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Evidence Based Case Study on Hyperosomar Hyperglycaemia

Introduction
The rate of hospital hyperosomar hyperglycaemia state has been increasing gradually. However, it accounts for few cases of all primary diabetic admissions.  Despite the significant advances in the understanding of their pathogenesis and universal agreement about their treatment and diagnosis, hyperosomar emergencies are important causes of morbidity and mortality among diabetic patients (Sinclair, 2009, p, 198). Hyperosomar hyperglycaemia state is a state whereby alteration of sensation may often be present without comma, and it may consist of moderate to variable degrees of clinical ketosis. Therefore, Emergency Department nurses should be keen when assessing for diabetes because older patients may in hyperosomar hyperglycaemia condition.  This paper reflects the aspects of care that were provided to a patient, Mr. B,  in the Accident and Emergency  department, while applying triage, A-G assessment, ECG and fluid management competencies.
Triage
Triage involves the separation of a patient who requires prioritized care because of the severity his or her condition. This applies most in the Emergency Departments, where doctors and nurses have to determine who gets care first. According to the English Dictionary, the term triage refers to the process of determining the most important people or things from among a large number that requires attention (Oxford University Press, 2013). In medical use, triage is the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties.
Since every day, Emergency Departments have to attend to a large number of patients who suffer from a wide range of problems, it is essential to have a system that ensures that these patients are seen in order of their clinical need, rather than in order of attendance.  Triage manages a patient flow safely when clinical needs exceed capacity.  It involves identification of the problem, determination of the alternatives and selection of the most appropriate alternative (Manchester Triage Group, 2008, p, 7).  Identification of the problem involves obtaining information from the patients, their careers and any pre-hospital care personnel.  (Manchester Triage Group, 2008). The Emergency Department acts as a transfer station through which the casualties should pass, as quickly as possible, on their way to surgery, intensive care, or a ward (Nutbeam & Boylan, 2013, p, 181).
In this case, the patient was triaged by an experienced emergency nurse who has undergone specialist training.  In the problem identification phase, information was collected from the patient’s son who provided past history of the patient. From the history, it was established that the patient experienced sudden onsets of lethargy, strange behaviour such as waking up at three in the morning to have a shower, reduced frequency in mitcuration and reduced drinking.  When the patient was examined, it was found that the patient was alert, did not exhibit limb weakness, and was quiet, which is unusual. Besides, the patient was not clammy or sweaty. The vital signs awarded an early-warning  score of 1, given that a tachycardia of 112 beats per minute was exhibited. Consequently, the patient was placed into priority category three, as per the Manchester Triage System.  This required the patient to see the doctor within one hour. However, the patient was seen by a doctor, four hours after triage, which is against the requirements of priority three allocations, at triage. Furthermore, due to lack of trolleys and large volume of patients in the department, the patient was allocated on majors’ chairs instead of trolley.
A-G Assessment
A-G assessment is essential in facilitating the diagnosis and administration of severe and chronic primary health problems that are found in adult clients, especially the aging patients.  The assessment also aids nurses in various areas such as in a patient’s physical assessment and in clinical decision-making. It is through A-G assessment that one can carry out a comprehensive assessment of patients, especially the nonverbal, cognitively impaired or functionally impaired ones. Also, assessment of physiological and functional changes that occur because of aging can be done. This includes the assessment of age specific risk factors. Further, a health practitioner can assess the interaction between acute and chronic physical problems. A-G assessment uses valid and reliable age-appropriate assessment instruments to assess acute and chronic health concerns among patients. Finally, assessment of manifestation of health disorders such as dehydration can be done by use of A-G assessment model.
In this case, the patient was assisted onto the trolley by family members because he was unsteady on his feet. He changed into a hospital gown, and was attached to electrical cardiogram monitor.  This was to assess the patient’s heart activity. The patient was assessed with an A-G assessment model, as per trust policy. The patient was allowed to maintain own airway, and respiratory rate was found to have increased, as compared to triage rate. Furthermore, oxygen saturation was below the normal range. This implies low cellular perfusion of oxygen in blood, which can lead to less oxygen supply to the brain, resulting to confusion and drowsiness. The patient exhibited symptoms such as dry lips, pale face, which is a common phenomenon where patients tend to be hyperkalaemic, caused by the hyperglycaemia. This is a result of the increased osmotic pressure that causes potassium loss from cells into the blood stream and sodium into the cells, and is followed by dieresis, which leads to dehydration. Therefore, the A-G assessment model was used because the patient was old, and most of the old age patients who exhibit the aforementioned symptoms may be having undiagnosed diabetes, and they could be in risk of other illnesses.  It could help prevent the patient from further infection.
ECG
The electrocardiogram being a simple and useful test that records the electrical activity and rhythm of a patient’s heart, it detects problems with one’s heart rate or heart rhythm. These problems are referred to as arrhythmiasis. A critical care nurse can use the ECG to detect whether the patient is having a heart attack, or if the patient a heart attack in the past (British Heart Foundation, 2013). However, it should be noted that clinical diagnosis by the use ECG is dependent on a patient’s history, and not the physical examination itself. ECG may provide evidence to support a diagnosis. It is extremely crucial for patient management. ECG should be used as a tool, and not an end itself (Hampton, 2008).
In this case, ECG was adopted as a tool because it is an essential tool for diagnosis, and therefore, can be vital in the management of abnormal cardiac rhythms. In reading ECG, peaked T waves are normally characteristic of hyperkalaemia, and flat T waves are normally characteristic of hypokalemia (Rowlands & Sargent, 2011, p, 57).  ECG monitoring is therefore, important when taking care of a critically ill patient, especially an old age patient. This is because it avoids misinterpretation of arrhythmias, wasted investigations, mistaken diagnosis and mismanagement of the patient. A nurse ought to be keen to treat the patient, and not the ECG monitors (Jevon & Ewens, 2012, p, 114). When a critical care nurse notices a serious problem from the ECG trace and the loss of arterial pressure, he or she can call for assistance from doctors (Adam & Osborne, 2005, p, 210).
ECG is a pillar of decision making for nurses in Emergency Departments of hospitals (Kucia & Quinn, 2013). Accurate ECG interpretation of cardiac arrhythmias is essential to ensure that most appropriate managements. Therefore, a systematic approach to ECG interpretation of cardiac arrhythmias is paramount in nursing care for patients who are in critical conditions (Jevon, ECGs for Nurses, 2009, p, 40).
It is also important to note that Dieresis, if not corrected in time, may lead to cardiac arrhythmiasis, including cardiac arrest, restlessness, confusion and drowsiness.  These conditions are life threatening during a period when blood sugar levels are abnormal, peripheral blood sugar is high and the whole body is characterized with weakness.  That is why ECG was used to assess possibilities of any underlying danger facing the patient.
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