion
Parathesias (a burning or prickling sensation usually felt in the hands, arms, legs, or feet, but can also extend to other body parts)
Congestive Heart Failure
Death

1. Iron-Deficiency Anaemia

Iron-Deficiency Anaemia is a type of anaemia in which there is lack of iron in the body. Iron is required for the production of haemoglobin for red blood cells to carry oxygen throughout the body.

2. Pernicious Anaemia

Pernicious Anaemia is a type of anaemia in which the intrinsic factor is missing. This results in lack of Vitamin B12 absorption. While Pernicious Anaemia is very common in older individuals and individuals who have had a gastric resection, it may also result from malnutrition in which B12 intake is low, such as in vegetarian diets or lack of dairy products intake.

3. Aplastic Anaemia

Aplastic Anaemia is caused by a deficiency of all blood cell types due to bone marrow development failure. Aplastic Anaemia is considered to be a rare disease.

4. Thalassemia

The term ‘Thalassemia’ refers to a group of hereditary disorders in which there is defective haemoglobin-chain synthesis. In Thalassemia there is an abnormal decrease in RBCs’ haemoglobin (hypochromia), small RBCs (microcytosis), blood element destruction (haemolysis) and anaemia.

Anaemia Clinical Manifestations

Retrieved from https://medlineplus.gov/genetics/condition/iron-refractory-iron-deficiency-anemia/ on 19th May 2022

Retrieved from https://www.kindpng.com/imgv/hiRwoTJ_symptoms-of-anaemia-symptoms-of-anemia-hd-png/ on 19th May 2022

Anaemia Nursing Care

Assessment

What type of anaemia is involved?
What symptoms is it exhibiting, and to what extent?
How are these symptoms leaving an impact on the patient’s daily life?
What medication has the patient been on – past and present? Was the patient on medications which may have caused a reduction in bone marrow activity, caused haemolysis, or affected folate metabolism?

Diagnosis

Fatigue (due to haemoglobin decrease i.e. reduced oxygen saturation)
Malnutrition (lack of required nutrition and nutrient intake)
Decreased Tissue Perfusion (due to reduced blood volume – hematocrit)
Poor Medication Compliance

Implementation

ensure adequate rest to reduce fatigue along with periods of feasible activities to promote physical activity, whilst also assessing for other conditions such as pain, depression, and insomnia, which may further exacerbate fatigue
encourage and/or ensure adequate nutritional intake through a healthy diet comprising of adequate iron, vitamin B12, folic acid, and protein intake (if required supplements may be recommended), whilst avoiding alcohol
ensure adequate tissue perfusion through blood transfusions, IV fluids, and if required supplemental oxygen (monitor vital signs and SPO2)
educate about the importance of medication compliance and management of side effects
promote complication avoidance by assessing for heart failure, assessing the patient neurologically, evaluating the patient’s gait and balance, and complaints of parathesias

Evaluation

assess for signs and symptoms of heart failure
measure and document the patient’s weight on a daily basis
intake and output charting
assess for possible need of diuretics in the case of fluid retention

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Blood Groups and Blood Transfusions

Blood Groups

Erythrocytes contain antigens called agglutinogens or isoantigens which are genetically determined. At least, 300 blood group systems may be detected on red blood cells’ surface. However, the focus is on 2 major classifications of blood groups, namely the ABO Blood Grouping System and the Rhesus System.

ABO Blood Grouping System

there are 2 types of agglutinogens: Agglutinogen A and Agglutinogen B
individuals with red blood cells containing Agglutinogen A have a Blood Type A
individuals with red blood cells containing Agglutinogen B have a Blood Type B
individuals with red blood cells containing both Agglutinogen A and B have Blood Type AB
individuals with red blood cells containing NO Agglutinogen A and NO Agglutinogen B have Blood Type O

The BLOOD PLASMA contains antibodies called agglutinins or isoantibodies.

Agglutinin A attacks Agglutinogen A
Agglutinin B attacks Agglutinogen B

Retrieved from https://cbm.msoe.edu/crest/ePosters/a16gtaBloodType.html on 14th May 2022

Rhesus (Rh) System

the Rh system is based on the presence (or lack of) of agglutinogens which can be found on the surfaces of erythrocytes
individuals with red blood cells containing Rh agglutinogens are said to be Rh+
individuals with red blood cells containing NO Rh agglutinogens are said to be Rh-

Retrieved from https://www.scienceabc.com/humans/is-it-important-to-compare-blood-groups-with-your-partner.html on 14th May 2022

Blood Transfusions

Blood transfusions are commonly indicated for circulatory shock, anaemia (lack of healthy red blood cells leading to inadequate oxygen distribution to the body’s tissues), haemophilia (bleeding disorder, usually inherited, with an improper blood clotting mechanism), and haemolytic disease of the newborn (a disease in which there is fast destruction of red blood cells).

Incompatible blood transfusions may cause very bad consequences such as kidney damage, brain damage, and even death.

Further Information…

Red Cell Concentrates – indicated for anaemia and acute blood loss: help increase oxygen carrying capacity through raising haemoglobin concentration in the patient. Can be stored in a temperature of 4 +/-2°C for 42 days (or for 28 days if irradiated). If unused or left for more than 30 minutes in the transport box, Red Cell Concentrates should be returned to the Blood Bank to minimise the risk of bacterial growth.

