Clinical Encounter Analysis: Hypoglycemia and Tachycardia

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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