Sepsis is defined as the inflammatory response toward an infection (1). It is either simple or severe sepsis depending on the organ dysfunction involved as a result of the infection and other factors (2). In terms of the pathophysiology of severe sepsis, a cascade of inflammation and activation of the coagulation system associated with impaired fibrinolysis causes changes in microvascular circulation associated with organ dysfunction, severe sepsis, multiple organ dysfunction syndrome, and death (3).

In terms of definitions of other sepsis-associated symptoms, it was generally agreed at the International Sepsis Definitions Conference which was convened in 2001 and the following definitions of sepsis syndromes were published in order to clarify the terminology used to describe the spectrum of disease that results from severe infection. “Sepsis is the presence of infection in association with meeting the Systemic inflammatory response syndrome (SIRS) criteria (Box 1 (2)). The clinical significance of meeting SIRS criteria in the absence of organ dysfunction or shock is still unclear. Severe sepsis is defined as evidence of end-organ dysfunction such as altered mental status, episode of hypotension, elevated creatinine, or evidence of disseminated intravascular coagulopathy. Septic shock is defined as persistent hypotension despite adequate fluid resuscitation or tissue hypoperfusion manifested by a lactate greater than 4 mg/dL. Bacteremia is defined as the presence of viable bacteria within the liquid component of blood” (1). Acute pyelonephritis is defined as an acute infection of one or both kidneys; usually, the lower urinary tract is also involved (4).

Antibiotic regimen of choice for Sepsis that is associated with urinary tract infection is Co-amoxiclav 1.2g 8 hourly intravenously together with Gentamicin IV dose of 5mg/kg once daily (5). Although that is controversial whether to use the ideal body weight (IBW) or to obtain blood samples indicating Gentamicin level to get the optimal dosing regimen for Gentamicin in obese patient due to risk of accumulation with Aminoglycoside and the fear of oto- and nephrotoxicity (6). Other supportive measures depend on the patient’s status; table 1 (1) contains helpful measures that indicate markers of organ dysfunction.

Case Summary

Our patient, C.M., is a 56 years old female who was admitted to the Accident and Emergency department (A&E) due to an increased urinary frequency and a high temperature of 40.5°C. Other complaints were back pain and shortness of breath (SOB). Also, the patient had reported a fall the night before admission. Moreover, the patient had vomited the night before and in the morning of admission.

C.M. is a previous smoker who had stopped smoking several years ago and she lives with a partner. She is clinically obese weighing 100kg and her height is 152.4cm. Giving this, her ideal body weight (IBW) comes to 49kg. The only known allergy for this patient is microspores tapes.

The patient’s past medical history (PMH) included asthma, non-insulin dependent diabetes mellitus (NIDDM) and fibromyalgia. She was on one puff daily of each Symbicort Turbohaler 200/6 µg and Ventolin Accuhaler for the management of her stage 3 asthma. Metformin 1g daily was prescribed for her diabetes control; however, its formulation was not mentioned (whether it is a sustained release tablet or a normal release one!). For her fibromyalgia, she was taking 300mg of Quinine sulphate daily together with 150mg of Amitriptyline daily (which is a very high dose; low dose of tricyclic antidepressant (T CA) is recommended i.e. 20-30mg of Amitriptyline). For her pain, the patient was on Co-codamol tablet as required (strength, dose and frequency were not mentioned). Having that she is a diabetic patient over 40 years old, a dose of Simvastatin 40mg daily was prescribed as a primary cardiovascular disease (CVD) protection measure. In addition, Omeprazole 20mg daily was one of her regular medications with unclear indication.

Investigations

On admission, an Electrocardiography (ECG) was performed and indicated sinus tachycardia; which could be related to the high temperature, pain or sepsis. The patient’s vital signs were abnormal having a respiratory rate (RR) of 22 breaths per minute (normal is ~ 12bpm), a heart rate (HR) of 117 beat per minute (normal is ~ 70bpm) and a blood pressure (BP) of 142/65 mmHg (target for diabetic patients is < 130/80 mmHg).

Her laboratory investigations were almost normal except for some parameters. The Sodium level was a bit low which could be a result of the frequent urination or an Amitriptyline hyponatremic effect. Glucose and C-reactive protein (CRP) levels were high which might indicate the presence of infection. Thrombocytopenia may be caused by Quinine or Simvastatin administration!

Impression and related Management Plan

The patient was diagnosed as a pyelonephritis and sepsis case; so empirical antibiotic regimen was initiated with 1g Amoxicillin intravenously six hourly and 500mg ciprofloxacin orally once daily. Also, 1g Paracetamol intravenously six hourly and one liter Normal Saline intravenously over 24hours was started.

Urinalysis on the first day indicated the presence of leucocytes, nitrites, glucose, ketones and blood which means a presence of infection. On the second day, blood culture showed a growth of E. coli which is sensitive to Gentamicin, therefore, 400mg Gentamicin intravenously every 24 hour was prescribed and ciprofloxacin was discontinued. Gentamicin plasma level was requested 6-14 hours after administration of the first dose. In addition to the patient’s regular medications, 50 mg of Cyclizine eight hourly and 20mg of Citalopram once daily were added, paracetamol IV was switched to orally in the second day and 30mg of oral codeine as required was prescribed ; but the patient’s Salbutamol Inhaler had been stopped for unclear reason.

