DIABETES MELLITUS
The patient is a 48-year-old unconscious woman admitted to the ED. She
has a known history of type 1 diabetes mellitus. Her daughter accompanies
her and tells the staff that her mother has had the “flu” and has been unable
to eat or drink very much. The daughter is uncertain whether her mother
has taken her insulin in the past 24 hours. The patient’s vital signs are
temperature 101.8° F; pulse 120, weak and irregular; respiration 22, deep,
and fruity odor; and blood pressure
80/42 mm Hg. Blood specimens and arterial blood gases are drawn and an
IV infusion begun.
1) Based on this patient’s history, give the probable changes in laboratory results
for serum glucose, serum osmolarity, serum acetone, BUN, arterial pH, and
arterial Pco2. What medical emergency do these data indicate?
Diabetic ketoacidosis
2) What type of IV solutions should the nurse be prepared to administer to this
patient? What drugs should the nurse be prepared to give? Explain your
answers.
3) The patient is placed on continuous cardiac monitoring. What is the rationale for
this intervention?
Monitor for fluid overload and cardiac complications of K imbalances
4) During the first 24 hours, what complications should the nurse monitor for in
this patient? Why?
Heart failure and pulmonary edema, rapid fluid replacement can overload the circulatory
system
5) The patient eventually becomes normoglycemic, regains consciousness, and
begins a 1500-calorie diabetic diet. Develop a teaching-learning plan for her
about this diet.
o 1500 calorie diabetic diet
Achieving and maintaining blood glucose levels in the normal range or as
close to normal as is safely possible
Achieving and maintaining a blood lipid profile that reduces the risk for
vascular disease
Achieving blood pressure levels in the normal range or as close to normal
as is safely possible
Preventing or slowing the rate of development of the chronic
complications of diabetes by modifying nutrient intake and lifestyle
Addressing patient nutrition needs taking into account personal and
cultural preferences and willingness to change
Maintaining the pleasure of eating by limiting food choices only when
indicated by scientific evidence
Meeting the nutrition needs of unique times of the life cycle, particularly
for pregnant and lactating women and for older adults with diabetes
, Providing self-management training for patients treated with insulin or
insulin secretagogues for exercising safely, including the prevention and
treatment of hypoglycemia, and managing diabetes during acute illness
(Ignatavicius 1319)
6)
Before this emergency, this patient had been monitoring urine glucose and ketones for
self-care and insulin administration. Her physician prescribes blood glucose monitoring
instead of urine testing. What is the rationale for this change?
Blood monitoring gives more accurate result of circulating glucose, urine testing can be affected
by fluid intake, urine concentration, and certain drugs.
7)
Which aspect of diabetic self-care should the nurse discuss with this patient before her
discharge?
Medication, administration techniques, skin care, exercise, glucose monitoring, risks associated
with ADL’s
8)
The patient is to be discharged on a mixed-dose regimen for insulin. She is to receive
10 units regular insulin and 18 units NPH insulin before breakfast and another 5 units
regular insulin and 12 units NPH at dinnertime. Develop a teaching-learning plan for
these medications.
Teach proper mixing of the insulins, explain difference between regular and NPH insulin, teach
techniques of injection, instruct about safety factors for self-administration
9)
Considering the patient’s insulin protocol, the patient should keep in mind what
principles about the actions of the insulins she is taking?
Regular insulin will peak after breakfast and again after super, and the NPH will peak after lunch
and after dinner, at bedtime. She should have a small snack at bedtime to avoid hypoglycemia.
She needs to make sure to eat her meals as well in order to avoid hypoglycemia.
10)
What should the nurse discuss with this patient about diabetes, insulin, and illness?
What can this patient do to prevent future emergency episodes? Consider
“Instructions for Sick Day” rules.
Sick-Day Rule
Notify your health care provider that you are ill.
Monitor your blood glucose at least every 4 hours.
Test your urine for ketones when your blood glucose level is greater than 240 mg/dL
(13.8 mmol/L).
Continue to take insulin or oral antidiabetic agents.
