Nursing Placement Report: Pathophysiology and Assessment

This report provides a detailed analysis of a nursing placement case study involving a patient named Jackson Roland, admitted to Hampstead hospital with a cervical spine injury and a complex medical history including Type 1 Diabetes Mellitus (DM), hypertension, Ischemic Heart Disease (IHD), atonic bladder, Peripheral Vascular Disease (PVD), and prior surgeries. The report focuses on the pathophysiology of these conditions, particularly diabetes and hypertension, and their interrelation in contributing to the patient's sensorimotor polyneuropathy, increasing the risk of falls. The analysis covers the mechanisms of DM, hypertension, IHD, and PVD, as well as the complications such as postural hypotension and atonic bladder. The report also discusses the impact of these conditions on the patient's health, the need for assessment and diagnosis, and the importance of maintaining patient confidentiality. The study also explores the patient's transmetatarsal amputation, carpal tunnel surgery and CABG, linking them to the underlying diseases. The document highlights the interconnectedness of these conditions and their contribution to the patient's overall health status and the risks associated with their presentation.

Running head: NURSING PLACEMENT
NURSING PLACEMENT
Name of the Student
Name of the University
Author note

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Introduction
The purpose of the paper is to gain a deep insight regarding the importance of
pathophysiology, pharmacology, assessment of the diseases that are manifested by the patient in
the given case study. In the given case study, the patient named Jackson Roland was admitted to
Hampstead hospital as he fell in the aged care and got injured sustaining cervical spine. The
actual patient name has been used in here. As he has no one to look after him, he has
permanently stayed in aged care. Jack had a past medical history of Diabetes Mellitus (DM) type
1, hypertension, Ischemic Heart Disease (IHD), atonic bladder (SPC), Peripheral vascular
disease (PVD). A catheter that is inserted surgically through the lower part of the
abdomen directly into the bladder is known as suprapubic catheter or SPC.
He also underwent bilateral transmetatarsal amputation, carpal tunnel surgery and CABG* 2 8
stunt 2008. As he is suffering from severe sensorimotor polyneuropathy due to diabetic
neuropathy, there is risk for fall due to decreased sensation and lack of muscle coordination and
control. Due to high blood sugar level, the nerves are damaged and can lead to neuropathy
enhancing the risk for fall (Vinik et al. 2015). This condition is a diabetic complication and
mostly occurs when diabetes remain undiagnosed or not well controlled. This could be the
reason for Jack’s fall and his need for admission at the hospital.
For the access to Jack’s information, informed consent is required from him or his
caregiver at the aged care. The confidentiality is important while getting access to his personal
information like past medical history, current medications, past surgeries and in getting previous
medical records (Keast 2016, pp.20). Patient confidentiality has been maintained in here. The
main risk for Jack after admission is the moderate or severe brain injury that could be associated
with the sustained cervical spine injury (Theologis et al. 2014, pp.356-361). Therefore, there is a

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requirement of diagnosis and management of cervical spine trauma and assessment of diabetes
and hypertension being the major concern and SPC supra pubic catheterisation due to atonic
bladder.
Pathophysiology
As mentioned above, the medical history of Jack revealed that he is suffering from DM
type 1, IHD, PVD, hypertension, atonic bladder (SPC) and severe sensorimotor polyneuropathy.
Diabetes and hypertension are the major concern that could have manifested the signs and
symptoms in Jack and made him prone to fall.
Type 1 DM or juvenile diabetes is a condition when the body does not produce insulin
that is important to break down the starches and sugars for energy generation (American
Diabetes Association 2015). The pathophysiology of DM type 1 is the destruction of beta cells
that secrete insulin from the islets of Langerhans in the pancreas (Jennings 2015). There is
decline in beta cell mass that in turn decreases the insulin secretion until there is no adequate
insulin to maintain the normal blood sugar levels where autoimmunity is the major DM type 1
pathophysiology (American Diabetes Association 2015). There is sensory neuropathy caused by
segmental demyelination and axonal degeneration that is manifested in Jack making him prone
to fall due to sustained hyperglycaemic condition. A patient having chronically elevated glucose
level is exposed to damage to the longest nerves in their bodies that convey sensory information
from the feet and toes to the spinal cord. The loss of muscle tone and sensation are worst felt at
the ankles and feet. This makes it difficult for the patient to walk or stand up. This is more
prominent at old age. The condition brought about by neuropathy is one of the major reasons that

