Results The article by Ayers and colleagues (2013) goes into depth on recommendations from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), but this is not the topic of this paper. The specific recommendations chosen are extremely important regarding how to provide safe care to the patient and avoidance of complications associated with glycemic control during PN therapy. The authors recommend that each health care facility has a PN policy in place. The article goes on report “that the PN ingredients should be “only ordered for one day at a time, for adults, or amount per kilogram per day, for pediatric and neonatal patients, rather than in amount per liter, percent concentration, or volume” (p. 299). A health care provider …show more content…
should decide which type of PN is going to be effective for this patient and should collaborate this order with the rest of the health care team. For 100% safe administration of PN, the PN orders should be authorized by a trained individual who performed this task at normal bases. A pharmacist plays a huge role regarding PN. When looking at reordering, it is important to review laboratory values and the patient’s condition before mixing ingredients together. The A.S.P.E.N. has precise information that they want to include on the bag. This information can be found on page 309-310. Also to include on the label is the purpose for PN. Additional administration recommendations related to the policy should include management of extravasation of PN into the tissues and factors associated with this problem, proper set-up of tubing, types of tubing and filter to be used, when to change the tubing and the container, glucose monitoring, and finally co-fusion of medications should be reviewed for compatibility. Filters are an important component that will prevent adverse effect that can be devastating to the patient. Moreover, problems that can occur with the use of no filter include “harm from particulates, micro-precipitates, microorganism, and an air emboli” (Ayers et al., 2013, p. 328-329). Another recommendation that is important is the infusion practice. Changes in the rate should be based on what the patient is able to tolerate and the metabolic stability. Furthermore, the authors recommend that PN to be infused over 10-12 hours and this will offer better benefits overall. Hyperglycemia can occur if the approach to the infusion is not tolerated well by the patient. During the transition of PN, glucose levels should be closely monitored and insulin should be given based on individual patient’s needs. Unscheduled interruptions of should not be done and will lead to metabolic complications. In regards to training, it is recommend that training of PN is implemented by the health care organization and in schools related to Pharmacy. There is a lot of risk associated with implementing and planning PN therapy. The authors conclude their article by restating the importance of minimizing risks that are associated with PN therapy. Secondly, to provide safe practice, a nurse should always reference to the hospital policy if unsure what is recommended. It was not until further research on this topic, that it was noted that RCRH has a policy for both TPN and PPN. The reason for the doctor’s statement “that a glucose check is not necessary” finally made sense. With PPN, RCRH’s policy does not require a glucose check every six hours. The biggest difference between the two relates to the nursing responsibilities. With TPN, it is recommended that “blood glucose is monitored every 6 hours for 48 hours and then every 12 hours” (Regional Health, 2017, p. 3). There is no mention of a glucose check regarding PPN. In this case, the nurse will need to use judgement regarding how the individual patient is being monitored and abnormal laboratory values will need to be reported to the health care provider and the pharmacist in a timely manner. Noticeable, RCRH’s policy recommendations for TPN and PPN actually follow the A.S.P. E.N. guidelines. Next, a cohort study by Jakoby and Nannaoaneni (2012) researched an insulin protocol implementation, for the management of hyperglycemia in 22 patients receiving PN therapy and in another group consisting of 26 patients that were considered the control group. In the group that was part of the insulin protocol, a capillary blood glucose (CBG) level was checked every 4 hours and had a goal of 80-140 mg/dL. This group received insulin at an “insulin/carbohydrate ratio (ICR) of 1 U/20 gram carbohydrate for hyperglycemia with no documented history of DM and a non-diagnostic hemoglobin A1C (15)” (p. 184). If CBG was noted to be high, on day two an ICR of 1 U/15 gram was indicated. The control group was managed based on the UMC’s sliding-scale insulin protocol and CBG were checked in a 6 hour time frame. Insulin was added to the formula based on the results. The authors found that “glycemic control improved on the first day of protocol directed management and remained superior to non-protocol care patients that were on a sliding-scale insulin regimen, throughout the PN therapy” (p. 186). Although, hypoglycemic did occurred more frequently in the protocol patients than the controlled group. The authors conclude that this study proved that a “protocol directed insulin dosing closely linking insulin to carbohydrate leads to a better control of hyperglycemia induced by PN than ad hoc insulin dosing strategies that rely heavily on a sliding scale insulin protocol” (p. 187). Thirdly, Gosmanov and