Introduction to Case Study

Key Words: Aboriginal , Atrial Fibrillation , Cardiovascular-Conduction , Endocrine System , Foot Ulcer , Heart , Indigenous, Occupational Illness and Disease, Pancreas, Peripheral Circulation, Peripheral Neuropathy, Post-Traumatic Stress Disorder (PTSD) , Residential Schools , Type II Diabetes, Type II Diabetes, Heart Failure, Liver Cancer, ISBAR, CPR, Cardiac Rehabilitation, Wound swab, Nursing Management in Radiation Therapy

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Discipline Breakdown

Meet Jack

• Born 1946 to Ojibwe parents in Northern Ontario
• Age 6 years, taken away to a Residential School
• Given the name ‘Jack’ by the priests
• Worked odd jobs, finally landing a job at a mine
• Met and married Mary
• Had two children, Phillip and Nancy

Shingwauk Residential School – Sault Ste. Marie, ON

• Owned & operated by The Anglican Church of Canada
• Opened August 2^nd, 1875
• New school opened October 3^rd, 1935 & housed 140 pupils
• The school focused on teaching trades & agriculture

Jack was often subjected to:

• Harsh discipline
• Malnutrition
• Poor health
• Physical, emotional, and sexual abuse
• Deliberate suppression of his culture & language

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Daily Schedule

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Residential Schools on Indigenous Health

• Personal or familial residential school attendance is related to health in a multitude of ways
• People who attended residential schools generally feel their health or quality of life has been negatively impacted

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Occupational Illness & Disease

• Occupational health focused on the physical health – respiratory disease, the impact of noise, heat and vibration on the miners’ health

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• A significant number of miners are experiencing high levels of stress, anxiety, and depression (Centre for Research in Occupational Safety and Health)

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Jack’s Story Continues

• Jack felt he had nothing to offer his children (Nancy & Phillip)
• He had lost his ancestral heritage
• He often took Nancy fishing & hunting
• He attended his daughter’s sports events
• Did not spend much time with Phillip
• Worked hard to provide for his family
• He loved his wife Mary, but often missed the family & culture he grew up with

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PART A: TYPE II DIABETES MELLITUS (TIIDM)

Before we talk about Jack’s health…

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Signs & Symptoms of TIIDM can develop slowly:

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Type II DM is the result of 2 interrelated problems:

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How Insulin Works

Insulin is a hormone that comes from the pancreas & regulates how the body uses sugar in the following ways:

• Sugar in the bloodstream triggers the pancreas to secrete insulin
• Insulin circulates in the bloodstream, enabling sugar to enter the cells
• The amount of sugar in the bloodstream drops
• In response to this drop, the pancreas releases less insulin

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The Role of Glucose

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When glucose levels are low, the liver breaks down stored glycogen into glucose

• In TIIDM, sugar does not enter the cells, builds up in bloodstream Increasing release of insulin impairs cells
• In TIDM, the immune system mistakenly destroys beta cells, leaving the body with little to no insulin

Risk Factors

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Which of these risk factors apply to Jack?

Back to Jack

• Based on some of Jack’s symptoms and risk factors, he gets blood work done to assess his blood-glucose levels.
• Jack worked hard to maintain the home that he has shared with his wife for almost 50 years.

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What affects blood-glucose levels?

Glucose concentration is affected by:

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1. Which one of this may be a problem when performing glucose tests on Jack?
2. Where would we use whole blood for glucose testing?

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Interferences include:

1. Which of these are preanalytical factors?
2. Which of these are analytical factors

Medlab

More potential tests for Jack…

Diabetes can be diagnosed by:

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Medlab

Diabetes Diagnosis

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1. If dipstick shows POSITIVE, what sugars are present?
2. If dipstick shows NEGATIVE, what sugars are present?

Medlab

Jack was diagnosed with TIIDM

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• Jack was diagnosed just before he turned 50.
• He now has to take short-acting insulin with meals.
• Jack required insulin injections, because his meal planning, weight loss, exercise and prescribed medications did not achieve targeted blood glucose (sugar) levels.

Prescribing Jack’s Insulin Mixture

• For convenience, there are premixed rapid- and intermediate-acting insulin
• The insulin will start to work as quickly as the fastest-acting insulin in the combination
• It will peak when each type of insulin typically peaks, and lasts as long as the longest-acting insulin

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Examples include:

Acute Crisis Situation�

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Jack has not been in good control of his glucose levels since his wife Mary has been in the hospital. This puts him at risk for:

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Characterized by glucose levels >35 mmol/L with NO ketoacidosis

Insulin levels prevent ketosis via lipolysis, but cannot prevent hyperglycemia & osmotic diuresis

FATAL if not treated!

Mortality rate: 10-20%

Medlab

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Over the last 5 years, Jack has been struggling with pain and numbness in his feet which has affected his ability to maintain his home.

�Jack started doing less and less as time went on due to the pain and numbness.

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Jack suffers complications from his TIIDM

Complications & Frequent Comorbidities

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Complications & Frequent Comorbidities

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Which of these complications are present in Jack’s case?

Preventing diabetes

PART B: Diabetic Foot Ulcer

Jack is found by his daughter unkempt, shortness of breath, limping slightly, and has a strange odor coming from him. Jack states he has not been eating or managing his blood sugars & insulin well.

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He has not bathed since his wife went to hospital because he is unable to access the bathtub safely. His daughter Nancy, finds an open, oozing wound on Jack’s foot.

