Question

P.W. Is a 40-year old disabled man who recently lost his wife to metastatic breast cancer. His brother has taken him into his home. P.W. has a 22-year history of insulin-dependent diabetes mellitus (Type-1). Until recently, he has taken responsibility for the management of his disease and has been actively involved in the local chapter of the American Diabetic Association. PMH includes 2 amputated toes on his R foot, retinopathy and visual impairment in both eyes, and angina on exertion from coronary artery disease that severely restricts his activity. Since he began treatment with an Ace-inhibitor 2 years ago, his blood pressure has gone from 182/128 to 126/78 mm Hg. Currently, he is 71” tall and weighs 135 lb. P.W.’s sister-in-law, who is an LPN says P.W. has lost about 12 lbs in the past 3 weeks. Over the past few years, P.W. has been administering a multidose (3 injections) regimen of regular Humulin insulin to himself before meals and at night. Recently his BG levels have been increasingly inconsistent and labile, and he has been labeled “noncompliant.” It is Monday. You are the home care nurse assigned to visit P.W. 3 times per week for teaching and evaluation. P.W.’s brother and sister-in-law express concern that P.W. seems to be indifferent about his nutritional and pharmacologic regimens. As you start to review the above measures with P.W., you notice he already seems aware of what he should do to control his blood glucose. You are concerned that he seems too distracted and drifts off in the middle of a discussion; his affect also appears flat. You ask P.W if he has been taking all his medications. He says “yes” but adds that he discovers “extra” blood pressure pills left over at the end of each week. He seems to be confused about the reason for the “leftover” pills. You decide to do a glucose stick. He registers 348 mg/dl. P.W.’s provider says she wants to hospitalize him for evaluation and stabilization; this also would give the opportunity for a psychiatric consult. P.W. says he refuses to go to “that hospital where my wife died.” In discussion with P.W. and the physician, it is decided that you will check his progress daily; someone from the home care agency will call q8h for a progress report on his progress daily. P.W.’s sister-in-law agrees to monitor his BG and vital signs and see that he takes all his medications. If P.W.’s condition does not improve or becomes worse, he must enter the hospital for treatment. The provider is concerned that P.E. may be depressed and starts him on Sertraline 50 mg qd to be taken with his bedtime snack. The next day, during your midafternoon visit to P.W.’s home, he tells you he has a headache and is feeling “fidgety” His pulse is 124, his gait is unsteady, speech is slightly slurred, and blood glucose is 48 mg/dl. P.W.’s sister-in-law informs you that his blood glucose is too high for the machine to read. You tell her to dial 911 immediately; advise her to tell them P.W. is diabetic and his blood glucose is over 400 mg/dl

PLEASE ANSWER THIS QUESTION:

1. Following the DKA episode, for which P.W. was hospitalized, P.W. shares with his nurse, “I don’t have the will to go on living without my wife… I wish everyone would just let me die.” How should the nurse respond?

A few days later you visit P.W. to facilitate his discharge, you find the combination of an antidepressant and improved health status has contributed to an improvement in P.W.’s mental status. He impresses you as being alert and intelligent. Although he verbalizes a sense of great loss and sadness about his wife’s death, he no longer seems to be so overwhelmed. He says he has not heard about the ADA’s nutrition recommendations and principles for people with diabetes mellitus and expresses an interest in learning as much as he can.

2. Report your diet teaching recommendations for P.W. below using the ADA recommendations as your guide.

Answer 1

(1) It clearly indicates that the Mr. P.W don't want to live more and hence has suicidal thoughts , This time is most precious for the heathcare provider team to be kept Mr. P.W under the observation and managed their suicide risk thoughts . Mr P.W expressing the suicidal ideation and a nurse 's role in confidentiality are going to distress and difficult situation for the nurse as to encounter this .If the nurse informs the Mr. P.W 's healthcare team , then Mr. P.W 's autonomy and the confidentiality is to be violated . But if the nurse maintain the coonfidentiality and the Mr.P.W 's safety may be at the risk . In this situation , the ethical principle s of the autonomy and the beneficence cannot be chosen without one violating the others . The autonomy is na agreement to the respect the another's rights to self determine the coures of the action . And the support of the independent decision making .However the autonomy can be the overridden in order to avoid the suicide attempt and maintaing the patient safety . The beneficence as the compassion , and taking as the positive action to help Mr. P.W and desire to do as good - the core priniciple of the patient advocay .