The patient is a 48-year-old unconscious woman admitted to the ED. She
has a known history of type 1 diabetes mellitus. Her daughter accompanies
her and tells the staff that her mother has had the “flu” and has been unable
to eat or drink very much. The daughter is uncertain whether her mother
has taken her insulin in the past 24 hours. The patient’s vital signs are
temperature 101.8° F; pulse 120, weak and irregular; respiration 22, deep,
and fruity odor; and blood pressure
80/42 mm Hg. Blood specimens and arterial blood gases are drawn and an
IV infusion begun.
1) Based on this patient’s history, give the probable changes in laboratory results
for serum glucose, serum osmolarity, serum acetone, BUN, arterial pH, and
arterial Pco2. What medical emergency do these data indicate?
Diabetic ketoacidosis
2) What type of IV solutions should the nurse be prepared to administer to this
patient? What drugs should the nurse be prepared to give? Explain your
answers.
3) The patient is placed on continuous cardiac monitoring. What is the rationale for
this intervention?
Monitor for fluid overload and cardiac complications of K imbalances
4) During the first 24 hours, what complications should the nurse monitor for in
this patient? Why?
Heart failure and pulmonary edema, rapid fluid replacement can overload the circulatory
system
5) The patient eventually becomes normoglycemic, regains consciousness, and
begins a 1500-calorie diabetic diet. Develop a teaching-learning plan for her
about this diet.
o 1500 calorie diabetic diet
Achieving and maintaining blood glucose levels in the normal range or as
close to normal as is safely possible
Achieving and maintaining a blood lipid profile that reduces the risk for
vascular disease
Achieving blood pressure levels in the normal range or as close to normal
as is safely possible
Preventing or slowing the rate of development of the chronic
complications of diabetes by modifying nutrient intake and lifestyle
Addressing patient nutrition needs taking into account personal and
cultural preferences and willingness to change
Maintaining the pleasure of eating by limiting food choices only when
indicated by scientific evidence
Meeting the nutrition needs of unique times of the life cycle, particularly
for pregnant and lactating women and for older adults with diabetes
, Providing self-management training for patients treated with insulin or
insulin secretagogues for exercising safely, including the prevention and
treatment of hypoglycemia, and managing diabetes during acute illness
(Ignatavicius 1319)
6)
Before this emergency, this patient had been monitoring urine glucose and ketones for
self-care and insulin administration. Her physician prescribes blood glucose monitoring
instead of urine testing. What is the rationale for this change?
Blood monitoring gives more accurate result of circulating glucose, urine testing can be affected
by fluid intake, urine concentration, and certain drugs.
7)
Which aspect of diabetic self-care should the nurse discuss with this patient before her
discharge?
Medication, administration techniques, skin care, exercise, glucose monitoring, risks associated
with ADL’s
8)
The patient is to be discharged on a mixed-dose regimen for insulin. She is to receive
10 units regular insulin and 18 units NPH insulin before breakfast and another 5 units
regular insulin and 12 units NPH at dinnertime. Develop a teaching-learning plan for
these medications.
Teach proper mixing of the insulins, explain difference between regular and NPH insulin, teach
techniques of injection, instruct about safety factors for self-administration
9)
Considering the patient’s insulin protocol, the patient should keep in mind what
principles about the actions of the insulins she is taking?
Regular insulin will peak after breakfast and again after super, and the NPH will peak after lunch
and after dinner, at bedtime. She should have a small snack at bedtime to avoid hypoglycemia.
She needs to make sure to eat her meals as well in order to avoid hypoglycemia.
10)
What should the nurse discuss with this patient about diabetes, insulin, and illness?
What can this patient do to prevent future emergency episodes? Consider
“Instructions for Sick Day” rules.
Sick-Day Rule
Notify your health care provider that you are ill.
Monitor your blood glucose at least every 4 hours.
Test your urine for ketones when your blood glucose level is greater than 240 mg/dL
(13.8 mmol/L).
Continue to take insulin or oral antidiabetic agents.
