Healthcare and Patient Safety Assessment

This healthcare assignment assesses various aspects of patient safety, including the risks associated with diabetic foot ulcers, long-term diabetes complications, mental illness, and obesity measurement. It explores the importance of regular foot examinations for patients with diabetes and highlights the increased risk factors for developing diabetic foot ulcers. The assignment also examines the unique challenges posed by mental illness in healthcare settings and emphasizes the need for understanding and addressing patient safety concerns related to these conditions. Additionally, it compares BMI and waist circumference as measures of obesity, discussing the limitations of BMI and the advantages of waist circumference in accurately reflecting abdominal fat deposition.

URN: QUT19418 | PATIENT: BRENNAN,
Michael
Mr Michael Brennan 52yrs is attending his General Practice surgery for
his regular six monthly check-up. He presents today with complaints
of fatigue, difficulty losing weight and no motivation. He denies any
polyuria, polydipsia, polyphagia or blurred vision. He notes a marked
decrease in his energy levels, particularly in the afternoons. He is
tearful and states that he is not taking his antidepressants. He states
that every time he tries to cut down on his eating he has symptoms of
shakiness, diaphoresis, and increased hunger. He does not follow any
specific diet and has been fearful of hypoglycaemia that he often eats
extra snacks.

Caring for a patient with Diabetes, Obesity and Mental Illness
Setting the scene
Michael’s holistic assessment by the General Practitioner
(GP) today indicates:
Physical:
 Weight 140kg (up from 135kg six months ago)
 Height 176 cm
 BP 160/70; HR 88
 Temp 37.7
 BGL: 9.0mmol
 Pain in his knees and ankles (rated as 4/10 on pain
scale) – patient states this makes it difficult to do any
exercise
 Laboratory testing indicated that chemistries, Blood
Urea Nitrogen, creatinine, liver function tests, thyroid
function tests and urine microalbumin are all normal
 Glycated Haemoglobin (HBA1c) was 7% for one year
but is now 9%
 LDL: 2.2 mmol/L
 HDL: 1.6mmol/L
Previous history:
 9 year history of diabetes
 Obesity
 Depression
 Hypertension
 Arthritis
Surgical history:
 Trans-urethral resection prostrate
 Cholecystectomy
Medications:
Nurofen, Metformin, Coversyl, Atorvastatin, Lexapro
Social:
Michael lives on his own after losing his wife five years ago. He has learned some cooking
skills and prepares most of his meals although takeaways are an easy option for him
during his work day as a taxi driver. He has good family support from one daughter, one
son and two grandchildren who live close. Michael has little social engagement other
than his children and often chooses not to leave the house.
Epidemiology / pathophysiology of disease processes
The National Health Priority Areas of Diabetes Mellitus, Obesity and Mental Health were
established with the aim of improving health outcomes in these areas. Review your
modules, references and extended reading in regard to these National Priority areas.
Diabetes is a chronic condition marked by high levels of glucose in the blood caused by
either the inability to produce insulin or by the body not being able to use insulin
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effectively. The main types of diabetes are Type 1, Type 2 or Gestational. In 2014-2015
approximately 1.2 million people (6% of Australian adults) had diabetes, based on self-
reported data. This is a growing issue with increasing hospitalisations due to diabetes and
one in ten Australian deaths having diabetes as an underlying and/or associated death.
In 2011-2012, almost 2 in 3 (63%) of Australian adults are overweight or obese. Obesity is
a major risk factor for cardiovascular disease, Type 2 diabetes, some musculoskeletal
conditions and some cancers, while making the management of and controlling of chronic
disorders difficult.
Mental health and behavioural disorders describe a wide spectrum of disorders which
can vary in both severity and duration. The most common disorders are depression,
anxiety and substance use disorders and are important drivers of disability and
morbidity. There is also an association between diagnosis of mental health disorders
and a physical disorder with 1 in 8 (12%) of people with a 12-month mental disorder also
reporting a physical condition and 1 in 20 (5%) reporting two or more physical
conditions.
There is a clear bidirectional association between diabetes and mental illness. Statistics
show that Australians with diabetes have a higher prevalence of poor mental health than
those without diabetes. People with diabetes are more than twice as likely to have
mental or behavioural problems as those without diabetes.
Your Task:
Use the Clinical Reasoning Cycle on the following pages to review the nursing priorities in relation to
the care of Michael.
