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Diabetes Millitus

Order Description

Case Study

Chief Complaint/History of Present Illness:
Shannon O’Reilly, 24 years old, was found unresponsive by her mother this afternoon. Her mother states she went to work this morning and her daughter

was asleep. When she called home later in the morning, her daughter did not answer the phone and she rushed home to check on her. She found her

unconscious, lying on the sofa. She has had the flu for the past couple of days with vomiting and loss of appetite. Her mother said since her

daughter wasn’t eating, she hadn’t taken her insulin.
Shannon arrives at the emergency department by EMS with O2 on at 15L via non-rebreather and an IV NS insitu in her right arm. The NS is currently

infusing ‘wide open’.

Vital signs on admission: T 37.9°C, P 144 (reg) BP 82/50, RR 28, SpO2 99% via NRB

Biographical data
• Age: 24
• Gender: female
• Height: 5ft 8in
• Weight: 71kg

Past Medical History
• DM type 1 since 3 years of age
• Surgical: none
• Allergies: NKDA
• Immunizations: UTD, including influenza vaccine

Home Medications
• Shannon normally takes 10 units Humulin regular and 20 units of Humulin NPH before breakfast and 10 units of Humulin NPH at bedtime.

Social/personal History
• Major support: mother & father
• Occupation: accountant
• Education level: University degree
• Religion: Catholic

Family History
• Unknown, adopted

Cultural Considerations
• Language: English
• Ethnicity: Irish
• Nationality: Canadian
• Culture: no significant cultural considerations identified

Physician’s Orders
• Neurovital signs q 15 min
• cardiac monitor
• Bedrest
• CBC, electrolytes, glucose, BUN, creatinine, serum ketones, ABG’s
• IV regular insulin drip at 0.1units/kg/hr
• IV NS 1L over 1hr
• CBS q1h
• Foley catheter
• Hourly intake/output
• O2 via non-rebreather mask

Admission Nursing Assessment
• Resp: respiratory rate 28, deep & regular; chest clear with good air entry bilaterally; SpO2 on 15L via non-rebreather is 100%
• CV: BP 82/50, HR 144 regular; skin warm, dry & flushed with dry mucous membranes, poor turgor, cap refill is 3 – 4 sec; peripheral pulses weak
• MSK: flaccid response

I. Pre-Clinical Critical Thinking

Identify foundational knowledge; Identify disease origins/process; Significance of medications; Identification of relevant clinical information and

meaning of nursing assessments.

1. Compare and contrast the complications of Type 1 & 2 DM, including rationale for the differences found.

2. Describe the pathophysiology and associated risk factors of DKA.

3. How would you differentiate signs and symptoms of hyperglycemia from those of hypoglycemia?

4. What physical findings would result from hyperosmolar diuresis?

5. How does the body attempt to compensate for metabolic acidosis?

6. DKA is a medical emergency; why is it a life-threatening crisis?

II. Identifying Focused Relationships: Clinical Reasoning

Prioritize care, and rationale for nursing interventions; Anticipate changes in clinical status; Identify significance of new data; Incorporate

nursing theory.

1. What is the relationship between the medical history and the current concerns for this client?

2. What else would you like to know about Shannon’s recent history and events leading to her hospitalization.

3. What information is missing from the initial assessment and state the significance of performing this assessment

4. Relate the assessment findings to the pathophysiology of DKA.

5. Provide rationale for the physicians orders and, therefore, subsequent collaborative care.

Shannon’s condition has improved in the Emergency dept. Her NS bolus is completed and IV insulin is infusing as per physician’s orders. The

maintenance IV fluid as been changed to NS with 40mEQ KCL/L @ 200cc/hr and is currently infusing with 500cc TBA.
Vital signs are: T 37.5 C, P 112, BP 102/52, RR 24 deep & regular, GCS 13
Her latest blood values are:
• ABG’S: pH 7.27, PaO2 95mmhg, PaCO2 35, HCO3 16mmol/L, SaO2 98%
• K+: 4.0
• Capillary blood sugar: 8.1

6. Provide a concise SBAR report that the nurse would provide to the physician to communicate these latest lab results and Shannon’s condition. (Do

not use point form for this question; full sentences, please, as if you were speaking to the physician).

S (situation):

B (background):

A (assessment):

R (recommendation):

7. Describe your rationale for the recommendations made.

III. More Clinical Reasoning: Education Priorities/Discharge Planning

Understand changes in baseline health; Teach and communicate priorities to patient/family.

Shannon has been on a medical unit for 3 days and is now ready for discharge. She has resumed her usual insulin dosage this morning, with the

addition of a regular insulin dose mid-afternoon for the next 2 days dependent on her CBS at that time. She is eager to go home and resume work, gym,

and other activities.

1. Given that Shannon will be discharged today, what are the nurse’s priorities?

2. In general, what modifications would a nurse need to make to teaching methods based on a patient’s developmental stage, age, culture, preferences,

and level of health literacy (consider this question generally, using examples)?

3. Discuss how Shannon’s family may be included in discharge planning and education.


Category: Uncategorized

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