CMV (CytoMegaloVirus) Negative Blood: indicated for intrauterine transfusions, neonate transfusion (28 days post EDD) and pregnant women transfusion.

Irradiated Blood: indicated for intrauterine transfusion, BM/ stem cell transplantation, Hodgkin’s disease, etc.

For more details on the administration of blood and blood components click here.

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Blood Components and Functions

The internal environment of the human organism is made up of blood within the blood vessels, interstitial fluid surrounding the body cells, and lymph inside the lymph vessels.

The blood is able to pick up:

nutrients (from the digestive tract)
oxygen (from the lungs)
hormones (from the endocrine glands)
enzymes (from multiple body sites)

The blood can also act as a transportation means for disease-causing organisms. For this reason, the lymphatic system helps in picking up wastes from the interstitial fluid, cleansing them of bacteria, and returning them bacteria-free into the blood.

Physical Characteristics of the Blood

blood components — Retrieved from https://quizlet.com/96941163/56-what-is-the-normal-ph-of-blood-181b-physical-characteristics-of-blood-flash-cards/ on 12th May 2022

Blood Functions

1. Transportation

Blood helps in the transportation of:

Oxygen (from the lungs to the body’s cells)
Carbon Dioxide (from the cells to the lungs)
Nutrients (from the digestive organs to the cells)
Waste Products (from the cells to the kidneys, lungs, and sweat glands)
Hormones (from the endocrine glands to the cells)
Enzymes (to various cells)

2. Regulation

Blood helps in the regulation of:

pH (through buffers)
Body Temperature (through heat-absorbing and coolant properties of its water content)
Water within the Cells (mainly through dissolved sodium ions)

3. Protection

Blood helps in protecting the body against:

Blood Loss (through the blood clotting mechanism)
Toxins and Foreign Microbes (through special combat-unit cells such as white blood cells)

Blood Composition

Blood is made up of 2 portions:

1. Formed Elements

make up 45% of the total blood volume
include Red Blood Cells, White Blood Cells (Granular – neutrophils, eosinophils & basinophils; and Agranular – lymphocytes & monocytes), and Platelets.

2. Plasma

makes up 55% of the total blood volume
water (91.5% of total plasma)
proteins (7% of total plasma)
other solutes (1.5% of total plasma)

Haematopoiesis – Blood Cell Formation

Haematopoiesis a.k.a. blood cell formation takes place within the Red Bone Marrow (myeloid tissue in the humerus, femur, sternum, ribs, vertebrae & pelvis) and Lymphoid Tissue (in the spleen, tonsils & lymph nodes).

Red Blood Cells, Leucocytes & Platelets are produced within the Bone Marrow.
Agranular Leucocytes (lymphocytes & monocytes) are produced by the Bone Marrow and the Lymphoid Tissue.

Red Blood Cells a.k.a. Erythrocytes

do not contain a nucleus
cannot reproduce
cannot carry on extensive metabolic activities
plasma membrane is selectively permeable
plasma membrane encloses cytoplasm and haemoglobin
have a biconcave shape which promotes increased surface area for diffusion purposes
contain a lot of haemoglobin molecules which increase their capacity for oxygen transportation
allow transportation of a small amount of carbon dioxide along with haemoglobin

Normal Haemoglobin Values

Infants	14-20gm/dl
Adult Females	12-15gm/dl
Adult Males	14-16.5gm/dl

Erythropoiesis – Erythrocyte Production

erythropoiesis and erythrocyte destruction usually proceed at the same pace
if the balance between erythropoiesis and erythrocyte destruction is disrupted, a homeostatic mechanism is initiated to promote erythrocyte production
in oxygen deficiency, particular kidney cells release the enzyme Renal Erythropoietic Factor which converts plasma protein into the hormone erythropoietin, which, when reaching the red bone marrow, stimulates haemocytoblasts to develop into red cells

NOTE: Blast is a short name for an immature WBC, such as a lymphoblast or myeloblast. In normal circumstances, less than 5% of the cells in healthy bone marrow at any one time are blasts. Within the bone marrow, normal blasts develop into mature, functioning blood cells and are then released into the bloodstream.

Retrieved from https://labpedia.net/erythropoiesis-rbc-maturation-rbc-counting-procedure/ on 12th May 2022

Haemoglobin in Erythrocytes

erythrocyte life span is around 120 days long
the plasma membrane of depleted cells are removed from the circulation by macrophages in the spleen, liver, and bone marrow
haemoglobin is broken down into Haemosiderin (iron-containing pigment which is stored or used in the bone marrow for the production of new haemoglobin for new RBCs), Bilirubin (pigment secreted by the liver into bile) and Globin (protein metabolised in the liver).