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Gain an initial impression of
your patient
Question 1:
Review the anatomy and physiology of the three types of
diabetes (Type 1, Type 2 and Gestational).
a. What type of diabetes do you think that Michael has? Justify
the reason for your answer
Your Answer:
The patient had been suffering from diabetes for the past nine years and his signs
all indicate at the possibility of the patient having diabetes type two, which is the
most common type of diabetes seen in adults.
It has to be mentioned in the justification of this diagnosis is the fact that high
blood glucose levels are characteristic feature of this type of diabetes which is high
in case of the patient as well. Moreover, The type 1 diabetes in mainly juvenile
diabetes which is hereditary and is manifested in the early childhood years, which
is not the case of the patient, as he had been suffering from diabetes only for 9
years.
For gestational diabetes as well, this condition occurs to pregnant women, which is
not the case fir the patient under consideration. Hence the patient has been
suffering from type 2 diabetes, a chronic lifestyle based condition for the adult to
middle aged patients (American Diabetes Association, 2010).
Gain an initial impression of
your patient.
Question 2:
a. What is Michael’s BMI and how is this calculated?
b. Discuss what this BMI means for Michael?
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Your Answer:
Michael’s BMI: 45.2
The BMI is generally calculated by a complex ratio involving the height and weight
of the particular individual involved.
According to the most common statistical metrics, the BMI of 30 or higher relates to
the fact that the person is obese and needs immediate attention to their excessive
body weight. It has to be mentioned in this context that the patent under
consideration for this assignment had a BMI of 45.2, which is far higher than the
normal range. Hence it can be stated that with the extremely high BMIU that the
patient has, the chances of the patient being severely overweight is extremely high
and the subsequently the health risks of the patient is also going to be extremely
high like hypertension, anxiety and several other health complications (Feng et al.,
2012)
Gain an initial impression of
your patient.
Question 3:
Review and recall your knowledge of diabetes and the possible
adverse complications that may occur.
a. List four signs and symptoms of hypoglycaemia that
Michael might experience
b. Using your knowledge of anatomy and pathophysiology,
explain in detail why one of these signs and symptoms
could occur.
Your Answer:
a. As the patent high blood glucose levels and extremely obesity situation, the patient
will have increasingly high risk of having hyperglycemic attacks that the patients will
have to be very careful to detect early and take adequate actions. The four signs
and symptoms of the possible hyperglycemia attacks tat the patient will need to be
very careful about include: suddenly higher than normal heart rate, paleness,
sudden bouts of fatigue, and blurred vision (Inzucchi et al., 2012).
b. Hyperglycaemia can be considered a situation where the patients with high diabetes
or high blood glucose levels encounter the effect of a sudden change in the plasma
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glucose levels and the concentration of free immmunoreactive insulin and C-peptide
immunoreactivity. Emphasizing on the manifestation of one of the symptoms, the
increased feeling of hunger and fatigue is directly reacted to the sudden reduction in
the plasma glucose levels of the patient below the normal threshold. This reduction
acts on the cellular and metabolic activity of the body and the feeling of fatigue and
hunger in the patient (Luitse et al., 2012).
(a)Review current
information
(b)Gather new information
(c)Recall knowledge (A&P,
ethics, law, cultural
safety)
Question 4:
Review current information: review and think about Michael’s
presentation, the observations that have been carried out and
what further assessment you would want to carry out now.
a. Lexapro is a commonly used medication to treat anxiety and
depression in adults. Describe the mode of action of this
medication for Michael.
b. How should this medication be taken?
c. List two side effects of the medication.
Your Answer:
a. Lexapro oral is the trade name for the medication Escitalopram which is a very
common medication given to the patients to treat depression and anxiety. It has to
be mentioned in this context, that this a key medication that helps in reducing and
maintaining the level of anxiety and depression in the patients by regulating and
maintaining the level of a key signaling factor, serotonin. Serotonin belongs to the
class of selective serotonin reuptake inhibitors (SSRI), and is a neuromoderating
factor that helps to maintain the levels of serotonin in the brain relaxing the patient
and relieving the patient of the feeling of tension or stress. Along with that this
medication can also help in improving the energy levels of the patient and can help
the patient feel good (Uher et al., 2011).
b. The administration of this medication should be based on the discretion of a
registered health practitioner, however the most frequently observed mode of
administration for this medication is orally. This medication is to be consumer once
everyday wither in the morning or in the evening.
c. Two side effects of this medication are: nausea and constipation.