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people with diabetes have such a high risk for falls (Atkinson, Eisenbarth and Michels 2014,
pp.69-82).
Pathophysiology of hypertension is multi-factorial and complex where kidney acts as the
major target organ and contributing factor. Arterial hypertension is the persistent systemic blood
elevation where the cardiac output is elevated or systemic vascular resistance increase. There is a
strong link between hypertension and diabetic neuropathy where hypertension acts as the
independent risk factor as RBCs and Na/K ATPase decrease. An alteration in the
microcirculation plays an important role in this regard. Hypertension leads to up-regulation of
matrix metalloproteinase (MMP) expression at the sites of myelin thinning at sensory nerve
fibers. This potentially worsens comorbid diabetes (Visser et al. 2014). This could be the
pathophysiology of hypertension in Jack with diabetes, both being intertwined conditions sharing
significant overlap in the manifestation of the underlying risks (Burnier and Wuerzner 2015,
pp.655-683).
There are macrovascular complications associated with longstanding hypertension or
diabetes which includes IHD (Ischemic Heart Disease) and PHD (American Diabetes
Association 2015). Microvascular complications include sensorimotor polyneuropathy that is
witnessed in Jack on admission.
IHD is a condition in which there is narrowing or blockage of the blood vessels that
affects the blood supply to the heart. This occurs due to cholesterol deposition on the walls of the
vessels reducing the nutrient and oxygen supply to the heart muscles that is essential for the
proper functioning of the heart. Therefore, this condition occurs when some part of the heart is
deprived of the oxygen and blood supply that can lead to heart attack (Shepard et al. 2015,

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pp.455-456). In the given case study, Jack is suffering from DM type 1 that is the major risk
factor for the disease. Hypertension also acts as a risk factor for the development of IHD and
with time, the disease progresses. The longstanding high glucose levels damages arteries that
make them hard and stiff. There is building up of fatty materials on the walls of these vessels
blocking the blood flow to brain and heart that can lead to stroke (Shepard et al. 2015, pp.455-
456).
PVD is also caused due to diabetes and hypertension, being the primary factor for the
development of the disease. There is slow narrowing or blocking of the blood vessels that can
also cause spasms. PHD is a progressive circulation disorder that also involves blood vessels
outside heart like arteries, lymphatic vessels or veins. These vessels supplying blood to brain,
legs are also constricted and results in improper functioning. PHD most commonly affects feet
and legs where there is decrease in the inner size of vessels and eventually blocks the major
arteries (Mascarenhas et al. 2014, pp.149-166).
Postural hypotension (PH) is the one of the signs associated with Jack’s fall, which he
sustained at home and it could be a risk for him as he suffers from type I Diabetes Mellitus. PH
is defined as fall in the systolic blood pressure > 20mm Hg or a fall in the diastolic blood
pressure > 10mm Hg, following 3 minutes of continuous standing. It is associated with
sympathetic autonomic dysfunction in patients suffering from diabetes mellitus (Bharucha et al.
2013, pp.330-339). It can cause renal failure and even sudden death. It is caused as a result of
poor diabetic control and ageing. Diabetes is linked to PH as autonomic neuropathy and
inappropriate usage of antihypertensive medications can give rise to sudden drops in the blood
pressure, thereby resulting in falls as a result of syncope or fainting (Hjortkjær et al. 2016,
p.e012307). Under normal conditions, when an individual changes to a standing position from a

