NURS-FPX 6021 Assignment: Biopsychosocial Concepts for Advanced Nursing Practice 1

NURS-FPX 6021 Assignment: Biopsychosocial Concepts for Advanced Nursing Practice 1

NURS-FPX 6021 Assignment: Biopsychosocial Concepts for Advanced Nursing Practice 1

Acute Renal Failure Related to Diabetes Concept Map

This concept map demonstrates a biopsychosocial approach to the care of an adult patient admitted to the intensive care unit with high glucose and diagnosed with acute renal failure. It can be used in place of a care plan to achieve high-quality outcomes for both the acute and home community environment. Using evidence-based research, the following will be clearly illustrated on this concept map to explain three important nursing diagnoses, assessments, diagnostics, treatments, interprofessional strategies, and outcomes.

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Patient Information and Diagnoses

Mrs. Smith is a 52-year-old African American female who presented to St. Anthony’s Medical Center with a chief complaint of high glucose. This patient has a history of Type II Diabetes Mellitus and was admitted to the Intensive Care Unit with acute renal failure related to diabetes. Mrs. Smith stated that she has not voided as she usually does, has increased swelling in the bilateral lower extremities, and feels short of breath when walking to the mailbox. She also mentions that she feels weak and nauseous. On admission, her hemoglobin A1c (glycated hemoglobin) was 8.5%. In patients with type 2 diabetes, providers should make an effort to keep the HbA1c level between 7% and 8% (Qaseem et al., 2018). Studies have shown that diabetes could be an independent risk associated with acute kidney injury (Yu & Bonventre, 2018). Mrs. Smith was also diagnosed with acute kidney failure. As an African American, Mrs. Smith is at a higher risk for diabetes (Mayo Clinic, 2021). This concept map will demonstrate an acute care treatment plan and outcomes in a home setting. Three primary nursing diagnoses are metabolic syndrome, fluid volume excess, and self-care deficit syndrome.

Evidence-based Treatments

Diabetes is defined as a complex and chronic condition that requires continuous and multifactorial reduction methods in addition to glycemic control (American Diabetes Association, 2021). A complication of diabetes mellitus is Diabetic kidney disease (DKD). This microvascular complication is a prevalent occurrence of end-stage kidney (ESRD) and results from metabolic changes in the kidney (Hasegawa & Inagi, 2021). Aligning with a biopsychosocial care approach, the primary nursing diagnosis is metabolic syndrome. “Metabolic syndrome is an accumulation of several disorders, which together raise the risk of an individual developing atherosclerotic cardiovascular disease, insulin resistance, diabetes mellitus, and vascular and neurological complications such as a cerebrovascular accident” (Swarup et al., 2022, Chapter Metabolic Syndrome).

Metabolic Syndrome

In this case study, metabolic syndrome is related to unstable blood glucose, as evidenced by high blood glucose on admission, an average fasting blood glucose level of 200, and an average of 350 after meals, as stated by the patient (Ackley et al., 2019).  A normal blood glucose level is less than 140 mg/dL. A random glucose of 200 or more suggests diabetes (Mayo Clinic, n.d.). Acute care facility initial evaluation should include hemoglobin A1C, lipid panel, basic metabolic panel, “C-reactive protein, liver panel, thyroid study, and uric acid can be drawn to investigate the existence of further and support the diagnosis of metabolic syndrome” (Swarup et al., 2022, Chapter Metabolic Syndrome). According to the American Diabetes Association, initial therapies should be patient-centered, based on comorbidities and management of comorbidity-related needs (2021). An evaluation and treatment plan for comorbidities should be comprehensive.

Metformin should be initiated once insulin has been initiated. Recommendations include adding therapies such as a glucagon-like peptide 1 (GLP-1) receptor agonist and making therapy changes to accommodate therapeutic needs (American Diabetes Association, 2022). A high-functioning interprofessional healthcare team works well together, which improves and simplifies the management and cost of patient care delivery (Varpio et al., 2021). Therefore, in the inpatient acute care setting, this patient should be evaluated and treated by the endocrinologist to form a treatment plan for diabetes management. The diabetes educator should also evaluate Mrs. Smith to assess her educational needs.

