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  1. spotangel

    I Have to Go to Work!

    Friday the 16th of August was a busy day in the clinic. I was on triage duty. Mr Grainer had signed in for shortness of breath and near syncope. I called him in and observed him walking in breathing normally. As he sat down, I noted that he was neatly dressed in summer clothes; shorts and cotton shirt with a straw colored hat that he removed displaying his salt and pepper hair. His ankles didn't have any edema and he did not look like he was in any acute distress. I sat across him observing him as I spoke to him quietly. "Good Afternoon Mr. Grainer! My name is Nurse Annie and I am the triage nurse in the clinic today. How are you doing?" "I am good! Can't complain. Please call me Carl!" "Thank you Carl. Why did you come today?" " Nurse, something's not right." "You seem worried. What do you mean by something's not right?" "I am normally pretty healthy and can walk four miles a day but for the last two weeks, I feel like I am going to pass out after walking one block." 'Is this something new? " "Yes. I never felt like this way before." "Do you get short of breath? " "Yes! Just in the last two weeks." My mind went into overdrive as I scanned through his chart. He was a diabetic and hypertensive. In my mind I always equated shortness of breath with the heart in a diabetic until proven otherwise. Just in case, I asked him questions to rule out a Pulmonary emboli. He had no risk factors, no travel, no smoking or recent prolonged immobilization. I took his pulse manually and immediately figured out what was wrong. His vitals all were great except for one. He had a heart rate of 38 bpm. Probably a heart block but totally asymptomatic! "I have some good news and bad news Carl! Which one do you want first?" "The good news " "I figured out what is wrong with you and why you feel this way." "Why?" It's your heart. It's beating really slow and any activity puts a huge strain on it." "What do you mean?" "For some reason your heart is beating very slow and that is causing your symptoms. I need to send you to the ER right now ." " Nurse! What about work? I have to go to work tonight!" I realized that he did not grasp the seriousness of the situation. I had to give him a verbal jolt and be honest. After all we nurses are known to be the most trusted profession! "Carl, let me be very frank. I am surprised that you made it into the clinic after walking four blocks from home. It's only a matter of time before something happens to your heart. Do you think your work will care if you drop dead? At this time you need to take care of you!" He stared at me and saw the truth in my eyes. "Nurse you are right. OK, I will go. What happens next?" "Just relax. You are safe here. Let me make a few calls." I called for an ambulance ALS team, informed the front desk and lobby about their impending arrival, printed out his paperwork and informed his doctor that I was sending him. She agreed 100 percent with the plan. I then called our main hospital and gave report to the ED charge nurse who was named Carl too! I informed Carl what to expect in the ED; Labs, line, EKG, portable chest, being hooked to a monitor, no food and possibly a cardiology fellow visit and a recommendation of putting in a pacemaker. The ambulance crew came and whisked him away to our main hospital. In three hours he went through all that was discussed and was taken to the cardiac cath lab with a second degree heart block and a pacemaker was placed. He went home on Saturday with no complications. I followed up with him via phone on Monday and got him an appointment for a follow up with a provider the same week and in two weeks with his own PMD. When he came for his first visit, I was out sick and he went around the clinic looking for me. One of my nurses told me. Yesterday, I saw him in the clinic for his two week follow up waiting in a room for his doctor. He jumped out of the room and hugged me and kept thanking me. I went into the exam room, sat down and caught up with the latest in his health. He showed me the dual pacemaker site and I noted that the skin was healing well. "Nurse Annie, thank you. Thank God you were there that day." "Carl, lets give all glory and thanks to God! He put me in your path that day and I am glad that I was able to help you." 'Nurse, I want to treat you to dinner!" "Thank you Carl! That is very sweet but not necessary! " "Nurse! I want to do something for you!" "Just say a prayer for my family and do something good for someone else and pass it on!" I left the room feeling grateful and feeling appreciated. It is not often that one gets appreciated in our profession. I reflected how my years of experience kicked in when needed but more than that I marveled at the way our skills are utilized to help others in the grand plan of our lives and in the lives of others. Each person is created in God's image and likeness but we have been given strengths and weaknesses that together as a human race fit together perfectly like pieces of a puzzle. It is wonderful to be a nurse! I have a question for the readers. Can you share your stories where you felt that you made a difference in a person's life in and out of work? These stories need to be shared with each other and the world!
  2. Nurses frequently care for patients with one or more type of diabetic neuropathy. Approximately 50% of diabetics have some degree of nerve damage and the greatest rates occur in people who have been diagnosed with diabetes for over 25 years. The most commonly recognized symptoms of neuropathy are numbness, tingling and pain in the arms and legs. However, depending on the affected nerves, diabetic neuropathies can lead to more severe problems and even organ damage. The impact of neuropathy on quality of life is significant and may include anxiety, depression and loss of mobility. This will provide a review of not only peripheral neuropathy but will help give you an understanding of all four types of diabetic neuropathy- peripheral, autonomic, proximal and focal. High blood glucose sustained over a long period of time is the most common cause of diabetic neuropathy. Other contributing factors include damage to blood vessels caused by high cholesterol levels, mechanical injury (i.e. carpal tunnel syndrome) and lifestyle factors, such as alcohol use or smoking. Peripheral Neuropathy Peripheral neuropathy, also known as distal polyneuropathy, is the most common form of diabetic neuropathy. Nerves branch off of the spinal cord in the lumbar region and form a long network to the