Discussion

Revising the management plan for this patient and in comparison to the local guidelines for the management of pyelonephritis and sepsis patients, we would notice that 1.2g intravenous Co-Amoxiclav is the first-line choice of Penicillins, not Amoxicillin, together with Gentamicin. However, if the ideal body weight is required to obtain the appropriate dosing of Gentamicin for obese patients, so in this case, 245mg of Gentamicin supposed to be prescribed instead of 400mg which is the maximum daily dose (Although that some infectious diseases specialist would recommend going to the maximum dose to make sure that we get the maximum benefit; but we must consider patient status and severity of infection!). Also, it is essential to check the optimal timing for monitoring each drug plasma level, in our case, Gentamicin therapeutic drug monitoring (TDM) has not deviated from the local guidelines recommendation for the once daily dosing of Gentamicin i.e 6-14 hours after giving first dose.

Having a patient with increased urination and vomiting, we must consider fluid replacement. Replacing with one liter Normal Saline (NS) might have not met the patient’s requirement! So it is recommended to check patient’s need to ensure appropriate replacement i.e. at least 2.5-3 liter daily. We could have recommended giving 2 liter NS each over 8 hours plus the addition of 500ml 5% Dextrose to ensure calories intake if the patient cannot tolerate oral intake.

Considering the patient’s asthma control, we must confirm that Salbutamol inhaler was not mistakenly missed after admission. Since that SOB was one of the patient’s complaints, we must ensure that it was relieved, if not, consider 5mg of Salbutamol nebulizer four times daily to be added to the regimen and if nebulizer is not necessary, ask for Salbutamol inhaler to be charted as if required basis (6). Also, blood gases were not mentioned so it is probably safer to ask for the oxygen and carbon dioxide saturations to consider if oxygen therapy is needed! Confirm that the patient and nursing staff are aware of inhalers techniques.

The patient is on Amitriptyline 150mg orally daily which is considered an old practice for the treatment of fibromyalgia (high dose TCA) and the current recommendation states 20-30mg of Amitriptyline daily for 8 weeks (6) so it is better to re-consider dosing or to change regimen. Low dose Sertraline or high dose Venlafaxine therapy may be effective (6) so consider changing if no further benefit of the use of Amitriptyline. For the associated pain, Paracetamol with Tramadol has better efficacy than Co-codamol. Pregabalin (150-300mg every 12 hours) may improve pain especially if combined with Tramadol; it also improves sleep and morning stiffness (6). So, knowing the patient’s control with the current medication would be helpful to consider treatment change or modeling to get the most of pharmacologic treatment. Suggesting alternative ways to manage symptoms is also recommended, e.g. spa therapy, physiotherapy, stress management, acupuncture or diet (6).

NICE guidelines for the management of type II diabetes mellitus state that Metformin is the first line choice for obese patients. Choosing appropriate formulation that suits the patient’s lifestyle is essential to ensure patient’s compliance. Once daily dosing of sustained release formula could provide 24 hour control over glucose, but in this case the present of infection interfered with having accurate reading so it is logical to check the HbA1c to check the glycemic control over the last 8 weeks to consider any therapy modification. Also, pre- and post-prandial glucose level monitoring is required to avoid both hyper- and hypoglycemia using the current regimen.

Statins must be prescribed for all diabetic patients who are over 40 years old (6) and having any risk factor of Coronary Vascular Diseases (CVD). The patient was on Simvastatin 40mg daily but no Cholesterol level obtained (consider Ezetimibe if high Cholesterol). Monitoring liver function tests (LFTs) and any muscular side effect is important. Also, having a high BP on admission, checking that BP is normal after sepsis reveals is vital. If persistent high BP, consider adding ACE inhibitors, having the benefit of BP control and protecting the heart in patients susceptible to Vascular Diseases. Weight loss in this patient is advisable so consider dietitian and physiotherapist review to consider going on diet and exercise. Also, annual eye check is recommended to control retinopathy due to DM.

Cyclizine was prescribed on regular basis, so we better check if the patient is really on need of a regular anti-emetic, otherwise, consider changing it to as required basis. Regarding Paracetamol, it was prescribed on as needed basis but it was not put clear not to exceed the maximum daily dose, so it is recommended to clarify that to not give the patient more than 4g per day. It is safer to contact the patient’s GP to confirm the indication of Omeprazole and to consider discontinuation if no clear indication was obtained. Additionally, the patient was thrombocytopenic, which could be a side effect of administration either Quinine or Simvastatin, so monitoring the platelets count is highly recommended to prevent any complication, although DVT prophylaxis is not needed as long as the patient is mobile.

Conclusion

In conclusion, the overall patient management had no much deviation from the current guidelines recommendation except for some practice that need to be reviewed considering the current patient’s status. Therapeutic monitoring should be carried on because the patient is under risk of many complications or side effects. Lastly, patient’s awareness of her clinical condition and treatment requirement for each problem is helpful to prevent or reduce future health problems.