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(a)Review current
information
(b)Gather new information
(c)Recall knowledge (A&P,
ethics, law, cultural
safety)
Question 5:
A normal BGL is:
a) 2.5-3.5mmol
b) 4.0-8.0mmol
c) 5.0-10.0mmol
d) > 10.0mmol
Your Answer:
A normal BGL or blood glucose levels for the adults has to be option b) 4.0 to 8.0 mmol
(a)Review current
information
(b)Gather new information
(c)Recall knowledge (A&P,
ethics, law, cultural
safety)
Question 6:
Obesity puts Michael at risk of what four conditions?
Your Answer:
Obesity can be considered as one of key health adversities and extreme obesity
puts the patients at extremely high risk of many health conditions. For instance, it
has to be mentioned that obesity is a health condition where the victim carries at
least more than 20 % more body weight than what is required based on the height,
age and body structure.
Excessive body weight puts the patient under the risk of coronary heart diseases
and cardio- vascular complications which is by far one of the most harmful and
deadliest of health adversities (Dixon, 2010).
Along with that, high body weight also increases the chances of the patient
developing chronic high blood pressure which in turn paves way for many health
adversities.
The next health risk that the patient is under due to obesity and high body weight
is High blood cholesterol and triglycerides.
And lastly, the possibility of bone and joint problems like osteoarthritis can be the
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outcome of excessive body weight (Zalesin, 2011).
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Interpret data – what does
it all mean?
It is important to consider
the potential inter-
relationships between
diabetes, obesity and
mental health issues
Question 7:
Michael has indicated that he does not follow any specific diet and
takeaways are an easy option. What allied health professional
would you consider referring Michael to?
Give a rationale for your answer.
Your Answer:
It has to be understood that obesity is a health condition that paves way for many
health risks and equal amount of health complexities. that is the reason why the
patients suffering with health conditions like obesity must take acute care to
maintain a healthy and fulfilling diet that will help them regain control of their body
weight without compromising on the daily nutritional requirements. In this case,
that patient under consideration is highly obese and has been already dealing with
type two diabetes which can be considered as one of the most crucial health
adversities affecting the living condition and lifestyle of the patient effectively. In
this context, not having a controlled and efficient diet plan can be extremely
harmful for the patent and can increase the risk of the patient developing
cardiovascular conditions (Psaltopoulou, Ilias & Alevizaki, 2010). Hence, I would
recommend the patient to consult a registered nutritionist or a registered dietician
and follow a planned diet.
According to the authors, it has to be mentioned that the concept of nutritional
counseling is considered to be a very important element of the overall care
planning that the patients undergo in an attempt to maintain the health statistics
after diabetes type two. Consuming uncontrolled amount of fatty food can be
extremely harmful for the patient and can lead to many health related concerns for
the patient and can worsen the obesity due to unwarranted consumption of
triglycerides. Keeping aside the threat of obesity for a diabetic maintaining a BGL
balance is extremely crucial and hence following a professionally designed patient
centered diet developed by the registered dietician or nutritionist will be
significantly beneficial (Azadbakht et al., 2011).
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Interpret data – what does
it all mean?
Question 8:
Of the physical assessment on Michael – what finding is of most
concern?
a. BGL
b. BP
c. Temperature
d. Pain
Discuss why this is of most concern.
Your Answer:
As per the objective data gathered of the patient the two most concerning health
statistics that the patient is showing can be the fact that the patient has extremely
high blood pressure at 160/80 and the blood glucose level at 9mmol. However, it
has to be mentioned that the normal blood glucose levels of a patient with diabetes
is close to 7.0 mmol, and concerning that fact that the patient has been suffering
from diabetes for nine long years a slight fluctuation to 9.0 an not be on the most
important priority list.
On the other hand, in this case the patient had high blood pressure in the patient
which is 160/80. Now it has to be mentioned that as per the vita; signs of the
patient, the SBL and DBL figures shown by the patient indicates that the patient is
in hypertension stage II (Kotsis et al., 2010).
There are various risk factors are associated with the various health risk factors
which can be potentially fatal for the patient. The very first risk factor is the
coronary arterial blockages and resultant heart attacks. It has to be mentioned in
this context that the patient can be at life risk for the cardio- vascular
complications he can develop due to stage II hypertension. Along with that patient
had also been suffering through conditions like renal and peripheral arterial
diseases. Hence, it can be stated that the patient under consideration in this case
study assignment is at high risk of lower life expectancy due to the extremely high
blood pressure. Hence, this is the most important health concern for the patient
(Hall et al., 2014).
