Q1.

1. Ruby Pascal has type 2 diabetes which she controls using insulin and metformin. The metabolic disorder is a result of the failure of insulin receptive tissues to respond to insulin (Baynest, 2015, P. 2). Type 2 diabetes results in decreased uptake of glucose. The pancreatic cells release insulin to regulate blood glucose concentrations. The failure of this mechanism results in a metabolical imbalance that causes type 2 diabetes mellitus. Obesity has been noted to contribute to the development of the disease.

Frequent urination coupled with excessive thirst are common signs of type 2 diabetes. The disease results in excess glucose levels in the body (Baynest, 2015, p. 1). When this happens, the kidneys work excessively to filter and absorb the excess glucose. However, if the kidneys fail to absorb this excess glucose, it is passed out of the body in urine. Other tissue fluids are dragged along, resulting in tissue dehydration. The patient will frequently drink more fluids to hydrate the body, resulting in increased urination. These two signs could be early signs of type 2 diabetes.

Obesity and lack of exercise contribute to the development of type 2 diabetes (Y. Parmar, 2018, p. 2). Ruby is overweight with a body mass index (BMI) of 35. The excess body fats result in the body cells becoming less sensitive to insulin. This is because fat cells have higher resistance to insulin than muscular cells. Being obese, the patient is unable to exercise regularly. During physical activity, muscle cells use more glucose hence lowering the risk of diabetes. Inactivity will result in the body using less glucose since the muscle cells become less sensitive to insulin (Baynest, 2015, p. 5). The excess glucose in the cells may result in diabetes. These two factors may have contributed to ruby getting type 2 diabetes.

Q2

Pulmonary embolism occurs when a blood clot blocks pulmonary arteries in the lungs. It occurs when a venous thrombosis develops and travels to the pulmonary arteries, where they cause blockage to one or more blood vessels (Casselman and Babcock, 2015, p. 1). The patient may experience sharp chest pains and shortness of breath, as is the case with Ruby.

Obesity can cause a pulmonary embolism. Ruby Pascal has a BMI of 35, meaning she is obese. Obesity interferes with factors that affect coagulation in the body. Patients with obesity may produce more adipocytes which affect platelet activity in the blood. Plasminogen activator inhibitor-1 is also overproduced by the fatty cells. The inhibitor-1 leads to inability to break down clots raising the risks of pulmonary embolism.  She is also using contraceptives. Though it is rare, the risk of developing a blood clot is high when a patient is using contraceptives. Oral contraceptives containing drospirenone increase the risk of pulmonary embolism. The hormone, just like oestrogen and other lipophic hormones affects gene transcription of proteins. This will result in increased concentration of clotting factors. Therefore, high doses of these oral contraceptives may directly contribute to the formation of clots which increases the risk of pulmonary embolism.

Q3

Ruby’s medical condition has deteriorated, resulting in her being in the emergency department for three days. She has a history of general anxiety disorder. However, on presentation to the emergency department, she has chest pains, nausea and vomiting. The leading cause of her deterioration may be due to the physicians attending her attributing her present symptoms with an existing condition. Her history with anxiety, though useful, should not be used to treat her present condition exclusively. Recently, Ruby had also been reluctant to seek medical attention regarding her condition.  She has been self-medicating, according to her admission. This may also contribute to her condition worsening.

To halt the deterioration, the physicians should come up with a system that detects, recognizes and responds to the deterioration in her condition. The physicians should identify the causes of her current condition and not attribute it to the earlier physical and mental symptoms. They should also be able to recognize the potential early symptoms that could signal a decline in her mental state.

Q4

The priority clinical problem facing Ruby is chest pains. This is because chest pains can be an onset for other conditions such as heart failure and AMI. The short term goal should be to stabilize her condition to halt the deterioration and alleviate the pain. This goal should be achieved within the shortest time possible to safeguard the life of the patient.