Appendix 1: PATIENT MEDICATION PROFILE

Patient details

Name

C.M.

Consultant

General Practitioner

Address

Gender

Female

Weight

100 kg

Height

152.4 cm

Community Pharmacist

Date of Birth (Age)

56 y.o.

Known Sensitivities

Micropores tapes

Social History

Previous smoker, lives with partner

Patient hospital stay

Presenting complaint in primary care / reason for admission

Admission date

2008

Increased urinary frequency

Back pain

Shortness of breath

Vomiting

Fall (the night before)

Fever (40.5°C)

Discharge Date Discharged to

Relevant medical history

Relevant drug history

Date

Problem Description

Date

Medication

Comments

Asthma

Symbicort 200/6 Turbohaler 1 puff daily

Ventolin Accuhaler 1 puff daily

Non-insulin dependent diabetes mellitus

Metformin 1g daily

Formulation?

Fibromyalgia

Co-codamol PRN

Strength?

Amitriptyline 150mg daily

Too high!

Quinine sulphate 300mg daily

Duration?

Simvastatin 40mg daily

1ry CVD prevention

Omeprazole 20mg daily

Indication?

Relevant non drug treatment

Prescribed Medication

Start

Stop

Clinical/Laboratory Tests

Result

1

Paracetamol 1g IV 6 hourly

Day 1

Day 2

ECG

Sinus tachycardia

2

0.9% sodium chloride 1000ml IV over 24 hours

Day 1

HR

117 bpm

3

Amoxicillin 1g IV 6 hourly

Day 1

BP

142/65

4

Ciprofloxacin 500mg PO OD

Day 1

Day 2

RR

22 bpm

5

Metformin 1g PO OD

Day 1

Urine analysis

Leucocytes, nitrites. Glucose, ketones, & blood +ve

6

Omeprazole 20mg PO OD

Day 1

Blood culture

E. coli

7

Quinine sulphate 300mg PO OD

Day 1

Na

134 (135-145)

8

Simvastatin 40mg PO OD

Day 1

CrCl

145.3 (78-120)

9

Amitriptyline 150mg PO OD

Day 1

Glucose

8.9 (3.9-5)

10

Symbicort 200/6 inhaler 1 puff daily

Day 1

CRP

180 (<10)

11

Codeine phosphate 30mg PO PRN

Day 1

Bilirubin

35 (3-16)

12

Citalopram 20mg PO OD

Day 1

PT

17 (12-15)

13

Cyclizine 50mg PO 8 hourly

Day 1

APTT

39 (20-30)

14

Gentamicin 400mg IV 24 hourly

Day 2

Platelets

70 (150-400)

15

Paracetamol 1g PO PRN

Day 2

Clinical management

Diagnosis

Pharmaceutical Need

Pyelonephritis

Evidence-based treatment

Sepsis

Treatment according to guidelines

Care Issue/Desired Output

Action

Output

Confirm drug history + reconcile drug history

Ask patient how and when she takes her medication and the indication for each medicine.

Compare with GP’s DHx + Phone GP for indications for amitrip., omep. and quinine, and when they were initiated.

All regular meds have been charted except prn salbutamol.

Patient is SOB; advise Dr to chart it prn.

Confirm antibiotic regimen for pyelonephritis/sepsis in addition to TDM

Check the local guidelines that amoxicillin is first-line for the indication (culture sens. to gent.).Calc. her ideal body weight and CrCl.Calc. gent. dose based on ideal body weight and compare to 400mg iv od (max dose).Check local guidelines whether 6-14 post dose gent. level is correct procedure. Chase level.

Monitor BP, Temp, Pulse, RR for signs of resolving sepsis whilst on current regimen.

Co-amox 1.2g iv tds is first-line with gent 5mg/kg (max 400mg, ideal body wt 49kg, CrCl 71ml/min).

Recommend switch to co-amox because she needs 7/7 iv + oral.

Recommend 245mg gent iv od

Obtain level before 2nd dose is given+TDM for gent is correct. Review need for gent in 48h

Fluid requirements possibly not being met by 1L N. saline in 24hours

Request a running fluid balance chart due to vomiting + increased urinary frequency. Ask patient if she can tolerate oral liq. or if feels thirsty.

Assess if iv is necessary (2.5L daily + replace losses)

Advise doctor to amend first bag to 8 hours and chart 1L N.saline over 8hours + 500ml glucose 5% over 8 hours if patient can’t tolerate oral liq.

Is her current SOB being treated appropriately?

If patient is still wheezy, ask for PaCO2 + PaO2.

Request salbutamol nebs 5mg qds + O2 60% to be charted.

If not currently SOB, ask for accuhaler to be charted prn.

Assess inhaler technique for both inhalers when breathing ok

Is her fibromyalgia regimen in-line with current evidence?

Check Brit. Soc. Rheum for current guidance on fibromyalgia.

Check that citalopram is the SSRI of choice in fibromyalgia since it has been started on admin.

Review quinine; if has been in use for 3 months with no benefit consider stopping it

High dose TCA is an old practice; current evidence states 25mg/day for 8 weeks.