White Blood Cells a.k.a. Leucocytes

there is a much lesser amount of WBCs than RBCs in the human body: 700 RBCs per 1 WBC
leucocytes contain nuclei
leucocytes do NOT contain haemoglobin
leucocytes have surface proteins called Human Leucocyte Associated Antigens (HLA) which are unique to each and every person

There are 2 types of WBCs:

GRANULAR LEUCOCYTES:

NEUTROPHILS (POLYMORPHS) – make up the biggest amount of total leucocytes; involved in phagocytosis of bacterial pathogens and the release of antimicrobial chemicals
EOSINOPHILS – involved in phagocytosis of antigen-antibody complexes, allergens and inflammatory chemicals, and the release of enzymes which help weaken or destroy parasites
BASOPHILS – involved in the secretion of histamine which promotes blood flow to a particular tissue, and the secretion of heparin which promotes mobility of other WBCs by clotting prevention
develop from red bone marrow
have granules in the cytoplasm
have a lobed nuclei

AGRANULAR LEUCOCYTES:

MONOCYTES – turn into macrophages; phagocytise pathogens, dead neutrophils, and dead cells debris; and present antigens that activate other cells within the immune system
LYMPHOCYTES – assist with immune memory, secrete antibodies, present antigens for the activation of other cells within the immune system, and help in destroying cancer cells, virus-infected cells, and foreign cells
develop from lymphoid and myeloid tissue
do not have granules in the cytoplasm

Retrieved from https://www.pinterest.com/pin/452752568781425426/ on 13th May 2022

Differential Blood Count

*Type of White Blood Cell*	*Normal Differential Count*	*High WBC Count Implication*
Neutrophils	60% – 70%	damage caused by invading bacteria
Eosinophils	2% – 4%	allergic reaction
Basophils	0.5% – 1%	allergic reaction
Lymphocytes	20% – 25%	antigen-antibody reaction
Monocytes	3% – 8%	chronic infection

Life Span of Leucocytes

leucocytes can live from just a few days to a few months, depending on what type of leucocytes they are
during infection, white blood cells become very active, usually living for only a few hours

Platelets

platelets contain no nucleus
platelets have a life span of between 5 to 9 days
platelets help prevent fluid loss through a chain of reaction leading in blood clotting
stem cell development from haemocytoblast to platelets takes place in the red bone marrow

Stem cell developmental pathway. Retrieved from https://slideplayer.com/slide/12774626/ on 14th May 2022

Plasma

Plasma is made up of:

WATER – 90% of total amount of water in plasma is derived from the GI tract; 10% is derived from cellular respiration; water absorbs heat and acts as a solvent and suspending medium for the blood’s solid components
SOLUTES – makes up 8.5% of the total plasma volume
PROTEINS – ALBUMINS (55% of plasma proteins) are produced by the liver; provide viscosity in the blood which helps maintain blood pressure; exert osmotic pressure to help in maintaining water balance between the blood and the tissues; help regulate blood volume; GLOBULINS (38% of plasma proteins) a.k.a. antibodies; FIBRINOGEN (7% of plasma proteins) is produced by the liver; it helps in the blood clotting process

blood plasma components — Retrieved from https://www.austincc.edu/apreview/PhysText/Blood.htm on 14th May 2022

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Thyroid Disease & Patient Education Based on NICE Guidelines

The phrase thyroid disease refers to medical conditions which affect the way the thyroid gland works. The thyroid gland typically produces an amount of hormones which help the body to function well. Too much thyroid hormone production is referred to as hyperthyroidism, whilst too little thyroid hormone production is referred to as hypothyroidism.

Retrieved from https://www.easyyogasan.com/thyroid-test-t3-t4-tsh-normal-range/ on 10th May 2022

Hyperthyroidism usually causes tachycardia, weight loss, and nervousness. On the other hand, hypothyroidism may cause lethargy, weight gain, and cold intolerance.

Retrieved from https://terrainwellness.com/symptoms-of-hashimotos-flare-up/ on 29th April 2022

Thyroid Disease Risk Factors

family history of thyroid disease
medical conditions eg. type 1 diabetes and rheumatoid arthritis)
high iodine-containing medication eg. amiodarone
increased age
past thyroidectomy
past radiation

Hyperthyroidism Causes

Graves’ Disease
Nodules
Thyroiditis
Excessive iodine intake

Symptoms

anxiety
irritability
nervousness
heat sensitivity
insomnia
vision problems
eye irritation
goitre
tremors.
irregular periods
period cessation
shortness of breath – patient has high metabolism, muscle wasting, leading to exhaustion and fatigue, all of which can cause shortness of breath
weight loss – imbalanced nutrition due to high metabolic rate (adequate food intake needs to be ensured)
muscle weakness – in case of inadequate food intake, if no carbs or glucose are available to be broken down, the body turns to protein breakdown, leading to muscle wasting

Hypothyroidism Causes

Thyroiditis
Hashimoto’s Thyroiditis
Post-Partum Thyroiditis (usually temporary)
Iodine Deficiency
Non-Functioning Thyroid Gland

Symptoms

cold sensitivity
memory problems
voice hoarseness
hair dryness and coarseness
fatigue
weight gain
frequent and heavy periods

Thyroid Disease Diagnostic Tests

TFTs (TSH, T⁴ and T³ levels) – to check the amount of thyroid stimulating hormone (TSH) and circulating thyroid hormones in serum, so thyroid gland’s thyroid hormone production and regulation ability is assessed
CBC – to check amount of red blood cells in the blood (to rule out anaemia)
Renal Profile – to determine the kidneys’ health by evaluating parameters such as proteins, electrolytes, and minerals

Subclinical Thyroid Dysfunction

Subclinical Thyroid Dysfunction is a biochemical diagnosis in which TSH levels are outside the reference range, and circulating T₄ and T₃ are within the reference range.