A nutritionist should evaluate this patient and develop a plan for healthy eating. Healthy eating may result in weight loss, decreased blood pressure, and insulin resistance (Mayo Clinic, 2021). Management of metabolic syndrome should be geared toward treating modifiable factors such as diet and, possibly, the most important intervention, exercise (Swarup et al., 2022). Stated evidence is appropriate in this case and is the best available since a primary source, the American Diabetes Association sets the standard of care for diabetes management and education in the United States. Home therapies will be the management of blood glucose through medication management, diet, exercise, and monitoring blood glucose levels. The patient will demonstrate a treatment plan using the teach-back method. In the home care setting, an appropriate nursing diagnosis is a risk for unstable blood glucose related to noncompliance to diabetes treatment programs secondary to risk for metabolic syndrome (Ackley et al., 2019).

Fluid Volume Excess

In this case study, fluid volume excess related to renal insufficiency as evidenced by decreased urine output, shortness of breath, and bilateral lower extremity edema (Ackley et al., 2019). Important assessments for this condition are a complete set of vital signs, head to assessment, assess urine output, assess for chest pain since shortness of breath is present with activity. Consider heart failure and monitor natriuretic peptide. Diagnostic testing should include monitoring blood urea nitrogen and serum creatinine levels to evaluate kidney function. Since AKI can indicate or predict adverse outcomes such as doubling serum creatinine or end-stage renal disease in diabetic patients (Yu & Bonventre, 2018). Inpatient acute care treatment plans should include blood pressure control since lowering blood pressure prevents cardiovascular comorbidity and may also prevent ESRD (Perkovic et al., 2022). Patient education should include risk factors, diet, signs of kidney failure, blood pressure monitoring, and recognizing signs of stroke, heart attack, and heart failure. For example, lowering sodium intake can reduce edema in the lower extremities (Olendzki, 2021). Prevention and monitoring of kidney failure at home is part of patient education to benefit from early detection of potential chronic kidney disease and heart failure. Blood pressure should be maintained at or below 130/80 (Bakris, 2022). The nephrologist and cardiologist should also evaluate this patient to manage acute renal failure and assess the cardiac effects of fluid volume excess. Medication management could include diuretics, specifically loop diuretics, since they are used in emergency and critical care settings (Patschan et al., 2019). The outcome of care includes adequate urine output by the time of discharge, reduced BLE edema or absence, patient to demonstrate understanding of dietary requirements, daily weight, and treatment plan using the teach-back method. Home care assessments include daily weight, urine output monitoring, and blood pressure. Treatment included management of medication and fluid restrictions.

Self-Care Deficit

Continuing with a biopsychosocial approach to treating this patient, self-care deficit is discussed. The nursing diagnosis of self-care deficit related to activity intolerance as evidenced by shortness of breath and weakness with activities of daily living. Assessments, diagnostic, and treatment includes the evaluation and treatment plans with physical and occupational therapy. Diagnostics include monitoring oxygen needs while walking at predetermined distances to determine whether oxygen is needed in or outside the acute care setting. Both PT and OT will assess the need for assistive devices. American Diabetes Association Professional Practice Committee states that improving care and promoting health also means including discussions related to medication costs (2022). Therefore, a social worker should assess this patient also to assess barriers to obtaining medication and attending medical appointments. Patients with metabolic syndrome should be educated on the benefits of making good sleep hygiene a priority (Swarup et al., 2022). A member of the interprofessional team can complete this assessment. Outcomes: this patient will improve her ability to complete activities of daily living. This patient will remain free from falls throughout the admission. Mrs. Smith will demonstrate an understanding of education using the teach-back method.

An adequate home care nursing diagnosis is a Self-care deficit related to activity intolerance as evidenced by the need for assistance with meals. Since Mrs. Smith does not cook as she usually would, and her daughter is not available as often. A home health referral to meals of wheels should be offered. Outcome: Mrs. Smith has access to nutritious meals to maintain optimum health and normal blood glucose levels and prevent fluid retention. Meals on Wheels America provides otherwise isolated senior citizens healthy meals by delivering them to their door (Meals on Wheels America, n.d.).

Conclusion

In conclusion, since Diabetes is a complex health condition, multifactorial reduction methods are required. This condition presented with comorbidities creates metabolic syndrome. In this case study, acute renal failure is present, requiring the need for additional interprofessional collaboration and resources. Acute renal failure in the presence of Diabetes presents complications such as electrolyte imbalance if not corrected, which may further complicate the illness. A biopsychosocial approach will help prevent re-admission and emergent events and improve care outcomes. In this scenario, holistic care is important to care for the entire person. Although medical management of Diabetes is appropriate, it is not sufficient for the patient to reach optimum health. Assessing the big picture will have a more significant impact on reaching the goal of optimum care and improving self-care deficits.