Advise a review of Amitrip.

Low dose sertraline has better evidence for use in Fibro. Advise switch + show evidence to prescriber.

Tramadol with paracetamol has better efficacy than co-codamol. Suggest trial switch and monitor for dizziness due to recent unexplained fall.

Consider pregabalin.

Lifestyle advice: stress management, diet, physiotherapy/massage, etc.

Is her type II diabetes under control?

Check SIGN guidelines on diabetes for current management.

Request HbA1c test to determine control over last 2-3/12

Monitor glucose pre/post-prandial and random.

Ask patient how she takes the metformin and how regularly

Metformin is first-line in obese type II.

From lab results, assist endocrinologist in determining whether metformin dose should be increased + which preparation suits patient’s lifestyle.

Is her CVD primary prevention needs being met?

Check SIGN guidelines on CVD primary prevention.

Check BP + Cholesterol. Next U&Es ask for urine albumin + protein levels.

Ask patient about current diet and exercise plan (obese) + last eye test.

Simvastatin 40mg charted. Check cholesterol. If it is high, may need ezetimibe 10mg od. LFTs ok

BP 142/65, upon resolving sepsis recheck BP and initiate ACEi if appropriate.

Advise dietician review (obese) + physiotherapy review (or GP) for plan (30mins exercise 5/7).

Advise eye test once a year

Regular cyclizine may be unnecessary

Endorse chart for paracetamol’s maximum daily dose

Reassess patient’s need for a regular anti-emetic and re-chart cyclizine as prn instead of regular if required

Max 4g in 24 hours (e.g. 1g QDS)

Highlight patient’s thrombocytopenia

No need for DVT prophylaxis if patient is mobile.

Mention that quinine or simvastatin could be the cause of low platelets.

Suggest trial withdrawal of quinine if not planning on stopping anyway.

Monitor Platelets level if continued.

Indication for omeprazole

Determine indication from GP and patient.

Consider trial withdrawal if indication unknown.

Appendix 2: Box 1. Consensus Conference of the American College of Chest Physicians and Society of Critical Care Medicine definitions for the various manifestations of infection.

• Systemic Inflammatory Response Syndrome (SIRS):

Manifest by two or more of the following conditions:

1. A temperature >38oC or <36oC

2. A heart rate >90 beats per minute

3. A respiratory rate >20 breaths per minute or a PaCO2 <32 mmHg

4. A white blood cell count >12,000/mm3 or <4000/mm3, or the presence of >10% immature forms.

• Infection:Microbial phenomenon characterised by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by these organisms.

• Bacteraemia: The presence of viable bacteria in the blood.

• Sepsis (Simple): The systemic response to infection, manifested by two or more of the SIRS criteria pus an infection.

• Sepsis (Severe): Sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Hypoperfusion and perfusion abnormalities that may include, but are not limited to lactic acidosis, oliguria or an acute alteration in mental status.

• Septic shock: Sepsis-induced hypotension despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that may include, but are not limited to lactic acidosis, oliguria or an acute alteration in mental status. Patients who are receiving inotropic or vasopressor agents may not be hypotensive at the time that the perfusion abnormalities are measured. This is a subset of severe sepsis.

• Sepsis-induced hypotension: A systolic blood pressure <90 mmHg or a reduction of > 40 mmHg from baseline in the absence of other causes for hypotension.

Adapted from Bone RC et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992; 101: 1644-1655.

Appendix 3: Table 1. Clinical and laboratory markers of organ dysfunction.

Organ System

Clinical

Laboratory

Cardiovascular

Tachycardia

Hypotension

Cardiac arrest

Arrhythmias

Haemodynamic support

Altered CVP, PCWP

Reduced cardiac output

Endocrine

Weight loss

Hyperglycaemia

Hypoalbuminaemia

Haematological

Bleeding

Thrombocytopenia

Increased D-dimers

Abnormal white cell count

Abnormal clotting profile

Gastrointestinal

Ileus

GI bleeding

Acute pancreatitis

Acalculous cholecystitis

Decreased intestinal pH

Elevated amylase

Hepatic

Jaundice

Hyperbilirubinaemia

Increased PT

Elevated LFTs

Hypoalbuminaemia

Neurological

Delirium

Confusion

Altered consciousness

Altered EEG

Renal

Oliguria

Anuria

Renal replacement therapy

Elevated creatinine

Elevated urea

Respiratory

Tachypnoea

Cyanosis

Mechanical ventilation

PaO2 <70 mmHg

SaO2 <90%

PaO2/FiO2 <300

Immune

Pyrexia

Nosocomial infection

Altered white cell count

Impaired white cell function

Adapted from Balk RA. Pathogenesis and management of multiple organ dysfunction or failure in severe sepsis and septic shock. Crit Care Clin 2000; 16: 337-352.