Subclinical Thyroid Dysfunction is most commonly detected incidentally. However, in certain cases, individuals may exhibit symptoms of hypothyroidism or hyperthyroidism. Studies related to long-term consequences of subclinical thyroid dysfunction indicate increased cardiovascular morbidity and mortality, increased risk of osteoporosis, and possible links to dementia.

Thyroid Disease Patient Education – Based On NICE Guidelines (2019)

Ensure that information is presented to facilitate shared decision making…

Explain to people with thyroid disease who need treatment, and their family or carers…that:
– Thyroid disease usually responds well to treatment.
– The goal of treatment is to alleviate symptoms and align thyroid function tests within or close to the reference range.
– People may feel well even when their thyroid function tests are outside the reference range.
– Even when there are no symptoms, treatment may be advised to reduce the risk of long-term complications.
– Even when thyroid function tests are within the reference range, changes to treatment may improve symptoms for some people.
– Symptoms may lag behind treatment changes for several weeks to months.
– Day-to-day changes in unexplained symptoms are unlikely to be due to underlying thyroid disease because the body has a large reservoir of thyroxine.

Provide people with thyroid disease, and their family or carers…with written and verbal information on:
– their underlying condition, including the role and function of the thyroid gland and what the thyroid function tests mean
– risks of over-and under-treatment
-their medicines
-need for and frequency of monitoring
– when to seek advice from a healthcare professional
– how thyroid disease and medicines may affect pregnancy and fertility

Provide people with hypothyroidism, and their family…with written and verbal information on:
– possible drug interactions of thyroid hormone replacements, including interactions with over-the-counter medicines
– how and when to take levothyroxine
NICE Guidelines, 2019

Patients with thyroid disease need to have a clear understanding on the disease, treatment goals, and connection between thyroid function tests and symptoms. Medication (Levothyroxine) is frequently taken incorrectly, possibly leading to suboptimal treatment.

Patient information and support on thyroid disease help patients make informed decisions on the management of their condition.

A complete drug history of the patient helps determine if Levothyroxine may interfere with other medications currently being taken, in which case, the patient may be recommended to take Levothyroxine earlier or half hour before food and other medications.

Review of other drug intake should be made so if needed, changes may be made to drug prescription. Example: Iodine may cause toxicity problems with the thyroid gland and may lead to hypothyroidism. Example: Lithium use blocks thyroid hormone production.

The patient needs to be made aware that any side effects experienced may be due to thyroid disease, and that, if kept under control, such side effects may be reduced. Constipation, which is one of the side effects of hypothyroidism, may subside following regular use of Levothyroxine. However, if it persists, increasing high fibre intake and more fluids should help further. Movicol may also be prescribed to help with constipation (if other methods fail to help).

Regular exercise needs to be encouraged, starting slowly, and increasing gradually. This is because patients with thyroid disease such as hypothyroidism tend to gain weight. If necessary, patient may be referred to a dietitian.

Medication compliance is very important with regards to Levothyroxine. The patient needs to be educated about the condition – that it is a lifelong condition which needs to be controlled by medication. It is a chronic disease. Thus, Levothyroxine should not be stopped, even if patient feels well.

Patient should be encouraged to attend all follow-ups so as to ensure that the right dose has been prescribed. It may take a couple of follow-ups until the right dose is achieved. The patient should be instructed that in case of palpitations, chest pain, and tachycardia, contact should be made with clinician so as to ensure she is not going into hyperthyroidism instead.

References

Cleveland Clinic (2020). Thyroid Disease: Causes, Symptoms, Risk Factors, Testing & Treatment. Retrieved from https://my.clevelandclinic.org/health/diseases/8541-thyroid-disease on 5th May 2022

NICE Guidelines (2019). Thyroid Disease: assessment and management. Retrieved from https://www.nice.org.uk/guidance/ng145 on 5th May 2022

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Thyroidectomy Perioperative Nursing Care

The thyroid gland plays a major role in the metabolism, growth and development of the human body, regulating body functions by constantly releasing a steady amount of thyroid hormones into the bloodstream. At times however, an individual may require a thyroidectomy, which is the surgical removal of all or part of the thyroid gland. This may happen due to thyroid-related conditions such as Goitre and Carcinomas.

Hypothyroidism vs Hyperthyroidism

In hypothyroidism, the thyroid gland is underactive, hence it doesn’t produce enough thyroid hormone. On the other hand, in hyperthyroidism, the thyroid gland is overactive, hence it produces too much thyroid hormone.

Thyroidectomy Perioperative Nursing Care — Retrieved from https://terrainwellness.com/symptoms-of-hashimotos-flare-up/ on 29th April 2022

Thyroidectomy Indications

Goitre

A goitre a.k.a. goiter refers to swelling of the thyroid gland which causes a lump located at the front of the neck which moves up and down with swallowing. Nodules are lumps located within the thyroid gland.