The firt priority of the nurse to know the internal emotions of the Mr. P.W and prompt the more serious conversation with him a s becuase the without detailed understanding of the specific intention of Mr. P.W and without insght into its specific meanings , reason and the function it is difficult to understnd that why Mr.P.W wishing to die is important to him . And it appeared that the Mr. P.W has mentally disturb by the wife lost and feels loneliness in their life . And he feels that suicide is the best option .In this situation nurse should have to keep the Mr.P.W in safe environment , And encourage him to move on the life and importance of the what he have arround himself and to focus on it . Providing him the counselling session would be improves his mental status .

(2) .. For the Mr. P.W , if he take regular mealtime s and the regular amounts of various foods that helps him get the most out of the least amount of the medication. Because tpatient with diabetes are at risk of high blood pressure or high fat , it makes the sense to also choose the foods that are heart healthy that is to be lean fat and the one s that are in low in salt . The diet plan for all the methods for determinng the healthy eating habits for the diabetes management .

	BREAKFAST	MID- MEAL	LUNCH	EVENING	DINNER
SUNDAY	4 Idli + sambar 1/2 cup or 1 table of spoon green chutney / tomato chutney	green gram sprouts 1 cup	3 chappaties + 1/2 cup salad + fish curry + 1/2 cup cabbage subji	1 portion fruit ( but avoid high energy fruit s like banana , jack fruit , mango and chikku)	2 chappatie s + tomato subji 1 /2 cup
MONDAy	2 slice brown bread + 1 slice low fat cheese + 1 boiled egg + 1/2 cup low fat milk	1 portion fruit ( avoid that explained above )	veg fried rice 1 cup + 1/2 soya chunk curry + 1/2 cup low fat curd	1 cup light tea + 2 wheat rusk	2 chappati + 1/2 cup potato green peas curry
TUESDAY	3 chappaties + 1/2 cup potato green peas curry	1/2 cup of boiled black gram	1 cup rice + 1/2 cup pulses + 1 cup spinach + 1/2 cup low fat curd	1 portion of fruit ( but avoid those high energy fruits )	brocken wheat upma 1 cup + 1/2 cup green beans
WEDNESDAY	methi parata 2 slice + 1 tbs green chutney	1 portion of fruit but avoid high energy fruit	1 cup rice + chicken curry + 1 cup cucumber salad	1 cup light tea + brown rice flakes poha 1 cup	wheat dosa 3 slice + 1/2 cup bitter guard sabji
THURSDAY	vegetables oats 1 cup 1/2 cup of low fat milk	plane yoghurt with raw veges / grilled veg - 1 cup	1/2 cup rice + 2 medium chappati + 1/2 cup kedney beans curry + snake guard sabji 1/2 cup	1 cup boiled gram + light tea 1 cup / coffee	2 chappati + 1/2 cup mix veg curry
FRIDAY	1/2 cup low fat milk + 4 eggs omlette	1 portion fruit but avoid high energy fruits + nuts	3 chappati + 1/2 cup cluster beans + fish curry 1/2 cup	1 cup tea / coffee = 4 biscuits ( low calories / sugar free choice )	2 chappati + ridge guard sabji /2 cup
SATUARDAY	oatmeal 1 cup + 1/2 cup almonds + nut	1 cup boiled gram	1 cup rice + soya curry 1 cup + 1 cup ladies finger + 1/2 cup small cup low fat curd	1 portion of fruit but avoid high energy fruits + nuts	brocken wheat upma 1 cup + 1 cup green beans + chicken curry

DO's ;-

• selective fruits and veg  
• Whole grains
• small , frequent meals

DON'T s

• trans - fat
• processed sugars
• white flour
• sugar drinks