The following paper will reflect on an experience as a trainee assistant practitioner which involved the care and support of a patient with type 1 diabetes. For this reflection I will use Bill as a pseudonym name for my patient as The Nursing and Midwifery Council (2010) states that. “The common law of confidentiality reflects that people have a right to expect that information given to a nurse or midwife is only used for the purpose for which it was given and will not be disclosed without permission. This covers situations where information is disclosed directly to the nurse or midwife and also to information that the nurse or midwife obtains from others”. For this assignment Gibb’s Reflective Cycle (1988) will be utilised as I feel comfortable with this model. Gibbs (1998) refers to the experience as an incident which involves exploring good and bad feelings, however Johns (1995) suggests that the fundamental purpose of reflective practice is to enable the practitioner to interpret an experience in order to learn from it.

Type 1 diabetes is a lifelong condition in which the body cannot control the amount of glucose in the blood. This is because the body cannot produce the natural hormone insulin. Diabetes is a common, lifelong condition and as Zimmet et al (2001) identify that in developed countries one person in thirty may be affected and it is likely that by 2025 there will be three hundred million people with diabetes worldwide, this is mainly the result of more sedentary lifestyles and increased obesity. In 2006 Diabetes UK estimated that there were more than two million people with diagnosed diabetes and up to one million who are still undiagnosed (Diabetes UK 2006). A holistic approach to this long term condition is essential as it can come with so many complications. Complications may arise from inadequate management and treatment of the condition, which can adversely affect the quality of life and have financial implications for patients and the National Health Service (DH2001). There are two types of diabetes. In type 1 diabetes there is no production of insulin by the beta (ß) cells of the pancreas. In type 2 diabetes, which accounts for over 80 per cent of all cases of diabetes, insulin is produced by the ß cells and is released into the bloodstream, but it subsequently fails to act properly at the sites of glucose uptake, which are skeletal muscle, liver and adipose tissue (Donnelley and Garber 1999, Reginato and Lazar 1999).

As a trainee assistant practitioner I was asked by the district sister to visit Bill to do a blood test which had been requested by the general practitioner as Bill is housebound and unable to attend a blood clinic. The blood test was to check his full blood count and HbA1c which had not been done for almost a year. Bill is seventy four years of age, lives alone and has lived with diabetes for many years. Bills wife passed away a year ago and has one son who lives many miles away so sees him very little; he does however have a neighbour who pops in to check on him now and again. Bill administers his own insulin in the mornings and checks his blood sugar levels daily before giving his insulin.

My first impressions of Bill were that he looked frail and quite pale but having not met him before this may have been the norm for him. Whilst taking the blood sample I began chatting to Bill and he started to tell me that he had several episodes of feeling unwell recently and on that morning he had felt particularly unwell. I asked him to explain why he felt unwell and what symptoms he was experiencing. He explained the symptoms included shaking in his hands, feeling lightheaded and a fuzzy headache. As a trainee assistant practitioner I felt it necessary to explore what was wrong with Bill even further. First of all I began taking some basic clinical observations, his blood pressure was 140/90, pulse 80 and regular which were both within normal limits. He appeared pale and clammy so I checked his blood glucose level which was 3.2mmols; Bill was suffering from hypoglycaemia. Blood glucose levels are normally maintained within relatively narrow limits at about 5-7mmol/l (Williams and Pickup 2004).

My immediate concern was to ensure Bills blood glucose levels did not drop any further and the priority was to take short term action and increase his blood sugar to prevent it becoming any worse. Bill had no glucose tablets or glucogen so with his consent I looked in his fridge and cupboards to find something that would increase his blood sugars quickly. All that was in his fridge was a carton of milk a few slices of bread and some jam, I promptly gave him a drink of milk and made a jam sandwich. I felt it was my responsibility to sit with Bill until his blood glucose returned to acceptable levels and he had recovered from this episode of hypoglycaemia. I took Bills blood glucose levels every ten minutes until it returned to a safe and acceptable level. Bills blood sugar was now 5.2mmols and he was feeling brighter I checked to see if he ever recorded his blood glucose levels or kept a record of administration of his insulin but there was nothing. I asked him about his diet he said he hadn’t been feeling up to eating much, I asked who did his shopping which he informed me his neighbour gets his milk and bread and a few other little bits when he needed them. I was aware that the lack of food in the house was probably the cause of Bill suffering from hypoglycaemic attacks.

Hypoglycaemia occurs when the blood glucose level falls below 4mmol/L and is a common side effect of insulin therapy. Causes of hypoglycaemia include missed or late meals, not eating enough, taking too much insulin, exercise and excessive alcohol. National Health Services Choices (2009) state that hypoglycaemia should be treated with fast-acting carbohydrate, for example, 3-6 glucose tablets, 150ml fizzy drink or 50-100ml Lucozade, and followed up with a longer-acting carbohydrate, for example, biscuits or a sandwich. Glucose gels, for example, GlucoGel are useful to raise blood glucose levels and blood glucose should be recorded five to ten minutes after treatment.