Synthesise all information
that has been collected and
Question 9:
Select from the list below the three highest priority relevant
nursing diagnoses for Michael. Justify your answers.
a. Activity intolerance
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processed. b. Impaired social interaction
c. Cognitive impairment
d. Insomnia
e. Impaired nutrition
f. Antisocial personality disorder
Your Answer:
Among the different answers given below, the first highest priority while car
planning for the patient under consideration is the impaired nutrition that the
patient is having, it has to be mentioned in this context that the patient has had a
long term type two diabetes that the patient has been struggling with for 9 years.
Despite that the patient has been dealing with high obesity and extremely high
blood pressure which further increases the health risks that the patient in under. In
such a condition, despite having 45.2 BMI and 9.00 mmol BGL, the patient carries
on a more or less sedentary life style and has no planned diet or dietary restriction.
The patient has also shared that he even indulges in frequent snacking and has no
BMO diet plans in the nine years that he has been suffering with the diabetes. In
this case, the nutritional impairment is very clear, where the fat and carbohydrate
rich diet is contributing to the weight increase and uncontrolled blood glucose level
hike (American Diabetes Association., 2015).
The next highest priority for the patient is the activity intolerance that the patient
has due to his arthritis and joint pain. The patient has shared the fact that he is
unable to maintain a regular exercise regimen for the acute knee pain that he
suffers from. Hence, providing short term meditational and long term non-
pharmacological interventions for the knee pain can be necessary care goals for
the patient (Handelsman et al., 2011).
The third and final priority from the list can be the possible insomnia that the
patient might suffer from due to
the anxiety, depression and pain that the patient suffers from. The patient has also
shared that he had long stopped taking the antidepressants and has been feeling
increasingly helpless. Hence, insomnia medication prescribed to the patient along
with antidepressants can be beneficial.
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What should happen to
improve problems/issues and
by when?
Question 10:
From the list below choose the three most important short-term
goals and justify the importance for Michael’s management at
this time:
a. For Michael to lose weight
b. For Michael to sleep for eight hours/night
c. For Michael’s BGL to stablise
d. For Michael to be more social
e. To improve Michael’s mood
f. For Michael to take time off work.
Your Answer:
Among the given set of optiobs the three most important short term, goals for the patient
are:
For Michael to lose weight: the BMI for the patient is 45.2, which is excessively higher than
the normally permissible limit, indicating that the patient is obese. It has to be mentioned
in this context that the patient has been suffering from three adverse health consequences
of obesity like diabetes, high blood pressure and joint pain. Hence, losing weight is
extremely important for the patient to avoid further health complications like coronary
heart diseases and renal diseases.
For Michael’s BGL to be more stabilized: regardless of the fact that the patient has been
suffering from a long term diabetes type two, the permissible blood glues levels of a
diabetic adult is still upto 7.0 mmol. Whereas the blood glucose levels of the patient is at
9.0 mmol which is far higher than the desired level and can cause acute complications for
the patient (Kirkman, 2012).
To improve Michael’s mood: the patient has shared that fact that he had been
dealing with anxiety and depression for a considerable among of time and along
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with that the patient has stopped taking antidepressants prescribed to him. his
present health restrictions and his worsening condition has also worried and
depressed him further to a point where the patient feels helpless. Hence relaxing
the patent is one of the most important short term care goals for the patient.
What action/interventions
will you do?
Question 11:
The GP suggests to Michael that he might need to commence
insulin. List two strategies that you would suggest and
educate Michael on to avoid this.
Justify these strategies.
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Your Answer:
Insulin injection can be a very fearful and dangerous administrative task and hence
the patient needs o be educated on how to correctly and successfully administer
the insulin.
One of the greatest strategies to administer insulin to the new patents is injecting
in the abdomen. It has to be mentioned that the absorption in the abdomen issues
are much higher than in the arms, upper thighs and buttocks. Hence the patient
should be educated on the most effective injection site of the body (Peyrot et al.,
2012).
The second strategy to administer insulin is to regularly rotate the site of injection
so that any clotting or acute pain by injecting at the same site (Mader et al., 2013).
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What action/interventions
will you do?
Question 12:
If Michael develops a wound, being diabetic puts him at higher risk
of healthcare associated infections. Explain why this is the case?