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sitting position, the brain sends signals to the blood vessels of the legs to undergo constriction
reflexively and in an instant manner. This prevents blood to accumulate in the leg, preventing
blood and oxygen deprivation to the brain. However, in patients with diabetes mellitus, the
nerves involved in signalling send poor signals to the leg blood vessels and thereby results in fall
in blood pressure. This is a sign of sympathetic neuropathy and results in PH. However, anti-
hypertensives like diuretics and alpha-1-antagonists like terazosin and prazosin can also cause
postural hypotension. Individuals with diabetes are also at an increased risk of sustaining
dehydration. High blood glucose levels in can lead to decrease in water content of the body
resulting in dehydration. One of the symptoms of severe dehydration is fall in blood pressure,
which can cause fainting in individuals. The patient was suffering from diabetes mellitus, so one
of the reasons for his fall could be dehydration. Apart from diabetes, peripheral neuropathy can
also cause postural hypotension (Canal et al. 2013). The peripheral nervous system helps to
connect the central nervous system with the rest of the body like arms, legs, internal organs,
mouth, among others. In peripheral neuropathy the nerves associated with the connections and
the necessary signalling undergoes malfunction. These malfunctions are caused as a result of
damage to these nerves. One of the symptoms associated with peripheral neuropathy is a drop in
blood pressure, which can result in fainting. Nerve damage in peripheral neuropathy is mainly
caused by diabetes (Metzler et al. 2013, pp.2212-2219; Tsantoulas et al. 2017, p. eaam6072).
The condition of atonic bladder is also linked with poorly controlled or long-standing
diabetic condition. This condition is a urologic complication of diabetes referred as bladder
dysfunction. There are complaints of urge incontinence to decreased bladder or overactive
bladder and overflow incontinence. This is a condition faced by the patient as he had undergone
supra pubic catheterisation. Neurological destruction is linked to the development of atonic

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bladder. Destruction of damaging of the nerves that are responsible for bladder control are
associated with atonic bladder condition. This may result in obstructive urinary bladder,
underactive or overactive urinary bladder. This is caused as a result of the alterations in the
physiology of the detrusor muscles, neuronal impairment and urothelial dysfunction. This is the
reason SPC supra pubic catheterisation was being administered in Jack. This could be a reason
for dehydration in Jack leading to postural hypotension and risk for falls. An overactive bladder
can cause the frequent release of urine from the body and if this fluid is not replaced, it results in
dehydration (Chu, Tsai and Hwang 2016, p.S66; Ay et al. 2013, p. E135 ).
The resulting neuropathic condition that is witnessed in Jack in sensorimotor
polyneuropathy, where he has lost the ability to feel or move due to nerve damage.
Polyneuropathy is defined as the systemic or body wide condition where the nerves are damaged
in different parts of body like nerve fibres, nerve cells and nerve coverings (Taveggia et al. 2014,
pp.242-252). Sensorimotor polyneuropathy can cause damage in nerve cells, axons and the
myelin sheaths. This damage takes place in the covering of the nerve cells that makes nerve
signals to become slow or stop working. One of the causes of sensorimotor polyneuropathy is
diabetes. Transmetatarsal amputation (TMA) is performed to preserve limb viability and is used
to treat patients with diabetic neuropathy among other medical conditions. TMA is done in cases
of forefoot ulcerations and gangrene complicated due to the presence of diabetes mellitus. The
patient had also undergone carpal tunnel surgery. This surgery relieves pressure from the median
nerve, thereby preventing carpal tunnel syndromes. Carpal tunnel syndrome causes numbness,
weakness and tingling sensations in the hand because of pressure building in the median nerve of
the wrist. Diabetes is one of the causes of carpal tunnel syndrome. Reduction in heart rate
variability (HRV) is generally associated with diabetic sensorimotor polyneuropathy. The patient