After ensuring that Bill’s hypoglycaemic attack had subsided and he was feeling better I made him a cup of tea and left him another sandwich that he could have at lunchtime. My initial feelings were of concern for Bills safety in the future and as a trainee assistant practitioner I knew that it was my responsibility to see my mentor immediately to discuss the situation. I was satisfied that I had taken the time to find out what was wrong with Bill and that he had recovered from his hypoglycaemic attack which I may not have taken time to do in my previous role. From the years of working in the community nursing setting experience I was fully aware that other mutli-displinary agencies may need to be involved in the care of Bill. I returned to the office and fed back to my mentor and later that day we returned to Bill and a full assessment was undertaken, it came to light that Bill had been struggling for some time with his diabetes, personal care and shopping and housework. It was decided by my mentor that for the interim period until care and support for Bill could be implemented that the district nursing team would administer his insulin that way his blood glucose levels could be regularly recorded and ensure that he has eaten something. He was also referred to the community diabetic nurse for a review of his insulin regime.

Dietary management of type 1 and type 2 diabetes Nutritional therapy is an integral part of effective management of diabetes and has a vital role in helping people with diabetes to achieve and maintain optimal glycaemia control (Delahunt 1998, UKPDS 1990).I visited the general practitioner surgery and obtained some patient information on diabetes care and diet and took them to Bill, with the supervision of my mentor I sat with him and read through them. Once a care package was in place the carers would be informed of what foods Bill should and should not have and they would help with meal preparation. The British Diabetic Association (1999) suggest that ideally dietary information should be delivered by a diabetes specialist dietician, however in the case of Bill awaiting an appointment to see the dietician would have taken time and the information was needed on a more urgent basis.

McGough (2003) suggest that structured patient education plays an important role in enabling people with diabetes to manage their diabetes on a day-to-day basis and a greater emphasis should be on the benefits of regular physical activity and weight management. More flexibility in the proportion of monounsaturated fat and carbohydrate in dietary intake and sucrose should no longer be restricted to a specific amount. For Bill initially it was essential that he was provided with regular meals and snacks at least three times daily to prevent any further hypoglycaemic attacks. An urgent referral was sent to members of the multi-disciplinary team and a meeting was arranged the following day with a social services. Referrals were also sent to the community diabetic nurse, dietician and foot health services. On assessment with my mentor she identified that Bill had not been washing properly and had not cut his toe nails for some time, Bill was also experiencing pain in his legs and feet. Bill was likely to be experiencing diabetic peripheral neuropathy, and I completed a pain assessment chart with him. Hill (2009) identifies that painful neuropathy affects the feet, typically causing burning or stabbing pain, which is particularly apparent at night. This was a mirror of what Bill described his pain as and we reassured him that his pain control would be discussed with his general practitioner as at present Bill took no analgesia at all and there was none in the house. The general practitioner prescribed paracetamol 1000mg four times daily initially as he felt that the pain may improve once more control had been gained again with his diabetic control. I returned to assess Bills pain control several days after commencing paracetamol and it had improved, he was still experiencing slight discomfort but felt that he would like to continue on this regime as he did not want anything stronger at the present time. It was agreed with Bill that this would be reviewed again the following week.

A joint visit was done with the diabetic nurse, my mentor and myself and it was identified that Bills technique of giving his own insulin was poor due to poor dexterity in his hands and he was unable to turn his insulin pen properly or read the digits on the pen clearly. It was unclear how long Bill had been trying to manage in this way but Bill would certainly need long term care with his insulin from the district nursing team. The diabetic nurse identified that Bills eyesight was particularly poor and that he had not had his eyes checked for several years. Diabetic retinopathy is a major cause of blindness and many patients do not have any symptoms of the damage occurring in the retina until the complications have become advanced. NICE (2008) recommend annual screening for all patients with diabetes and that a record of the retina is made by digital imaging for year on year comparison to identify the development and progression of retinopathy. The general practitioner was informed that Bill had not had his eyes checked and he agreed that he would refer him for retinopathy screening.

As a trainee assistant practitioner I have learnt valuable knowledge in the management and care of patients with diabetes, from Bill requiring a routine blood test he has become a complex patient with multiple problems related to his diabetes. Due to the word limitations of the essay all areas of complications relating to diabetes could not be covered but through researching and reading around the topic I am aware of other complications such as nephropathy, cardiovascular, cerebrovascular and peripheral vascular disease. I have continued as an assistant trainee practitioner to visit Bill and monitor his progress with my mentor. His blood glucose levels have improved and are maintained controlled between 6-9mmols. Bill has needed some psychological support as he is used to seeing few people and all of a sudden his life has changed and he has several members of the multidisciplinary team visiting and reviewing him regularly. Overall I feel a sense of satisfaction that from a routine blood test and utilising a more advanced role all of this relating to Bill has been identified and his health and care are much more improved.

Hypertension is a modifiable risk factor for the development of coronary artery disease through the development of atherosclerosis. Hypertension develops primarily through an increase in systemic vascular resistance through any of the following mechanisms but not limited to: atherosclerotic development increases sympathetic nervous system activity, increase activity of the renin-angiotensin-aldosterone system, dysfunction of the kidneys or endothelial dysfunction. Hypertension further leads to atherosclerosis development through the stress and pressure on the endothelial lining, in which atherosclerosis development takes place, thus, further hindering blood flow to the damaged subdural area through the narrowing of blood vessel lumen causing further damage and delayed healing times through the lack of oxygen supply.