Solitary Nodular Goitre (single swelling) – most commonly benign, solitary nodular goitres are often left untreated. If upon examination cancer is not excluded, surgery is usually recommended. An overactive nodule a.k.a. hot nodule can be treated by pharmacological medication, radioactive iodine treatment, or surgery.
Multi-Nodular Goitre (multiple swellings) – common multiple swellings which usually do not require surgery unless breathing and/or swallowing become compromised, or in case of rapidly growing nodules, or the individual prefers to undergo surgery for aesthetic purposes (unsightly goitre).

Carcinoma

Thyroid cancer is a rare type of cancer affecting the thyroid gland. Types of thyroid cancers include:

papillary carcinoma – the most common type, affecting mostly females under 40; papillary carcinomas appear as irregular solid or cystic masses or nodules
follicular carcinoma – affecting mostly middle-aged females, these malignant epithelial tumors account for about 15% of malignant thyroid tumors
rare carcinomas – include thyroid teratomas, lymphomas, and squamous cell carcinomas.

Retrieved from https://basicmedicalkey.com/cancer-treatment-and-chemotherapy/ on 21st June 2022

Thyroidectomy Types

Hemi-Thyroidectomy – removal of half of the thyroid gland
Lobectomy – removal of either the right or the left thyroid gland lobe, commonly done in the case of solitary goitre
Total Thyroidectomy – removal of the whole thyroid gland, commonly done in cases of malignant thyroid tumors
Subtotal Thyroidectomy – removal of almost whole thyroid gland, commonly done in multi-nodular goitre (some thyroid tissue surrounding one parathyroid gland is preserved)
Near-Total Thyroidectomy – removal of almost whole thyroid gland, commonly done in multi-nodular goitre (some thyroid tissue surrounding one parathyroid gland is preserved)
Isthmusectomy – removal of the thyroid isthmus

Retrieved from https://cancer.ca/en/cancer-information/cancer-types/thyroid/treatment/surgery on 5th May 2022

Thyroidectomy Perioperative Nursing Care

Thyroidectomy Preoperative Care

BLOOD INVESTIGATIONS:

CBC
Urea, Electrolytes, & Creatinine
T₃, T₄, & TSH (Thyroid Stimulating Hormone)

SCANS:

Thyroid Gland ultrasound scan
Radio-Iodine Thyroid Scan
Neck X-ray
Chest X-ray

OTHER INVESTIGATIONS:

FNAC (Fine Needle Apiration Cytology) of thyroid nodule, if palpable
Indirect Laryngoscopy for pre-operative assessment of vocal cords functioning

CARE:

patient reassurance through answering of any questions in relation to surgery so as to help reduce patient anxiety and fear; this also helps in acquiring informed consent
patient education regarding neck support in preparation for post-operative self-care
administration of anti-thyroid medication eg. Methimazole to promote a euthyroid (normal thyroid function) state
preparation of Potassium Iodide (Iodine) which helps to decrease thyroid gland vascularity, thus reducing risk for haemorrhage
avoid prophylactic antibiotic administration in such a clean elective surgery unless indicated

Thyroidectomy Postoperative Care

PATIENT CARE ON DAY OF SURGERY:

monitor patient’s vital signs and document accordingly
keep patient NBM (nil-by-mouth)
administer between 2.5l-3l of supplemental IV fluid
administer analgesics as prescribed to reduce severe post-operative pain
in case of excessive blood loss during surgery, blood transfusion may be required

PATIENT CARE FROM DAY 2:

encourage initial sips of clear fluid; move on to free fluids, to a soft diet, and finally to a normal diet once each phase is tolerated
maintain vital signs monitoring – temperature rise following 3rd day of surgery indicates infection
monitor surgical site for signs of infection; change initial dressing after 48-72hrs following surgery (unless it’s soaked beforehand, in which case should be changed earlier); use dry dressings every alternate day if suture line is clean and dry; removal of sutures is recommended for the 5th day post-op to avoid scarring as much as possible
monitor daily output from Redivac Drain – remove drain after 48 hours OR when drainage is reduced to a few milliliters in a 24hr period
keep on administering prescribed analgesics, monitoring their effectiveness and taking necessary measures in case of inefficacy

Redivac Drain

Thyroidectomy Complications

haemorrhage – assess surgical wound area for drainage, monitor blood pressure and pulse to notice possible hypovolaemic shock earlier on; risk of haemorrhage is at its peak in the first 24 hours post-op
respiratory distress – assess respiratory rate, rhythm, depth, and strength; prepare suction equipment, oxygen, and tracheostomy set at hand since possible haemorrhage and oedema may result in tracheal compression
wound infection
voice hoarseness and aphonia (total vocal cord paralysis due to nerve damage which causes sounds to come out as just whispers) – assess speaking tone and ability; hoarseness, which eventually subsides, happens due to oedema or endotracheal tube used during surgery
hypocalcemic tetany (low calcium levels in the blood caused by accidental parathyroid glands removal in total thyroidectomy) – this complication may occur in up to 7 days post-op; signs and symptoms include tingling of toes, fingers, and lips; prepare calcium gluconate or calcium chloride in case it’s needed for IV use

Further Related Information

Graves’ Disease

Graves’ disease is an immune system disorder that causes overproduction of thyroid hormones a.k.a. hyperthyroidism. Signs and symptoms of Graves’ disease can be wide ranging.