Wagner Ulcer Classification System:

The most widely accepted classification system for diabetic foot ulcers and lesions is the Wagner ulcer classification system

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Based on

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Wagner Ulcer Classification System:

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Causes of Diabetic Foot Ulcers

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Jack gets a wound swab at the hospital

There are different types of wound swabs

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Medlab

Jack gets a wound swab at the hospital

Clinical Gram

• Good indicator of specimen quality

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• Good quality wound swabs have:
• pus cells present
• few epithelial cells

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Medlab

Treating Jack’s foot ulcer

Treatment primarily depends on the stage of the ulcer

Jack requires the following treatments:

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Ulcer care

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Preventing Diabetic Foot Ulcers

• Washing feet every day
• Keeping toenails adequately trimmed, but not too short
• Keeping your feet dry & moisturized
• Changing socks frequently
• Seeing a podiatrist for corn & callus removal
• Wearing proper-fitting shoes

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PART C: Atrial Fibrillation (Afib)

Jack states it feels like his heart is racing and he can’t catch his breath. His Radial pulse is 130 BPM (irregular).

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Jack is taken to the emergency department as per his family physician’s recommendation and is diagnosed with new onset of atrial fibrillation.

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He is admitted to hospital with a cardiologist and endocrinologist referral.

Complications may arise

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Complications of Afib

• Major concern is the potential to develop blood clots in the atria
• These clots may circulate to other organs & lead to ischemia
• May weaken the heart and lead to heart failure

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Cardiac Conduction

Symptoms for Atrial Fibrillation

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Which of these symptoms has Jack experienced?

Atrial Fibrillation may be:

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Possible Causes of Atrial Fibrillation

Which of these risk factors does Jack have?

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Jack treats his Afib with medication

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Rate Control: Slows the heart rate by blocking some of the incoming electrical signals in the atria and preventing them from being transmitted to the ventricles

Rhythm Control: Maintains sinus rhythm

Jack undergoes procedures for Rhythm Control

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PART D: Heart Failure

When the nurse working the morning shift comes by to see Jack, she notices that there is increased swelling of the ankles, feet and legs and his lower extremities were cool to the touch.

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When attempting to wake Jack, the nurse notices that he’s extremely tired and would not open his eyes. Jack responds to her questions in a very slow pace with a sluggish tone. He would further comment to the nurse that he does not know where he is and would like to see his wife.

Heart Failure

What is heart failure?

A condition caused by the heart not functioning as it should or a problem with its structure. It can happen if the heart is too weak or too stiff, or both. This can lead to different comorbidities such as fatigue, swelling in the legs and abdomen and shortness of breath which can be from fluid in the lungs

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What caused Jack’s Heart Failure?

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Signs & Symptoms

When the heart doesn’t pump well and congestion occurs, the following symptoms may appear:

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Which of these symptoms does Jack experience?

Treating Heart Failure Medications

A combination of medications was administered to Jack:

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• Relaxes blood vessels
• Decreases blood volume

• Manages heart rhythm

• Increases urine production

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Preventing Heart Failure

Prevention of heart failure mainly lies in lifestyle management

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After his assessment. The nurses overseeing Jack’s care during hospitalization, implement interventions to…

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Nursing Interventions

Jack’s nurses are focused on managing his activities and fluid intake

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Nursing Interventions

Jack’s nurses are also concerned about his mental health.

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Cardiac Rehabilitation

• There are multiple Cardiac Rehabilitation Centres across the GTA to support clients with progressive cardiac disorders to maintain their standard or living and recovery from major cardiovascular incidents
• Jack has had difficult transition in completing his physical activity, regulating his diet and taking his medications as directed

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Cardiac Rehabilitation Network of Ontario

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Main Goals of Cardiac Rehabilitation

Based on his health history would Jack qualify for cardiac rehabilitation at this time, if so why?

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PART E: LIVER CANCER

Due to Jack’s history with alcohol, he began to experience abdominal pain and swelling.

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At times, when he went to work, his co-workers would point out that his eyes and skin appear yellow. Jack books an appointment with his doctor to find out why he has these symptoms.

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During his appointment, the doctor collects information, performs a physical examination and ultrasound along with blood work. Unfortunately, his doctor diagnosed him with grade I malignant liver cancer.

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Benign vs. Malignant

Pathophysiology

Characteristics of malignant cells:

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What is Liver Cancer?

• Liver cancer occurs when liver cells develop changes (mutations) in their DNA
• A cell's DNA is the material that provides instructions for every chemical process in your body. DNA mutations cause changes in these instructions
• Cells may begin to grow out of control and eventually form a tumor — a mass of cancerous cells

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Pathophysiology of Liver Cancer

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Carcinogenesis:

What phase is Jack’s liver cancer in?

Tumor Staging & Grading

A complete diagnostic evaluation include identifying the stage and grade of the tumor

Staging: determines tumour size and existence of metastasis

Tumor, nodes, and metastasis (TNM) system

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Jack’s Grade I liver cancer

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The Role of the Immune system

Immune system

Some evidence indicates that the immune system can detect the development of malignant cells and destroy them before cell growth becomes uncontrolled. If the immune system fails to identify and stop the growth of malignant cells, clinical cancer develops

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Risk Factors

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Which of these risk factors does Jack have?

Jack receives radiation therapy for his cancer

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Jack’s liver was not greatly damaged. His doctor suggested radiation therapy as treatment, since his cancer could not be removed surgically

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