Hypertension also causes blood vessels in the brain to weaken, which is already weakened through age-related factors causing a further increase in the risk for the development of other complications (Lewis, 2011) (Huether and McCance,  2012). The disease process affects many individuals more than others, the African-American communities are at high risk for development of the disease due to the genetic makeup and the response to typical pharmacological interventions differ from other ethnic groups the incidence and prevalence trends highest in black women (77 per 1000) and men (67 per 1000). Furthermore, African-American communities are mostly in the low socioeconomic status that access to care is a limiting factor that leads to as a silent killer (Benenson et. al, 2019).

Vulnerable Population

Hypertension is an incredibly dangerous health condition affecting roughly 75 million people in the United States. Uncontrolled hypertension predisposes an individual to heart attack, stroke, heart failure, and kidney disease, among other conditions, and only half of those currently inflicted have their disease under control (CDC, 2016). African Americans have the highest risk of developing hypertension (Risk factors for high blood pressure, 2015). The prevalence of hypertension is approximately 40.1% among African Americans living in Alameda County (Bautista, Bell, Beyers, Brown, Cho, Guide, & Lee, 2014), and 28% of community members in Oakland identify as African American (Bay Area Census, 2010). African Americans experience a disproportionately high rate of hypertension-related illness and hospitalization when compared with other ethnic groups, this is due to the low socioeconomic status leading to poor lifestyle choices or access to a better lifestyle, and cultural belief as going to the doctors or admitting there is a problem can be a sign of weakness. (Bautista et al., 2014). This public health care initiative will provide hypertension screening at the High Street Pharmacy to 50 at-risk adults residing in East Oakland, California.

According to the National Heart, Lung, and Blood Institute, African American individuals are at the highest risk for developing hypertension (Risk factors for high blood pressure, 2015). A systematic review of 16 research studies conducted by multiple health-based organizations in Texas in 2007 supports that family history, incidence, and severity of hypertension is more prevalent in African American communities when compared to White communities of similar socioeconomic status and background (Kurian & Cardarelli, 2007). There are multiple hypotheses that attempt to describe the reason for the higher prevalence of hypertension in this community, including genetic indications, the slavery hypertension hypothesis, and multiple environmental and behavioral phenomena, among others (Fuchs, 2011).

Nursing Leadership Approaches to the Issues

In the city of Berkeley Public Health, the public health nurses develop a program supported by the HRSA grant on narrowing the gaps of disparities of care within the African American communities. The public health nurse leadership collaborated with nearby School of Medicine and School of Nursing, as well as Hospital Systems around the area and Churches to develop a program to screen and refer if the hypertension crisis was assessed. The program consists of an interdisciplinary team of healthcare professionals to make it possible. The program relies on volunteers from these aforementioned collaboratives will check in to the central base and received an assignment to go out of the community to conduct blood pressure screenings.

Current Scholarly Evidence Overview

The current management recommendation relies on the patient to come into a health proxy to be assessed for health and wellness. However, according to a systematic review of hypertension within African Americans, access to care and education is the significant gap that made the population high risk (Buckley, Labonville, & Bar, 2016). The lack of education and access to care is not a motivating factor for the population to get the check. Buckley et. al, (2016) suggested a reversed method of approach, where clinicians go to patient households or churches to be screened and provide just in time coaching and referrals.

The objective of this project is to provide hypertension screening and education to 50 individuals residing in East Oakland in accordance with HDS-12, a Healthy People 2020 initiative to increase the percentage of adults whose hypertension is under control from 43.7 percent to 61.2 percent (HDS-12, n.d.). I will conduct hypertension screenings at High Street Pharmacy, located at 4248 MacArthur Boulevard, Oakland, Ca 94619. The contact person for this organization is Richard and his phone number is 510-530-1335. He has had multiple groups conduct hypertension screenings at his pharmacy and welcomes my contribution to improving community health.

The Health Belief Model was utilized in conjunction with relevant peer-reviewed research to develop an effective method for providing hypertension screenings to a high-risk population. The proposed intervention focuses on preventative hypertension screening and the provision of health maintenance education to African American adults in a low-income neighborhood. The Health Belief Model was chosen as the model for this intervention as it identifies six concrete factors to consider when implementing a community-based health care

initiative, including risk susceptibility, risk severity, benefits to action, barriers to action, self-efficacy, and cues to action (Jones, Jensen, Scherr, Brown, Christy, & Weaver, 2014). These factors are imperative to consider as they act as barriers to engagement with activities to improve health.

Free hypertension screenings will occur at High Street Pharmacy in East Oakland with the goal of assessing and providing education to 50 African American individuals aged 18 or older. Any adult who wishes to have their blood pressure assessed will be provided with screening and educational materials, and data will be collected for participants who are African American. This pharmacy was chosen as it is accessible by public transportation and is located in a busy shopping area within a low-income neighborhood. A card that can be utilized for tracking blood pressure readings will be provided to each participant. Education addressing the importance of checking blood pressure, methods for improving blood pressure, healthy living habits, and when to visit a medical provider will be provided to each participant as appropriate.