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had also undergone coronary artery bypass surgery (CABG) to improve his blood flow to the
heart. Thus, the patient suffers from severe sensorimotor polyneuropathy, which has affected his
limbs like forefoot and wrists. Moreover, his heart is also affected.
From the above discussions regarding the pathophysiology of the conditions that are
manifested in Jack, it is evident that diabetes and hypertension are the main reasons for the
development and progression of these diseases. He developed postural hypotension as a result of
his diabetes. He also suffered from sensorimotor polyneuropathy, which is associated with
diabetes. For this reason, he had to undergo TMA to maintain his limb viability and also had to
undergo carpal tunnel surgery to relieve pressure from the median nerves in his wrist. Another
symptom of sensorimotor polyneuropathy is heart rate variability and as a result he had to
undergo CBG. The cervical spine injury also exhibit complications like bladder dysfunction that
leaves the detrusor muscles incapable of contraction and causes urine to flow back to the kidneys
and so, SPC is being used that permit passive urine drainage at regular intervals for the
prevention of bladder overfilling. The conditions are due to the complications of long-standing
diabetes or hypertension in Jack that was either undiagnosed or poorly managed. Therefore, the
main concern for his care are the diabetes and hypertension conditions and the SPC supra pubic
catheterisation due to atonic bladder.
Pharmacology
Jack’s current medications include Navorapid, Lantus solo star pen, Amlodipine. The
immediate concern is to manage his diabetes and blood pressure levels. He suffered a sustained
cervical spine injury, but it is not possible to reverse the spinal cord damage. However,
pharmacological medications could promote regeneration of nerve cell and improve the nerve

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functioning. Therefore, the pharmacological interventions in spinal cord injury treatment is
focused on the prevention of further injury and empowering Jack to lead a productive and active
life.
The medication NovoRapid is used for the lowering of the blood sugar levels, as the
pancreas cannot produce insulin to meet the requirements of the body (Wendt et al. 2017, p.
1932296817693254). The expected outcome of this medication is to lower the blood glucose
levels as glucose cannot store or accumulated by the body for use. Novorapid stimulates the
glucose uptake in fat and skeletal muscle, inhibits the production of hepatic glucose. This
medication also inhibits proteolysis or lipolysis and enhances protein synthesis
(Davisplus.fadavis.com, 2017). It has a rapid action and onset with shorter duration as compared
to human insulin. It has a therapeutic effect of controlling hyperglycemia and so it can control
the blood glucose levels of Jack, which were found to be high as he was suffering from type I
diabetes mellitus, which results in inability of the body to produce insulin. The side effects of
this drug include hypoglycemia in the endothelial cells and have local effects like swelling,
erythema, pruritis and liposystrophy. It also has miscellaneous side effects include allergic
reactions like anaphylaxis. The contraindications of this drug are in hypoglycemia,
hypersensitivity or allergy and should be cautiously used in infection and stress. As Jack is
suffering from type 1 diabetes, this drug must be used with longer-acting insulin that includes the
precautions before using this drug for lowering the blood glucose levels. These precautions
include inadequate dosing or treatment discontinuation. Inadequate or discontinuation of
treatment can lead to diabetic ketoacidosis and hyperglycaemia. NovoRapid must not be injected
if symptoms of hypoglycaemia develop. Dose adjustment is considered following blood glucose
adjustment. Rapid onset of action of NovoRapid can be expected in the case of patients with

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concomitant diseases. Concomitant diseases increases patient’s requirements for insulin and as a
result, the doses need to be changed. Insulin antibodies can form and insulin administration
needs to be regulated in order to prevent hyper or hypoglycaemia. The nursing considerations
include the proper administration of the drug and check for dose, type and expiration date. This
drug should be administered by disposable external insulin pump and discarding of cartridges
after 7 days. The infusion site should be changed every 48 hours and most importantly, insulin
aspart should be administered along with a long-duration acting insulin due to Novorapid’s short
duration of action (Jennings 2016, pp.132-23; Bowering et al. 2017, pp. 161770). The patient
used a Lantus Solostar pen for insulin injection.
Amlodipine is used to lower blood pressure and also helps to improve blood flow to the
heart, in case of blocked arteries. Amlodipine is an antihypertensive and calcium channel blocker
that inhibit the transportation of calcium into vascular and myocardial smooth muscle cells that
result in inhibition of excitation-contraction coupling and contraction. It has a therapeutic effect
of vasodilation that results in decreased blood pressure. This coronary vasodilatation result in
decreased severity and frequency of angina attacks and also helps in the treatment of high blood
pressure or hypertension. The patient in the case study is treated with Amlodipine for the
treatment of hypertension. However, the side effects of this drug include fatigue, dizziness,
angina, peripheral edema, hypotension, bradycardia, angina, palpitations and may cause flushing,
nausea and gingival hyperplasia. This drug is contraindicated in low systolic BP below 90 mm
Hg and hypersensitivity. This drug should be cautiously used in aortic stenosis, severe hepatic
impairment and should be used with utmost precaution. Before administration, nurse should
consider the dose, route of administration and expiry date and may be administered without
regard to the meals (Higaki et al. 2017, p.251). Amlodipine can cause low blood pressure, which