Your Answer:
It has to be mentioned that diabetes is a medical complication that comes with
many a complications and among all the possible restrictions impaired wound
healing can be considered as a very complicating one. It has to be mentioned that
wound healing is a very slow and meticulous process for diabetics and there are
many contributing factors to this phenomenon (Kolluru, Bir & Kevil, 2012). First and
foremost, it has to be mentioned that the possibility of uncontrolled and
excessively high blood glucose levels can damage the peripheral arterial diseases
and peripheral neuropathy. These two factors contribute to reduced blood flow in
the body and reduced supply of oxygen and nutrients, which are absolutely
necessary for healing. Hence for diabetic patients with uncontrollably rising
diabetes can be facilitator of delayed wound healing and eventual infections (Amos
et al., 2010).
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What action/interventions
will you do?
Who should be notified?
Question 13:
For Michael’s ankle and knee pain from osteoarthritis, in
addition to taking the prescribed Non-Steroidal Anti-
Inflammatory Drug, as a nurse you should also instruct him
to:
a. Start a regular exercise program
b. Avoid all fatty foods
c. Ensure eight hours sleep each night
d. Rest the ankles and knees as much as possible to decrease
inflammation.
Your Answer:
The patient while taking NSAID drugs must start a regular exercise program.
What action/interventions
will you do?
Who should be notified?
Question 14:
Give a rationale for your answer to Q13?
Your Answer:
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The NSAID drugs are known to effect the muscular growth and tenacity when
consumed on a long trem basis or in older age. A mild yet affective exercise
program can be very effective in bossting the muscle activity and growth
counteracting the negative effect of the NSAID drugs (De Weck et al., 2010).
Assess the effectiveness of
actions
Question 15:
List two signs and symptoms that would indicate that Michael’s
goals are being achieved.
Your Answer:
Two signs or symptoms that will indicate that the basic care goals are being met
are:
a. The BMI of the patient is decreasing which will indicate that the weight of the patient
is decreasing and the obesity situation that the patient had been under is improving
rapidly. Along with that a lower BMI will also indicate that the blood glucose levels of
the patients is decreasing.
b. The blood pressure of the patient will decrease to normal levels, and he will
eventually be more active and energetic.
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Assess the effectiveness of
actions
Question 16:
It is important for Michael to ensure that his feet are examined
regularly. Why is this?
Your Answer:
Diabetic foot ulcer is very common phenomenon in type two diabetes and is
considered to be one of the most significant risks of the patients. It has to be
mentioned in this context that for the diabetics the increased blood glucose levels
and the nerve and peripheral arterial damage leads to impaired or reduced blood
circulation throughout the body. The lack of proper circulation leads to impaired
oxygen flow to the peripheral parts of the body; hence, the regular pressure put on
the foot leads to blood clotting and develops infectious ulcers. Along with that fact,
it has to be mentioned that the body weight of the patient in this case is excessive
as well, with acutely high blood sugar level, which increases the chances of him
developing diabetic foot ulcers. Hence, he must examine his foot on a regular basis
to avoid any risks (Dorresteijn & Valk, 2010).
What have you learned from
this experience?
Question 17:
Long-term complications of diabetes include:
a) Increased risk for high blood pressure and atherosclerosis
b) Impaired sensation in the hands and feet
c) Increased risk for heart failure
d) All the complications listed above.
Your Answer:
d) All the complications listed above
Question 18:
Why are patients with mental illness at particular risk of patient
safety?
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What have you learned from
this experience?
Your Answer:
Among all the health risks and problems, it has to be mentioned that mental
illnesses are the most threatening and complicated of all the different health
adversities. It has to be mentioned in this cont4ext that mentally unstable patients
are completely dependable on their family members and the mental health care
providers. The mentally ill individuals are increasingly at risk for many hazards due
to the fact that they lack any reasonable thinking and better judgment. Along with
that it has to be mentioned that the patents dealing with mental illness are often
living in a fabricated reality than the rest of the individuals and hence these
patients often are at more risk of patient safety than the normal patients. It has to
be mentioned in this context that the mental patients often remain irritated,
agitated and vulnerable due to the societal stigmatization, lack of sense of safety
and security and ill treatment. This also increases their violent tendencies that can
be significant risks to their own safety (Sammer et al., 2010).
What have you learned from
this experience?
Question 19:
Waist circumference can also be used to determine obesity. Why
might this be a better measurement of obesity than BMI?
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