I will use the SHARE approach for collaborative decision making to direct my interventions and efforts as a Nurse Educator. This method promotes communication between providers and patients in order to obtain health care objectives through collaboration. The SHARE approach is especially beneficial for providers seeking an opportunity to understand the cultural needs of their patients, and to incorporate patient preferences into care planning. This approach is outlined below: Step 1: Seek your patient’s participation. Step 2: Help your patient explore and compare treatment options. Step 3: Assess your patient’s values and preferences. Step 4: Reach a decision with your patient. Step 5: Evaluate your patient’s decision (The SHARE approach, n.d.).

Research supports community-based hypertension screenings as a method for improving blood pressure for a given population, especially when screenings are repeated, results are reported to participants, and education is provided (Truncali, Dumanovsky, Stollman, & Angell, 2010). This health care initiative is supported by three research studies that provided free blood pressure screenings to a high-risk population and saw improvements in control of hypertension after implementing their interventions.

The program itself is being supported by the community and the surrounding churches hence the program will heavily run by volunteers. At the same time, the volunteers are from surrounding schools such as the University of California, California State University, and Samuel Merit University. The evaluation method will be based on the Healthy People initiatives for the years to come.

While factors including genetic contributions, the slavery hypertension hypothesis, and multiple environmental and behavioral phenomena have been hypothesized as contributing factors for increased incidence of hypertension in the African American community, there is no conclusive evidence to describe why African Americans are afflicted with hypertension more frequently than members of other ethnic groups (Fuchs, 2011). Interdisciplinary research utilizing health care, social, and economic experts is necessary to improve methods for increasing health for this vulnerable population.

References

• Bautista, E., Bell, S., Beyers, M., Brown, J., Cho, S., Guide, R., & Lee, T. (2014). Alameda county health data profile, 2014: Community health status assessment for public health accreditation. In
  
  Alameda County Public Health Department
  
  . Retrieved from http://www.acphd.org/media/353060/acphd_cha.pdf
• Benenson, I., Waldron, F. A., Jones Dillon, S. A., Zinzuwadia, S. N., Mbadugha, N., Vicente, N., … & Makdisi, C. (2019). Hypertensive emergencies in diabetic patients from predominantly African American urban communities. Clinical and Experimental Hypertension, 41(6), 531-537.
• Buckley, L., Labonville, S., & Barr, J. (2016). A systematic review of beliefs about hypertension and its treatment among African Americans. Current hypertension reports, 18(7), 52.
• City of Oakland. (2010). In
  
  Bay Area Census
  
  . Retrieved from http://www.bayareacensus.ca.gov/ cities/Oakland.htm
• Fuchs, F. (2011). Why do black Americans have a higher prevalence of hypertension?: An enigma is still unsolved.
  
  Hypertension
  
  ,
  
  57
  
  (3), 379-380. doi:
  
  https://doi.org/10.1161/HYPERTEN
  
  SIONAHA.110.163196
• HDS-12. (n. d.) In-
  
  Office of disease prevention and health promotion
  
  . Retrieved from https://www.healthypeople.gov/2020/topicsobjectives/objective/hds-12
• High blood pressure facts. (2016, November 30). In
  
  Centers for Disease Control and Prevention
  
  .Retrieved from https://www.cdc.gov/bloodpressure/facts.htm
• Huether, S. E., & McCance, K. L. (2008).
  
  Understanding pathophysiology
  
  (4th ed.). St. Louis, Mo.: Mosby/Elsevier.
• Jones, C., Jensen, J., Scherr, C., Brown, N., Christy, K., & Weaver, J. (2014, July 10). The health belief model as an explanatory framework in communication research: Exploring parallel, serial, and moderated mediation.
  
  Health Communication
  
  ,
  
  30
  
  (6), 566-576. doi:10.1080/10410236.2013.873363
• Kurian, A., & Carderelli, K. (2007). Racial and ethnic differences in cardiovascular disease risk factors: A systematic review.
  
  Ethnicity and Disease
  
  ,
  
  17
  
  . Retrieved from
  
  http://www.ishib.org/
  
  ED/journal/17-1/ethn-17-01-143.pdf
• Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2011).
  
  Medical-surgical nursing: assessment and management of clinical problems
  
  (8th ed.). St. Louis: Mosby.
• Risk factors for high blood pressure. (2015, September 10). In
  
  National Heart, Lung, and Blood Institute
  
  . Retrieved from
  
  https://www.nhlbi.nih.gov/health/health-topics/topics/hbp/atrisk
  
• The SHARE approach—Essential steps of shared decision-making: Expanded reference guide with sample conversation starters. (n.d.). In
  
  Agency for healthcare research and quality
  
  . Retrieved from https://www.ahrq.gov/professionals/education/curriculumtools/shareddecisionmaking/tools/tool-2/index.html
• Truncali, A., Dumanovsky, T., Stollman, H., & Angell, S. Y. (2010, June). Keep on track: A volunteer-run community-based intervention to lower blood pressure in older adults.
  
  Journal of the American Geriatrics Society
  
  ,
  
  58
  
  (6), 1177-1183. doi:10.1111/j.1532-5415.2010.02874.x