Umpierrez (2012) studied the effects of hyperglycemia during PN therapy. Although, their biggest focus was on TPN, it was interesting to see what the authors recommended. The authors state that if “dextrose exceeds above 4 mg/kg/min, it is a significant predictor of hyperglycemia in non-diabetic critical ill patients” (p. 158). So it is fair to report that in non-diabetic patients, that a lower loading dose of glucose in the formula should be administered if complications of hyperglycemia are to avoided. An interesting point that was observed in this article is, the practice of “supplementing TPN with alanine-glutamine dipeptide reduces the amount of insulin required to manage hyperglycemia by 54% compared with use of standard TPN” (p. 159). In an ICU setting, an effective process to manage hyperglycemia in a non-diabetic patient, is that the administration of insulin should be at a “rate of 1 unit per 20 gram of dextrose with further titration to 1:15 ratio if blood glucose is above 140 mg/dL” (p. 159). The authors conclude that glucose monitoring can be discontinued in non-diabetic patients if blood glucose levels are less than 140 mg/dL without any insulin therapy for 24-48 hours, while insulin therapy should be started for values more than 140 mg/dL. Insulin therapy is recommended if values are above 180 mg/dL in a non-diabetic patient. And finally, prevalence monitoring of the patient provides for a more accurate glycemic control (p. 160). With this in mind, the authors Worthington and Karen, (2012) recommend the first step to the safe and effective administration of PN should be a careful selection of the PN applicant and the formula should be custom made to each individual patient’s needs. A tight teamwork approach to PN therapy is an adequate way to make sure that the patient has the best possible outcome. Since glycemic control is the topic, the focus is on the carbohydrate content in the formula. Carbohydrate is the principle form of energy in the PN formula. The authors, Worthington and Karen, advocate in order to avoid hyperglycemia, the “infusion rate of dextrose should not exceed more than 7 mg/kg/min” (p. 55). It is important to note, if ridge management is made to control hyperglycemia, complications associated with hypoglycemia can occur. Due to this problem, some “healthcare organizations recommend a more relaxed goals for glycemic control” (p. 55). Impact of PN Therapy Providing care for patients requires measuring the needs of each individual person.
All health issues should be treated within a delicate timeframe. This type of care also involves the whole family. The parents and child need education regarding the risks and benefits of PN therapy. In addition, the authors Worthington and Gilbert (2012) acknowledge that if careful PN therapy is monitored, early complications will be noticed and will result in a quicker responds from the health care team. Careful monitoring will also empower health care providers to see the effectiveness of the PN therapy. When looking at the cost of this therapy, it is important to note that the risks related to PN therapy can result in a longer hospital stay and time away from school if illness occurs during the winter months. Another important component regarding cost is, that the Centers for Medicare and Medicaid Services (CMS) will not pay for certain hospital acquired conditions. One of the most recent complications that was added to this list in 2008 are “certain manifestations of poor control of blood sugar levels” (Medicare nonpayment for hospital acquired conditions, 2018). All complications related to blood glucose level can be decreased by closely monitoring laboratory values, glycemic control, objective and subjection status of the patient, and having all members of the health care team involved during this
process.
In the critical care population, patients on ventilator support require nutritional supplementation. To support the metabolic processes, healthcare providers address the initiation of feedings within the plan of care (Khalid, Doshi, & DiGiovine, 2010). For therapeutic nutritional support, providers compare the risks and benefits of enteral and parenteral feedings. Following intubation, one goal is to initiate feedings within 24 to 48 hours, to provide optimal patient outcomes, and decrease the risk of ventilator-acquired pneumonia (Ridley, Dietet, & Davies, 2011).
Journal of Continuing Education in Nursing, 44(9), 406. doi:10.3928/00220124-20130617-38. Torpy, J. M. (2011). The 'Standard' Diabetes. Jama, 305(24), 2592 pp.
When I am older I would love to be a Nurse Practitioner, I enjoy helping people when they are sick and taking care of them. Another reason I want to be a Nurse Practitioner is because my sister is also a Nurse Practitioner.
Karen is a post visit register nurse (PVRN) at Cincinnati Children’s Medical Center (CCMC). She has been an employee at CCMC for nine years but has only had this position for about four years. PVRN’s are responsible for following up on any positive culture results to make sure the patient is on an appropriate treatment plan. If they are not receiving the correct treatment, the PVRN must contact the doctor to get orders for the necessary medications and educate the family of the updated treatment plan. PVRNs also make follow up calls to patients who have been seen in the Emergency Department (ED) within the last 24 hours. During these calls, they make sure the discharge plan has been implemented and any follow up care is arranged.
