Clinical Encounter Analysis: Hypoglycemia and Tachycardia

This document is a clinical encounter analysis of a patient with hypoglycemia and tachycardia. It discusses the patient's symptoms, assessment findings, and the related nursing problems. The document also includes goals and nursing actions to address the problems, as well as the rationale for these actions. References to scholarly literature are provided to support the discussion.

CNA344: Becoming a RN: Practice consolidation
Practice Portfolio of Evidence PART B: Clinical Encounter Analysis
Consider the patient
situation/context
Provide an overview
of the encounter.
What happened, how
it occurred, etc what
was it that alerted you
to that fact that you
needed to take action
in the encounter.
(150 words)
The patient was 87 year old woman who was admitted to the hospital due to a left humerus post mechanical fall in the Liverpool Street. She was
suffering from the T2DM and had some morning medicines. The student nurses noticed that patient had the problem of dizziness and weakness.
In addition to this, the skin of the patient was looking pale and clammy than that of the normal skin of a normal person. Not only that, the
patient also had a hypertensive condition with a heart rate of 110 beats/ min. Although she had high blood pressure, the patient was still
conscious. In the contrary, it was assessed that, the patient had unexpected fall in the blood sugar level. Almost 2.9 mmol amount of blood
glucose level was lowered. According to the nurses of the Hospital, the patient was not willing to take her food and she did not take her food at
last night. In addition to this, the patient was not at all happy with the foods that she was given in the hospital.
Review: what key
information was
already available to
you and how did this
influence your
thinking? (eg:
handover, history,
charts, result of test,
assessments, medical
orders
etc.).
(150 words)
Gather:
What was the new
information you
gathered from
additional
assessment?
Review:
From the assessment following information was gathered about the patient.
BP- 150/90
HR ( Beats/min)- 110 beats/min
SpO2- 90%
RR- 20/ min
From the patient history it was noted that, the patient was a regular smoker and she was a patient of hypertension. However, She had stopped
her medication for treating the hypertension. After admitting to the hospital, the patient had complained about the frequent urination and she
also had reported that her urine had strong odour and in there was presence of blood in the first urine of the day. When she was asked about
the food she told the nurses that the urine was not crystal clear in colour, rather it was opaque. Another problem she is currently having is the
problem of tachycardia . Doctors had instructed the patient to take orange juice and after consumption of the juice the patient settled. The
blood glucose level was measured and it was 5.5 mmol after 15 minutes of the consumption of the juice.
Relevant medications (where relevant): (not included in word count)
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(150 words)
Dot points are fine for
this section
Recall:
Recall and apply your
existing knowledge to
the above situation to
ensure you have a
broad understanding
of what is/may be
occurring before
proceeding with the
rest of the cycle.
What was telling you
that the encounter
was presenting you
with a problem that
required resolution?
(200 words)
Use scholarly,
evidence-based
literature/clinical
guidelines and/or
policy/NSQHS
materials to
substantiate your
discussion
Gather:
From the nursing assessment the following information were gathered.
 The patient had lost her appetite.
 The skin colour of the patient was pale and clammy.
 She skipped the dinner at last night.
 Frequent urination was reported by the patient herself
 Patient had enough consciousness and it was reported by the nurses.
Recall:
The patient has unexpected lowering of the blood glucose level after consuming the metformin. Metformin is used as a first-line treatment of
the T2DM. The anti-hyperglycaemic effect is due to the inhibition of the hepatic glucose output. Although the mechanism of action of the drug
metformin is controversial, it is mostly recommended by the scientists that, metformin reduce the production of glucose in the liver. After
consumption of the drug orally, it is absorbed by the hepatocytes by the organic cation transporter 1(OCT1). Then it inhibits the Electron
transport chain ( ETC) and amount of ATP is lowered. On the other hand the AMP level increases. This high level of AMP activates the Adenosine
Monophosphate- Activated Kinase ( AMAPK). AMPK phosphorylates the transcription factors CRTC2 and CBP and that ultimately lowers the gene
expression of the gluconeogenic genes. In addition to this, the increased level of AMPK is also associated with the inhibition of the glycerol three
phosphate dehydrogenase and leads to increase amount of NADH. This stimulates the conversion of pyruvate to lactate and at the same time
lowers the gluconeogenesis process (Maruthur et al. 2016). According to Chaudhury et al. ( 2017), metformin can suppress the progression of
T2DM, reduce the mortality in the patients. In addition to this, it can also enhance the tyrosine kinase activity and enhances the insulin
sensitivity as well. According To Nitzan et al. ( 2015), the T2DM was closely associated with the hypoglycaemia . They also stated that, the
problem of T2DM was increasing very much in a worldwide manner.
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Process Information
Interpret, relate and
infer from the
information gathered
to demonstrate an
overall understanding
of the clinical
encounter to
determine the two
main nursing
problems.