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can result in dizziness and fainting. Thus, it is necessary to monitor the blood pressure before its
administration.
Lantus solostar pen or insulin glargine has therapeutic effect by lowering of the blood
glucose levels through stimulation of glucose uptake in the fat and skeletal muscles. It inhibits
the production of hepatic glucose and inhibition of lipolysis, proteolysis. It also enhances protein
synthesis and control hyperglycemia. The adverse reactions of this drug are hypoglycemia,
swelling, erythema, lipodystrophy and pruritis and can cause hypersensitivity including
anaphylaxis. Before administration, the nurse should consider the dosage and administration of
this drug as medication errors are common in insulin. Insulin syringes should be properly used
and there should be no mixing of the drug with other insulin solutions. The drug should be
administered subcutaneously once daily at the same time each day and should not be
administered with insulin pumps or IV (Rosselli et al. 2015, p.251; Ranjan et al. 2016, p.410-
418).
Investigations
The assessment of the vital signs and diagnostic tests or activities is important for the
patient-center care and planning. The patient history, vital signs, laboratory tests and physical
examination is important for the proper planning of care and disease management. Vital signs of
a patient are important for the healthcare professionals to determine the treatment options and
provide critical information to make the decisions for treatment and management. In the given
case study, after admission to the hospital, Jack was diagnosed with type 1 DM, hypertension
through the diagnostic testing of blood. He suffered a serious fall at his home as a result of
postural hypotension, which indicates that he had these medical conditions prior to hospital

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admission but was diagnosed after admission. Everyday Jacjkson was monitored thrice daily to
check his blood sugar level before administration of insulin. It is necessary to check blood
glucose levels before insulin administration, since, insulin administration following low blood
glucose levels can give rise to serious health concerns and can also give rise to hypoglycaemia.
Monitoring of blood glucose levels is essential to guide the therapy for diabetic patients. Patients
with Type 1 diabetes are usually given 2 injections of two types of insulin per day. This
generally progresses to 3-4 injections of different types of insulin. Types of insulin depends on
blood glucose levels. Monitoring of blood glucose levels is essential in order to modulate the
insulin dosage, activity and food consumption. The main reason for admission was fall, so X ray
was done to look for any kind of injury that he has sustained after cervical spine injury. The
patient’s past medical history revealed that he suffers from hypertension and diabetes. His blood
pressure and blood glucose levels had to be monitored in the aged care, so that proper
medications and nursing implementations were carried out to provide sufficient care to the
patient. In the aged care, the patient’s blood pressure was checked regularly. This was because,
he was suffering from hypertension, moreover, high blood glucose levels can also result in high
blood pressure. Jack also suffered from heart problems and hypertension is a major risk factor for
the development of ischemic heart disease. Therefore, it is necessary to monitor blood pressure,
in order to prevent ischemic heart disease. Measurement of blood pressure is also needed in
patients suffering from postural hypotension, which can increase the risk of falls. High blood
pressure can also intensify the symptoms in patients suffering from angina, which in turn can
increase the risk of heart attack. As Jack is hypertensive and sustained cervical spine injury, x-
ray and ECG are important to assess his heart condition and any kind of internal injury after
falling (Forbes and Watt 2015, pp.60). ECG can detect patterns in heart beats to monitor proper