arms and legs. This type of neuropathy causes nerve damage typically in the legs first and then arms as the disease progresses. It is not unusual for diabetics to have no symptoms of neuropathy, but signs are evident upon assessment. Peripheral neuropathy symptoms Numbness, tingling, burning or prickling sensations Sharp pains or cramps Decreased ability to feel pain or temperature changes Increased sensitivity to touch Muscle weakness Loss of reflexes (especially in the ankle) Loss of balance/coordination Serious foot problems- ulcers, infections and joint pain These symptoms are usually worse at night. Muscle weakness may cause gait issues, increasing fall risk. Hammertoes and collapse of the midfoot, as well as other foot deformities, may occur as the disease progresses. Decreased sensation in the feet increases risk of blisters and sore that may cause infection. The infection risk is increased when foot injury is not treated promptly and may spread to the bone and foot leading to amputation. It is estimated that 50% of all such amputations if treated in time could be avoided. Autonomic Neuropathy This type of neuropathy damages the nerves that control involuntary body functions and interferes with messages sent from the brain to other organs and the autonomic nervous system. Presenting symptoms will depend on the severity of nerve damage and where it has occurred. Autonomic neuropathy symptoms Orthostatic hypotension- dizziness or faintness when standing Bladder problems- hesitancy, incontinence, retention and increased urinary infections Sexual problems- erectile dysfunction and ejaculation problems in men, vaginal dryness, low libido and difficulty reaching orgasm in women. Poor appetite, difficulties with food digestion, nausea, vomiting, diarrhea, swallowing problems and heartburn Inability to recognize hypoglycemia Difficulty regulating body temperature due to sweating abnormalities Slow pupil reaction with difficulty adjusting to light Activity intolerance due to nerve messages not received to adjust heart rate to activity level People who chronic poorly managed hyperglycemia are at the greatest risk of autonomic neuropathy. Proximal Neuropathy (diabetic amyotrophy) Proximal neuropathy begins with pain in the thighs, hips, buttocks or legs. The pain is typically on one side of the body and more common in type 2 diabetes and in older people. Proximal neuropathy causes weakness in the legs leading to difficulty going from sitting to standing without assistance of another person. Treatment and recovery time depends on the type of nerve damage. Symptoms of proximal neuropathy Leg weakness Difficulty standing without assistance Sudden, severe pain in the hip, thigh or buttock on one side of the body Overtime- weak thighs with loss of muscle Abdominal swelling if abdomen affected Weight loss Focal Neuropathy (Mononeuropathy) Focal Neuropathy is unpredictable, occurs suddenly and affects specific nerves. The affected nerve usually causes pain in the head, torso or leg and may last weeks to months. Fortunately, focal neuropathy usually resolves on its own with no long-term effects. Older individuals are at higher risk, although diabetics at any age can have focal neuropathy. Symptoms of focal neuropathy Difficulty focusing the eye and/or double vision Pain behind one eye Bell’s palsy (paralysis on one side of face) Severe pain in lower back or pelvis Pain in front of thigh Pain in chest, stomach or flank Pain on the inside of the foot or outside of the shin Chest or abdominal pain The chest and abdominal pain may be mistaken for other conditions (heart disease, appendicitis etc). Entrapment syndromes, such as carpal tunnel syndrome, are also common in people with diabetes. Treatment of Diabetic Neuropathies First line treatment of diabetic neuropathies is long-term and consistent blood glucose management. Additional interventions for prevention, delaying or treating diabetic neuropathies may include treating and managing high blood pressure, weight control and healthy lifestyle changes. Prescribed medications are often used to relieve pain and may include: Anti-seizure drugs- pregabalin (Lyrica), gabapentin (Neurontin) and carbamazepine (Tegretol) Antidepressants- Tricyclics imipramine (Tofranil), desipramine (Norpramin) SNRIs- duloxetine (Cymbalta), venlafaxine (Effexor XR) Managing complications and restoring function Management of complications will depend on the specific neuropathy present and may require referrals to medical specialists, physical and occupation therapists. Complications requiring treatment may include: Urinary tract problems Digestive problems Orthostatic hypotension Muscle weakness Sexual dysfunction The cause of diabetic neuropathy is multifactorial with high blood glucose being the most common. The effects on the body range from mild to severe with the potential to significantly impact quality of life All four types of diabetic neuropathies can be delayed, prevented and treated with consistent management of blood glucose. The damage caused to nerves can affect areas throughout the body, significantly impacting mobility and quality of life. Patient education is important to promote good foot care and prompt follow-up with any problems. Lifestyle changes, such as smoking, alcohol intake and exercise are also important in the prevention and treatment of neuropathy. How do you approach diabetic neuropathy in your practice? Additional Resources: American Academy of Neurology, Evidence-based practice guidelines for painful chronic neuropathy. National Diabetes Education Initiative, Diabetes management guidelines. American Diabetes Association- Resources for professionals
  3. Hi All, I have a quick insulin scenario that I need help understanding. I am a student nurse currently working my gero rotation. I had a patient who is Type 1 diabetic with severe depression. Lunch is served at 12pm and I tested her BS at 11:15am. BS was 555 (normal for her). The sliding scale for BS > 450 = 6 units. The staff nurse advised me (and my instructor) to administer only 3 units of insulin AFTER lunch because the patient has a poor appetite (due to depression). This doesn't make sense me. I understand the rationale of administering only half the dose (wouldn't want BS to drop too low if giving 6 units since pt eats little); however, I don't understand why you wait to give insulin after lunch if the BS is already high. Wouldn't it make more sense to give before the meal? Can someone who is proficient with insulin please explain? I'm so confused. Thanks.

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