The nurse should give ruby supplementary oxygen and then perform a ‘PQRST’ pain assessment to determine the severity of the chest pains. Chest pains should be treated seriously since they could point to other severe conditions which are life-threatening. In performing the ‘PQRST’ pain assessment, the nurse will be able to determine whether the pain is cardiac or not. Chest pains resulting in acute myocardial infarction (AMI) are usually accompanied by vomiting and nausea.

Supplying the patient with supplementary oxygen will enable her to stabilize her breathing and improve blood flow(Raut&Maheshwari, 2016, p. 342). Supplementary oxygen to patients with AMI reduces cases of fatality by 50%. The oxygen improves the oxygenation of the ischemic myocardial tissues reducing the pains to the patient. The ‘PQRST’ pain assessment test enables the nurse to identify the severity of the pain. The nurse will rate the pain from 0 to 10, with zero being no pain and ten excruciating pain.

Q5

Anticoagulation therapy is used in the treatment of pulmonary embolism(Dobler, 2019, p. 48). The role of anticoagulant is to prevent the development and extension of an existing thrombus. They interrupt the process of forming a blood clot. The use of direct oral anticoagulants is recommended for a patient with acute pulmonary embolism.

In administering anticoagulants, one should be keen on identifying other comorbidities that the patient may be suffering from (Adderley et al., 2017, p. 588). Different types of anticoagulation therapies should be used depending on the condition of the patient. For instance, it is recommended that patients with diabetes be treated with oral non-vitamin anticoagulants to reduce risks of thromboembolic stroke.

The two convenient anticoagulation therapies to be applied in this case should be directly acting oral anticoagulants and vitamin K antagonist oral anticoagulants. The directly acting oral anticoagulants are more efficient and have faster reactions. The drugs have short lives and have no known drug interactions. Thus, monitoring and dose adjustments are not necessary. However, their effects on the body recede faster due to their short lives(Dobler, 2019, p. 46).

Vitamin k antagonist anticoagulants inhibit the liver from processing vitamin K into factors that aid blood clotting (Yamagishi, 2019, p. 1). In using these type of inhibitors, one is required to keep a low amount of vitamin K in the diet. This enables the doctor to estimate the correct dose. Blood tests are used to track the effects of the dose on the patient. The D-dimer blood test measures the levels of anticoagulants in the blood. This type of anticoagulants is easy to reverse in case of sudden changes in the condition of the patient (Dobler, 2019, p. 47).

Q6

Communication is essential in dealing with mental health patients. These skills are essential in helping the patient as well as developing a good nurse-patient relationship. In mental health, nurses are required to have good interpersonal skills to enhance the development of a therapeutic alliance between the nurse and the patient. Nurses in this field should be able to use a different type of skills depending on the patient needs. Listening and non-verbal communication are important skills in mental health nursing. There is great therapeutic value in listening since it gives the patient space to talk. Non-verbal communication takes place through our actions, eye contact, voice, physiological responses and facial expressions. It is important that nurses be cautious of their nonverbal body language.

Anxiety can be described as a normal reaction when faced with different situations. It’s like an internal warning system that alerts us about an incoming danger. However, when this anxiety becomes unmanageable or overwhelming, it becomes an anxiety disorder (Asakura, 2015, p. 6). Normal anxiety lasts as long as the situation. However, general anxiety disorder is much stronger last for a long time. People suffering from GAD tend to avoid situations that may trigger anxiety.

Severe anxiety attacks can have a physical sign that affects the patient. These main symptoms are nausea and chest pains (Asakura, 2015, p. 4). During anxiety attacks, the brain will release neurotransmitters to help the body respond to the cause of the anxiety. These transmitters usually enter the digestive system causing stomach upset and nausea. Chest pains are also common during severe anxiety attacks. Anxiety causes oesophagal spasms resulting in chest pains. These spasms are a result of muscular contractions as the body tries to protect itself from danger. The chest walls muscles contract causing pain during and after the attack.