Hashimoto’s Disease

Hashimoto’s Thyroiditis a.k.a. Hashimoto’s Disease is an autoimmune disease that causes the body to produce antibodies which attack thyroid cells, leading to the under-production of the thyroid hormone. Symptoms of Hashimoto’s Disease may include goitre, lethargy, weight gain, and muscle weakness.

Thyroid Storm

Thyroid storm a.k.a. thyrotoxic crisis is an acute, life-threatening, hypermetabolic state caused by excessive release of thyroid hormones in individuals with thyrotoxicosis. Thyroid storm may be the initial presentation of thyrotoxicosis in undiagnosed paediatric patients, especially neonates.

Retrieved from https://m.facebook.com/permalink.php?story_fbid=1866113336780022&id=777683445623022&locale2=ja_JP on 30th April 2022

Myxedema Coma

Myxedema coma, which is considered to be a medical emergency with a high mortality rate, is defined as severe hypothyroidism that causes decreased mental status, hypothermia, and other organs to slow down their functions.

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Thyroid Gland Anatomy and Physiology

The thyroid gland is situated just below the larynx, with its right and left lateral lobes lying on either side of the trachea, connected together by the isthmus. It plays a major role in the metabolism, growth and development of the human body, regulating body functions by constantly releasing a steady amount of thyroid hormones into the bloodstream. It receives a rich blood supply of about 80 to 120ml per minute.

Thyroid Gland Histology

The thyroid gland is composed of spherical sacs called thyroid follicles which are covered by a wall made up of Follicular Cells and Parafollicular Cells a.k.a. C Cells.

Follicular Cells produce thyroxine (T₄) and triiodothyronine (T₃). Whilst T₄ is usually produced in greater quantities than T₃, T₃ is up to 4 times more potent than T₄. Additionally, about a third of T₃ is converted to T₄ within peripheral tissues, especially within the lungs and the liver.
Parafollicular Cells produce calcitonin (CT).

Thyroid Hormone Formation, Storage & Release

The thyroid gland is the only endocrine gland that stores its hormonal products in large quantities, eventually releasing them steadily over time. Thyroid hormone formation, storage and release occurs through the following process:

Iodide Trapping – iodide ions are actively transported from the blood to the follicular cells
Thyroglobulin Synthesis – during iodide ion trapping, follicular cells synthesise the glycoprotein Thyroglobulin (TGB) which is released into the thyroid follicle lumen by exocytosis, resulting in colloid accumulation within the lumen and Tyrosine (amino acids) iodination in TGB
Iodide Oxidation – iodide ions bind to TGB following oxidation; simultaneously, iodine is formed by the action of peroxidase
Tyrosine Iodination – formed iodine reacts with tyrosine in the colloid; one iodine atom binding forms monoiodotyrosine (T₁); a second iodine atom binding produces diiodotyrosine (T₂)
T₁ and T₂ Coupling – T₁ and T₂ join and form thyroid hormones
Colloid Pinocytosis & Digestion – colloid droplets re-enter the follicular cells though pinocytosis, and then merge with lysosomes in the follicular cells; lysozyme breaks down TGB, and then produce T₃ and T₄ molecules
Thyroid Hormone Secretion – lipid-soluble T₃ and T₄ diffuse through the plasma membrane into the interstitial fluid, and then into the blood; T₄ is secreted in larger quantities than T₃, yet T₃ is much more potent than T₄
Transport into Blood – Thyroxine-Binding Globulin (TBG) which is a transport protein found within the blood plasma combine with both T₃ and T₄ and are carried around in the body within the blood; when T₄ enters a cell, most of it is converted to T₃ following removal of one iodine

NOTE: Iodine supplements may be given to pregnant women and for compensation of hypothyroidism.

Thyroid Hormone Regulation

Thyroid hormone secretion is stimulated by various factors…

Calcitonin (CT)

Calcitonin, which is produced by the parafollicular cells of the thyroid gland, is involved in the homeostasis of blood calcium level:

Calcitonin inhibits bone breakdown and promotes bone calcium absorption
Calcitonin is used in the treatment of post-menopausal osteoporosis along with calcium and vitamin dietary intake
Calcitonin secretion is controlled via a negative feedback system

NOTE: Diarrhoea is a possible sign of increased thyroid hormone. Similarly, constipation is a possible sign of underactive thyroid.

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Diabetes Nursing Management of Complications and Preventative Care

Whilst diabetes preventative care can help avoid the development of type 2 diabetes mellitus, adequate diabetes nursing management can help avoid or reduce the occurrence of serious diabetes complications, such as short-term complications which include hypoglycaemia, diabetic ketoacidosis, hyperosmolar non-ketotic coma, as well as long-term complications which include microvascular and macrovascular complications, and neuropathy.