(400 words)
Predict
What could/would
have happened in
your encounter if you
were to have taken
NO action and why?
Interpret, Relate and Infer:
According to De Wit et al. (2014), in T2DM, the patient would lose her appetite. The symptoms were also noted in case this patient as well. The
certain drop in blood sugar level after taking the drug metformin is due to lack of a poor diet as it is observed that, combination of metformin
with a poor diet can cause certain drop in the blood glucose level of the person (Slowiczek 2016). This was the reason of certain drop in the
blood glucose level of the patient as she had not taken proper diet since last night. In case of the patient, it was seen that the patient had the
problem of tachycardia and the heart rate was also high that was 110 beats/ min. In a study it was found that, the T2DM is closely related to the
problem of cardiac arrhythmia. In their study, conducted on 100 patients, it was observed that 32% patients with T2DM had the problem of
sinus tachycardia (Agarwal and Singh 2017). According to Koektuerk et al. (2016), the problem of T2DM is closely related to the problem of
cardiovascular problems. They stated that, due to the T2DMC can cause cardiovascular problems due to atherosclerosis in the coronary arteries
and large arteries. As a result, the heart rate may increase due to supply adequate oxygen to the cardiac tissues. It is observed that, the T2DM is
one of the leading causes of cardiovascular complications. In another study by Stahn et al. (2014), also supported the fact that the T2DM is also
a crucial reason of cardiovascular problems like tachycardia. In this study, 30 patients with T2DM was used as sample population. In this study,
the patient with cardiac problem who received metformin treatment had shown the symptoms of hypoglycaemia and arrhythmia. In the case
study, it was seen that, the patient had T2DM and also she was treated with metformin and she had the problem of the tachycardia. So it can be
said that, the T2DM is associated with the cardiovascular problem of patient. For the study it can be concluded that, the episodes of
hypoglycaemia are directly related to the risk factors of the tachycardia. In another population based cohort study it was seen that the T2DM
and the problem of tachycardia is closely related to each other. In their study they established the relationship between the T2DM and the
cardiac arrhythmia as T2DM enhances the chances of tachycardia among the patient ( Chang et al. 2014).
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(100 words)
Use scholarly,
evidence-based
literature/clinical
guidelines and/or
policy/NSQHS
materials to
substantiate your
discussion Predict:
However, if the condition is kept untreated there may be release of hormones like epinephrine and if the low level continues, there may be
onset of the hypoglycaemia associated autonomic failure or HAAF that is cessation of the re. The low blood sugar level may lower the hunger
level. The central nervous system is also affected by this condition of low blood sugar level and weakness, dizziness, light-headedness , clammy
skin may happen (Pietrangelo and Cherneym 2018). The patient also have those symptoms already. Moreover, there may be condition of stress,
anxiety and irritation due to this condition. The symptoms of irritation was also observed in the behaviour of the patient. From the symptoms of
the patients, it can be said that, if the condition is kept untreated the hypoglycaemic condition may cause more bad consequences of the
patient condition.
Identify the
Problem/s
List
in order of priority two key nursing problems that required resolution (not included in word count)
Problem 1 Hypoglycaemia after taking Metformin
Problem 2 Tachycardia
Establish Goals &
Take Action
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Work through the two
nursing problems
identified and
establish one goal and
then rationalise with
scholarly, evidence-
based
literature/clinical
guidelines and/or
policy/NSQHS
materials the related
nursing actions you
did/would undertake
(
125 words for each
rationale section).
Other sections not
included in word
count.
Problem 1 Goal Related nursing actions Rationale
Hypoglycemia Within next 8 hours, the blood
glucose level of the patient
should be within the normal
range.
 Dietary therapy can be
given to the patient.
 Monitoring of the patient
(Hamdy 2018).
 Enhance the awareness
among the patients.
 Monitor the blood
glucose level.
 As the patient had not
proper meal since last
night, dietary therapy will
be effective (Hamdy
2018).
 Continuous monitoring of
the patient condition is
also required in order to
maintain the proper diet
of the patient.
 The patient should be
taught about the
diabetes management so
that they can identify the
various symptoms of the
T2DM (Hogue and
Huntington 2017).
 The blood glucose level
should be assessed in
order to check any
improvement of the
condition (Rodbard
2016).
Problem 2 Goal Related nursing actions Rationale
Tachycardia
Manage the problem of
tachycardia as soon as possible.
 Commencement of ECG.
 Electrophysiological test.
 Cardiac imaging that is
electrocardiogram, CT
Scan, coronary
angiogram and chest x-
ray.
 ECG is the most useful
tool for assessing the
problem of tachycardia
and it is used to record
the timing and strength
of the heart by using
electrodes.
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 Performing a vagal
maneuvers.
 Anti-arrhythmic
medications to the
patients (Mayo clinic
2019).