Ruby is suffering from severe anxiety attacks. The attacks have become frequent since her husband was diagnosed with bowel cancer. Though she had a history of anxiety disorder for ten years, her husband condition has contributed to her current condition. To treat this, the nurse should consider using either cognitive therapy or behavioural therapy. In cognitive therapy, the nurse helps the patient understand the thoughts or situations that lead to excessive emotional responses. The patient can keep logs and self-monitor the situations causing anxiety and the ways to deal with this cognition. In behavioural therapy, the patient is exposed to anxiety-provoking conditions and patient is desensitized to the stimuli over time (Asakura, 2015, p. 5).

Q7

Interdisciplinary care relies on all health personnel in different fields collaborating to share responsibilities and achieve objectives. The patient, together with the team of healthcare providers creates a health care plan for the patient. On the other hand, multidisciplinary care involves each team member working independently to create a health care plan for the patient. However, the plans are implemented simultaneously without interaction with other specific care plans (Ino et al., 2018, p. 192).

Q8

In discharging Ruby, it is essential to consider all her existing comorbidities. In addition to a general practitioner and a diabetes educator, Ruby should consider using the services of a personal trainer or exercise physiologist and a dietitian. Ruby has not been able to exercise due to her inability to control her diabetes. She is also unable to maintain a diet during this time. The exercise physiologist and dietitian will help to achieve the required lifestyle, which helps control her conditions.

The nurse discharging Ruby should ensure that she is informed of the instructions to follow after being discharged. She should be informed of the various parameters that will enable her to gauge her recovery. She should also be informed of the various health specialist she should consult. This information should be well spelt to the patient to reduce the chance of her condition worsening. Finally, the nurse should assess the health condition of Ruby before discharging her. She should make sure that she is stable and can take care of herself at home.

References

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Asakura, S. (2015). Diagnosis and Clinical Evaluation of Social Anxiety Disorder. Anxiety        Disorder Research, 7(1), 4-17. https://doi.org/10.14389/jsad.7.1_4

Baynest, H. (2015). Classification, Pathophysiology, Diagnosis and Management of Diabetes          Mellitus. Journal Of Diabetes & Metabolism, 06(05). https://doi.org/10.4172/2155- 6156.1000541.

Casselman, E. L., & Babcock, E. (2015). Variable clinical presentation of acute pulmonary embolism. Journal of the American Academy of Physician Assistants, 28(10), 1–2. https://doi.org/10.1097/01.jaa.0000470537.25807.f4

Dobler, C. C. (2019). Overdiagnosis of pulmonary embolism: definition, causes and implications. Breathe, 15(1), 46–53. https://doi.org/10.1183/20734735.0339-2018

Ino, Y., Matsuyama, T., Tachi, T., Noguchi, Y., & Teramachi, H. (2018). Effect of Multidisciplinary Medical Care Team Education on Pharmacy Students. Iryo Yakugaku (Japanese Journal of Pharmaceutical Health Care and Sciences), 44(4), 191–202. https://doi.org/10.5649/jjphcs.44.191

Medication Safety Standard | Australian Commission on Safety and Quality in Health Care. (2021). Safetyandquality.Gov.Au. https://www.safetyandquality.gov.au/standards/nsqhs-standards/medication-safety-standard

Raut, M., &Maheshwari, A. (2016). Oxygen supplementation in acute myocardial infarction: To be or not to be?. Annals Of Cardiac Anaesthesia, 19(2), 342.             https://doi.org/10.4103/0971-9784.179594

Riedel, M. (2021). VENOUS THROMBOEMBOLIC DISEASE: Acute pulmonary embolism 1:    pathophysiology, clinical presentation, and diagnosis.

10. Parmar, M. (2018). Obesity and Type 2 diabetes mellitus. Integrative Obesity and Diabetes, 4(4). https://doi.org/10.15761/iod.1000217

Yamagishi, S. (2019). Concerns about clinical efficacy and safety of warfarin in diabetic patients          with atrial fibrillation. Cardiovascular Diabetology, 18(1).             https://doi.org/10.1186/s12933-019-0818-0.