Diabetes Mellitus & Cultural Competence and Awareness

NURS 4700

Lesson #6 Case Study

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Diabetes Mellitus & Cultural Competence and Awareness

 

In Class Learning Patient Care Scenario:

 

Meet your patient  J.S.

  • S., a 44-year-old Indigenous male, was admitted to the emergency department after he was found unconscious in his apartment by his wife. J.S. was diagnosed with diabetes mellitus (Type 2) just 11 months ago
  • Has been taking 48 U of insulin daily: 12 U of regular insulin plus 20 U of NPH before breakfast, 8 U of regular insulin before dinner, and 8 U of NPH at bedtime.cf
  • S. and his family moved to Oshawa from Moosonee 18 months ago and works as a part-time mechanic in Jiffy Lube, likes to relax after work and has never been involved in any regular activities or organized sports.
  • S. weighs approximately 95 kg and 175 cm.
  • S. has two sons aged 19 and 20 living at home.
  • S. has a history of flu for 1 week with vomiting and anorexia.
  • Stopped taking insulin 2 days ago when he was unable to eat.

 

Physical Examination

Objective Data:

  • Breathing is deep and rapid
  • Acetone smell on breath
  • Skin flushed and dry
  • BP 98/50, RR 32, Pulse 82, T. 37
  • Unconscious
  • O2 sats-94 % room air

 

Subjective Data:

  • S. found husband “blacked out on the floor of their apartment”, did not know how long he had been unconscious.
  • Called 911 immediately.

 

Physician’s orders for Mr. J.S.

  • Blood work includes: Blood glucose, CBC, Ketones, pH, electrolytes, BUN, Arterial blood gases, Urinalysis (SG, pH, glucose, ketones)
  • Initial IV 0.45% at 300 ml/hr
  • Initiate IV 0.9% NS at 300mL/hr to restore urine output to 30 to 60 mL/hr and raise blood pressure.
  • When blood glucose levels approach 14 mmol/L, 5% dextrose is added to the fluid regimen
  • IV insulin 1 unit/minute, titrate as glucometer readings improve
  • Monitor blood glucose levels q.1.h.
  • ECG monitoring
  • Oxygen to keep sats above 95%

 

Lab Results for Mr. J.S.

  • Blood glucose: (40.5 mmol/L) (Normal range 4-6 mmol/L).

Arterial Blood Gases pH 7.26, PCO2 32, HCO3 16  (Normal pH 7.35-7.45; PCO2 35-45 mm Hg; HC03 21-28 mmol/L).

  • CBC: Hgb 12.4 mmol/L (8.7-11.2 mmol/L normal range); Hct 0.75% (42-52% normal range).
  • Creatinine 11.2 mcmol/L (15.3-76.3 mcmol/L normal range); BUN 6.5 mmol/L (3.6-7.1 mmol/L normal range).
  • Electrolytes: Potassium 3 mmol/L (3.5-5.3 mmol/L= normal range); Sodium 128 mmol/L (135-145 mmol/L = normal range); Chloride 95 mmol/L (98-106 mmol/L normal range); Magnesium 0.65 mmol/L (0.65-1.05 mmol/L =normal range).
  • Urinalysis: Ketones positive, pH 4.3 (4.6-8.0 normal range); SG-1.039 (1.005-1.030 normal range), glucose positive.
  • ECG normal sinus rhythm

 

Critical Thinking Questions:

 

    1. Briefly explain the pathophysiology of the development of diabetic ketoacidosis (DKA) in this patient.
    2. What clinical manifestations of DKA does this patient exhibit?
    3. Explain the lab values. What does your clinical judgment suggest to you once you receive the results?
    4. What factors precipitated this patient’s DKA?
    5. Explain physician’s orders.
    6. What distinguishes this case history from one of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) or hypoglycemia?
    7. What teaching should be done with this patient and his family?

 

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