 The electrophysiological
test can be used to
detect the exact location
of the problem in the
heart.
 The various cardiac
imaging tests can be used
for detecting the
structural abnormalities
of the heart.
 Vagal maneuvers is used
to regulate the vagus
nerve for controlling the
heart rate.
 However, if the condition
of the patient is more
severe, medications can
be given for restoring the
normal heart rate (Mayo
clinic 2019).
Evaluate outcomes
Evaluate the
outcomes of your
clinical encounter
including effectiveness
Continuous glucose monitoring is required during the treatment of hypoglycaemic patient and it helps to reduce the risk factors
associated with the disease as well (Rodbard 2016). The ECG procedure is very much useful in assessing the tachycardia and the cardiac
imaging technique can be helpful for detecting the exact location of the tachycardia problem in the heart of the patient. The technique
of vagal maneuvers can also be used to treat the patients who are suffering from severe tachycardia (Mayo clinic 2019).
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of the care provided
with supporting
evidence-based
literature(100 words)
*Do not ‘reflect on
new learning’ in this
section. This will
occur in your next
assessment (Part C).
References:
Agarwal, G. and Singh, S.K., 2017. Arrhythmias in type 2 diabetes mellitus. Indian journal of endocrinology and metabolism, 21(5), p.715.
Chang, S.H., Wu, L.S., Chiou, M.J., Liu, J.R., Yu, K.H., Kuo, C.F., Wen, M.S., Chen, W.J., Yeh, Y.H. and See, L.C., 2014. Association of metformin with lower atrial fibrillation risk
among patients with type 2 diabetes mellitus: a population-based dynamic cohort and in vitro studies. Cardiovascular diabetology, 13(1), p.123.
Chaudhury, A., Duvoor, C., Dendi, R., Sena, V., Kraleti, S., Chada, A., Ravilla, R., Marco, A., Shekhawat, N.S., Montales, M.T. and Kuriakose, K., 2017. Clinical review of
antidiabetic drugs: Implications for type 2 diabetes mellitus management. Frontiers in endocrinology, 8, p.6.
De Wit, H.M., Vervoort, G.M., Jansen, H.J., de Grauw, W.J., de Galan, B.E. and Tack, C.J., 2014. Liraglutide reverses pronounced insulin-associated weight gain, improves
glycaemic control and decreases insulin dose in patients with type 2 diabetes: a 26 week, randomised clinical trial (ELEGANT). Diabetologia, 57(9), pp.1812-1819.
Hamdy, O., 2018. Hypoglycemia Treatment & Management: Approach Considerations, Complications, Long-Term Monitoring. Emedicine.medscape.com. Available at:
https://emedicine.medscape.com/article/122122-treatment#d1 [Accessed 6 Jan. 2019].
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Hogue, AL, & Huntington, MK 2017, 'Prevention, Detection, and Management of Diabetes in South Dakota', South Dakota Medicine: The Journal Of The South Dakota State
Medical Association, vol. Spec No, pp. 47-53.
Koektuerk, B., Aksoy, M., Horlitz, M., Bozdag-Turan, I. and Turan, R.G., 2016. Role of diabetes in heart rhythm disorders. World journal of diabetes, 7(3), p.45.
Maruthur, N.M., Tseng, E., Hutfless, S., Wilson, L.M., Suarez-Cuervo, C., Berger, Z., Chu, Y., Iyoha, E., Segal, J.B. and Bolen, S., 2016. Diabetes medications as monotherapy or
metformin-based combination therapy for type 2 diabetes: a systematic review and meta-analysis. Annals of internal medicine, 164(11), pp.740-751.
Mayo clinic., 2019. Tachycardia - Diagnosis and treatment - Mayo Clinic. Mayoclinic.org. Available at:
https://www.mayoclinic.org/diseases-conditions/tachycardia/diagnosis-treatment/drc-20355133 [Accessed 9 Jan. 2019].
Pietrangelo, A. and Cherney, K., 2018. The Effects of Low Blood Sugar on Your Body. Healthline. Available at: https://www.healthline.com/health/low-blood-sugar-effects-
on-body [Accessed 6 Jan. 2019].
Rodbard, D., 2016. Continuous glucose monitoring: a review of successes, challenges, and opportunities. Diabetes technology & therapeutics, 18(S2), pp.S2-3.
Slowiczek, L., 2016. Metformin Side Effects. Healthline. Available at: https://www.healthline.com/health/diabetes/metformin-side-effects [Accessed 6 Jan. 2019].
Stahn, A., Pistrosch, F., Ganz, X., Teige, M., Koehler, C., Bornstein, S. and Hanefeld, M., 2014. Relationship between hypoglycemic episodes and ventricular arrhythmias in
patients with type 2 diabetes and cardiovascular diseases: silent hypoglycemias and silent arrhythmias. Diabetes Care, 37(2), pp.516-520.
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