John Steinbeck and Martin Luther King, Jr. (MLK Jr.) have both gone down in American literature as some of the most influential authors, but why? Steinbeck was an influential author throughout the 20th century with pieces in many genres. On the flip side is Martin Luther King, Jr., a civil rights leader in the fight against racial discrimination. In order to gain a deeper understanding of the style of these two authors, it is necessary to compare them on the bases of repetition, tone, and purpose.
Licensed practical nurses (LPN 's) fill an important role in modern health care practices. Their primary job duty is to provide routine care, observe patients’ health, assist doctors and registered nurses, and communicate instructions to patients regarding medication, home-based care, and preventative lifestyle changes (Hill). A Licensed Practical Nurse has various of roles that they have to manage on a day to day basis, such as being an advocate for their patients, an educator, being a counselor, a consultant, researcher, collaborator, and even a manager depending on what kind of work exactly that you do and where. It is the nursing process and critical thinking that separate the LPN from the unlicensed assistive personnel. Judgments are based
P ICOT? Individuals with type II diabetes as well as their families and their healthcare professionals are impacted by this problem. The intervention identified as best practice focus on direct nursing support as the most effective management in diabetes patients. Interventions focused on management strategies prescribed by nurse practioners and medical doctors. The study results indicate that the use of direct patient support provided by nurse practioners were most effective for compliance and increasing management in diabetes
Summary and evaluation of interventions: The interventions provided to Liam were effective in managing his respiratory distress and dehydration. Liam’s respiratory rate and oxygen saturation improved, and he was able to maintain adequate hydration. The nurse provided education to Liam’s parents on the signs and symptoms of dehydration and encouraged them to offer small, frequent feedings to Liam. The nurse also involved Liam’s older sister in the care of Liam, which helped to reduce her anxiety and stress during Liam’s hospitalization.
Many diabetic patients undergo minor surgery in an ambulatory care setting. Basal insulin management must occur as outlined above. However, no evidence exists that perioperative blood glucose control improves outcomes after one-day surgery. Thus, it is not advisable to use a perioperative insulin drip, even if blood glucose values exceed the recommended goal. In the event of an excessively high blood glucose level, deliberation for postponement of elective surgery should be given. The definition of a cutoff point for cancellation should be in consensus with a hospital policy.
During one of my rotations, I was assigned a young adult patient who had run out of insulin and had been admitted to the hospital following a Diabetes Ketoacidosis (DKA) episode. I realized that my patient was probably torn between buying insulin and buying healthy food because her chart showed several admissions in the past following the same problems. This particular patient was in her room, isolated in a corner, and she was irritable. As her student nurse, I was actively involved in her care; I was her advocate for the day. The patient lived with her single mother and worked at a fast food restaurant. Since this was my first time dealing with a patient with DKA, it became a definite challenge for me.
After meeting with our patient twice, I believe we have set into place a relationship where the patient is very open to us about her health. This is helpful for my partner and I as an open and honest patient is beneficial as we assist them in their health. Goals for next semester include reducing our patient’s blood sugar as well as reducing our patient’s fibromyalgia pain. Our patient has expressed to us that her glucose is high but she is ok with the high number as long as she is feeling relatively healthy. We hope to give practical ways to reduce blood sugar throughout next semester so hopefully we can reduce that number by semester’s end. Our patient is going to see her physician soon, so we hope to get an update on the patient’s fibromyalgia
The IRS plans to have Christian non-profits take down the Social Security numbers of donors who give $250 or more in one year, which will put thousands of philanthropists at risk of identity theft and associated complications, experts say.
Diabetes is a common disease, which can be a serious, life-long illness caused by high levels of glucose in the blood. This condition is when the body cannot produce insulin or lack of insulin production from the beta cells in the islet of Langerhans in the pancreas. Diabetes can cause other health problems over time. Eye, kidneys, and nerves can get damaged and chances of stroke are always high. Because of the serious complications, the purposes of teaching a plan for diabetes patients are to optimize blood glucose control, optimize quality of life, and prevent chronic and potentially life-threatening complications.
What is the central component of advanced practice nurses (APNs) direct clinical practice and patient/families?
Point blank, diabetes is a serious disease and causes major effects on people’s daily lives. In a society where food comes in such abundance, people are overeating. Compared to the beginning of the twenty first century when only about five percent of the population had diabetes (Nazarko, 2009), today that number is rising and continuing to do so. This is starting to affect the health of children by being diagnosed with diabetes at a young age. When a child has diabetes it becomes very serious since children are at such a young age to deal...