Short-Term Diabetes Complications

Hypoglycaemia

Hypoglycaemia can be defined as a glucose concentration of 3.9mmol/l or below.

diabetes nursing management — Retrieved from https://www.facebook.com/photo/?fbid=272975211310190&set=a.111544340786612 on 16th April 2022

An individual with hypoglycaemia can be asymptomatic, usually due to adaptation of the brain to chronic hypoglycaemia, which presents with symptoms even at normal blood sugar levels. This can be avoided if the individual experiences a few weeks of good glycaemic control.

An individual with hypoglycaemia may also present with mild symptoms which can be self-managed, severe symptoms requiring medical assistance, and even coma.

Hypoglycaemia Causes

insulin or sulphonylurea overdose (deliberate or accidental) – insulin can cause hypoglycaemia; metformin does not
inaccurate injection administration
renal and liver impairment cause pharmacokinetic change, possibly leading to a hypoglycaemic episode; individuals with renal and liver impairment should be monitored closely
delayed or forgotten meal, or insufficient carbohydrate intake
alcohol intake – food needs to be taken with alcohol, otherwise hypogycaemia can be triggered
exercise – can trigger a hypoglycaemic episode following exercise or even several hours after
hot weather or saunas – insulin is absorbed quicker in warmer temperatures, thus, saunas and hot weather should be avoided
honeymoon period (following diagnosis is usually a period a.k.a. honeymoon period in which remaining beta cells may pump out enough insulin to control blood glucose, thus may require less insulin)

Nursing Management of Hypoglycaemia

If the patient presents with mild hypoglycaemia:

give 15-20g of glucose such as a sugary drink – water with 2 teaspoons of sugar
repeat after 10 minutes
check if patient is still hypoglycaemic through HGT testing
if stable give a snack eg. brown bread sandwich to prevent recurrence

NOTE: sugar helps stabilise the patient for that moment; a snack helps maintain glucose level higher for a longer period of time.

If the patient is uncooperative:

Administer GlucoGel (formerly known as Hypostop – raises sugar levels quickly and provides a fast-acting energy boost in the form of Dextrose Gel – 40% dextrose).

NOTE: following a hypoglycaemic episode, ALWAYS ESTABLISH CAUSE eg. problem with insulin administration.

If the patient is unconscious:

adjust patient into the recovery position
administer glucagon by intramuscular or subcutaneous injection OR 50cc of 50% dextrose intravenously.

Preventative Measures

The older person is at increased risk of suffering from fall injuries, heart attacks and strokes during hypoglycaemic episodes. Thus, teach older adults at risk of hypoglycaemia:

to carry an ID bracelet at all times
to check their blood glucose levels prior to risky activities
to know and identify early signs of an impending hypoglycaemic episode

Diabetic Ketoacidosis

Diabetic Ketoacidosis is the most acute state of Type 1 Diabetes. Diabetic Ketoacidosis onset may be both gradual or sudden, and is characterised by the following findings:

hyperglycaemia (15.0mmol/l and over)
ketonuria (if cells are not supplied with enough glucose, the body burns fat for energy whilst producing ketones which can show up in the blood and urine, evident in a urine dipstick test)
pH of 7.3 or less (normal blood pH level is 7.35 to 7.45)

Common causes for DKA include:

infection – most common cause of DKA eg. gastroenteritis, flu, small infection etc.
stressors – traumatic injuries and/or increased stress
insulin cessation – common in adolescents; patients need to be reminded that diabetes is a condition for life, thus needs to be controlled with ongoing treatment
anuria (not passing urine) – a minimum of 30ml/hr of urine should be passed
not eating – increases risk of DKA

Retrieved from https://eliteayurveda.com/blog/3-main-symptoms-or-3ps-of-diabetes/ on 25th June 2022

Kussmaul Breathing

Kussmaul Breathing is a sign of DKA. It is characterised by sweet-smelling breath which is rapid and deep. It manifests as a compensatory mechanism due to build-up of carbon dioxide and lack of oxygen.

Diabetes Nursing Management of DKA

An individual with DKA needs:

treatment for hyperglycaemia – patient needs to be kept nil-by-mouth along with administration of a continuous low dosage of insulin by IV pump. NOTE: monitor blood glucose levels and ensure it isn’t lowered at a rate faster than 5mmol/hr to avoid cerebral oedema.
treatment for dehydration, electrolyte imbalance, and acidosis – patient needs administration of IV fluids with electrolytes (eg. Hartmann’s – a clear solution of sodium chloride, potassium chloride, calcium chloride dihydrate and sodium lactate 60% in water) to help with dehydration and electrolyte imbalance, and insulin, which usually also corrects acidosis without the need for sodium bicarbonate administration. NOTE: monitor serum potassium levels and ECG tracings to ensure correct potassium level is achieved, and monitor for signs of fluid overdose. NOTE: if not NBM, patient should be encouraged to drink high-carb drinks eg. broth, soup, juices etc.
treatment for precipitating factors – DKA is commonly induced by infection, thus, antibiotic therapy should begin following C&S specimen, wound drainage, or blood results are obtained.

NOTE: If patient is sick with flu/cold etc., blood glucose needs to be monitored, insulin needs to be administered still. Within the body, carbs start to be broken down in an attempt to avoid going into DKA. Monitoring carb intake to avoid going into hyperglycaemia is recommended.