References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing diagnosis handbook e-book: An evidence-based guide to planning care (12th ed.). Mosby.

American Diabetes Association Professional Practice Committee. (2021a). 11. chronic kidney disease and risk management: standards of medical care in diabetes—2022. Diabetes Care, 45(Supplement_1), S175–S184. Retrieved October 10, 2022, from https://doi.org/10.2337/dc22-s011

American Diabetes Association Professional Practice Committee. (2021b). Summary of revisions: standards of medical care in diabetes—2022. Diabetes Care, 45(Supplement_1), S4–S7. Retrieved October 11, 2022, from https://doi.org/10.2337/dc22-srev

Bakris, G. L. (2022). Patient education: Diabetic kidney disease (beyond the basics) (R. J. Glassock, D. M. Nathan, & J. P. Forman, Eds.). UpToDate. Retrieved October 11, 2022, from https://www.uptodate.com/contents/diabetic-kidney-disease-beyond-the-basics?topicRef=3052%26source=related_link

Hasegawa, S., & Inagi, R. (2021). Harnessing metabolomics to describe the pathophysiology underlying progression in diabetic kidney disease. Current Diabetes Reports, 21(7). Retrieved October 10, 2022, from https://doi.org/10.1007/s11892-021-01390-8

Mayo Clinic. (n.d.). Diabetes – diagnosis and treatment – mayo clinic. Retrieved October 11, 2022, from https://www.mayoclinic.org/diseases-conditions/diabetes/diagnosis-treatment/drc-20371451#:~:text=A%20blood%20sugar%20level%20less,L)%20means%20you%20have%20prediabetes.

Meals on Wheels America. (n.d.). National office. Retrieved October 11, 2022, from https://www.mealsonwheelsamerica.org/learn-more/national

Olendzki, B. (2021). Patient education: Low-sodium diet (beyond the basics) (G. L. Bakris, M. D. Aronson, & J. P. Forman, Eds.). UpToDate. Retrieved October 11, 2022, from https://www.uptodate.com/contents/low-sodium-diet-beyond-the-basics?search=fluid%20volume%20overload%26source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4

Patschan, D., Patschan, S., Buschmann, I., & Ritter, O. (2019). Loop diuretics in acute kidney injury prevention, therapy, and risk stratification. Kidney and Blood Pressure Research, 44(4), 457–464. Retrieved October 10, 2022, from https://doi.org/10.1159/000501315

Perkovic, V., Badve, S. V., & Bakris, G. L. (2022). Treatment of diabetic kidney disease (R. J. Glassock, D. M. Nathan, & J. P. Forman, Eds.). UpToDate. Retrieved October 11, 2022, from https://www.uptodate.com/contents/treatment-of-diabetic-kidney-disease#H2715761590

Qaseem, A., Wilt, T. J., Kansagara, D., Horwitch, C., Barry, M. J., & Forciea, M. (2018). Hemoglobin a_1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: A guidance statement update from the american college of physicians. Annals of Internal Medicine, 168(8), 569. Retrieved October 10, 2022, from https://doi.org/10.7326/m17-0939

Swarup, S., Goyal, A., Grigorova, Y., & Roman, Z. (2022). Metabolic Syndrome. In StatPearls. StatPearls Publishing.

Varpio, L., PhD, Bader-Larsen, K. S., BSc, Durning, S. J., MD, PhD, Artino, A., PhD, Hamwey, M. K., PhD, Cruthirds, D. F., PhD, & Meyer, H. S., PhD. (2021). Military interprofessional healthcare teams: Identifying the characteristics that support success. Military Medicine, 186(Supplement_3), 1–6. Retrieved October 7, 2022, from https://doi.org/10.1093/milmed/usab088

Yu, S.-W., & Bonventre, J. V. (2018). Acute kidney injury and progression of diabetic kidney disease. Advances in Chronic Kidney Disease, 25(2), 166–180. Retrieved October 10, 2022, from https://doi.org/10.1053/j.ackd.2017.12.005