Additionally, monitor frequently the patient’s:

vital signs: blood pressure, pulse, temperature, and respirations
level of consciousness
intake and output
urine
blood glucose
ketone bodies
GFR renal profile – to check kidney function and serum electrolytes
HbA1c – to monitor glucose for the past 3 months
CBC – to check volume of white blood cells (low white blood cell count may be a sign of infection which could have been the reason behind the patient going into DKA
ABGs, serum K levels, urea, and RBGs – to check the partial pressure of CO² and to see if the patient is going into respiratory acidosis; tests also give an indication of electrolyte status (eg. potassium is lost in DKA due to polyuria, and kidney function may become impaired, causing electrolyte imbalance)
ECG (due to risk of cardiac arrest from hypokalaemia)

and ensure that the patient:

receives mouth care due to NBM and dehydration
for dehydration encourage patient to drink water unless NBM, in which case, IV fluids should be administered – monitor fluid intake and output!
is cared for in case of pain (assess for need of analgesics), abdominal pain, nausea (administer antiemetics) and vomiting (provide vomiting bags just in case)
is kept safe (attention: side rails, frequent turnings, call bell at arms’ length, and skin care)
airway patency is maintained (if unconscious)
always provide reassurance (helps reduce patient anxiety)

DKA Possible Treatment Complications:

hypokalaemia
hypotension
dehydration
impaired renal function
cardiac arrest
HAIs – ensure proper infection control principles are maintained so as to avoid patient getting an infection (may already be infected since infection is one of the problems leading to DKA)

When DKA is resolved:

insulin is administered subcutaneously (insulin IV should be continued for 1hr following SC insulin injection)
food is provided 30 minutes following insulin administration
monitor for DKA recurrence
teach patient ways to prevent recurrence

Hyperosmolar Non-Ketotic Coma

Hyperosmolar non-ketotic coma usually happens in individuals who have not been diagnosed with diabetes, usually type 2 diabetes, and is more common in individuals over 60 years of age. Characteristics are usually less severe, and most commonly develop over a long period of time.

Characteristics of hyperosmolar non-ketotic coma include:

hyperglycaemia
dehydration
no ketoacidosis

Nursing Management of Hyperosmolar Non-Ketotic Coma

Patients with Hyperosmolar Non-Ketotic Coma need to be treated in the same way as in Diabetic Ketoacidosis EXCEPT:

if serum Na (Sodium) is MORE THAN 155mmol/l use 0.45% NaCl instead of 0.9% NaCl
patient may require insulin infusion at a lower rate
patient should be administered an anticoagulant due to an increased risk for thromboembolism
patient should have central venous pressure catheter

NOTE: following resolution, patient may require insulin subcutaneously for a few weeks before transitioning to new treatment regimen consisting of diet, exercise, and hypoglycaemic agents.

Long-Term Diabetes Complications

Microvascular Complications

Microvascular complications of diabetes are long-term complications which affect small blood vessels. Complications typically include:

retinopathy – retina disease (most common cause of blindness in young people)
nephropathy – kidney function deterioration (affects 45% of diabetic patients, 25% of which develop end-stage renal disease)
peripheral neuropathy – impaired sensation in the peripheries (feet and hands)
autonomic neuropathy – bowel and bladder disorders

MACROVASCULAR COMPLICATIONS

Macrovascular complications of Type 2 Diabetes are primarily diseases of the coronary arteries, peripheral arteries, and cerebrovasculature. Cardiovascular disease is the primary cause of death in diabetic patients. Early macrovascular disease is associated with atherosclerosis.

Preventative Measures for Microvascular and Macrovascular Complications

in patients with stable glycaemic control assess glycaemic status through A1C or other glycaemic measurements at least every 6 months
in patients with unstable glycaemic control and/or who have had recent treatment change assess glycaemic status through A1C at least every 3 months
promote lipid management through the Mediterranean Diet or DASH, reduction of saturated fat and trans fat intake, increase in healthy fats intake, viscous fiber, plant sterols intake (found in vegetable oils, nuts and seeds), and increased physical activity to prevent atherosclerosis development
promote optimum glycaemic control in patients with triglyceride levels of >150mg/dL (1.7mmol/L) and low HDL Cholesterol amounting to <40mg/dL (1.0mmol/L) in men and <50mg/dL (1.3mmol/L) in women
screen for renal disease at least yearly through urinary-albumin-to-creatinine ratio and estimated glomerular filtration rate (EGFR) in individuals with 5 years or more of type 1 diabetes, and in all individuals with type 2 diabetes (monitor every 6 months patients with >300mg/g creatinine and EGFR 30-60mL/min/1.73m²)
refer to ophthalmologist for eye complication screening patients with type 1 diabetes within 5 years of diabetes diagnosis, and patients with type 2 diabetes upon diabetes diagnosis
provide general preventative diabetic foot self-care education to all patients with diabetes, and refer to registered podiatrist for annual foot evaluation to identify risk factors for ulcer formation and amputations

Statin Therapy

Retrieved from https://www.uchealth.org/ on 23rd April 2022

CVD Risk Assessment Tool for Healthcare Professionals

ESC CVD Risk Calculation App (Apple or Android)

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