Case Study, Chapter 51, Assessment and Management of

Patients With Diabetes

Jake Yvan Dizon
BSN-IV

1. Sallie Smith, 42 years of age, is newly diagnosed with type 2 diabetes.

During the patient education, the patient asks the nurse, “What should I do if
I am sick and can’t eat; should I still take my medicine for the diabetes?”
(Learning Objective 10)

a. What management strategies should the nurse provide the patient to

deal with “sick days?”
Nursing Management
1. Always check the blood sugar for 3-4 hrs when ill
2. Make sure to always take insulin
3. Eat 4oz of sugar-free, non-caffeinated liquid every 30
mintues to
prevent dehydration
4. Make sure you rest.
5. Call your physician if you experience:
i. Blood glucose levels greater than 240mg/dL. Test urine for
ketones
if able and report if found.
ii. A fever greater than 101.5 degrees farenheit that does not
respond
to Tylenol or lasts greater than 24 hours.
iii. Feelings or disorientation, confusion, rapid breathing
iv. Vomiting greater than once and diarrhea greater than five
times or
for more than 24 hours
v. Inability to tolerate liquids
vi. Illness lasting longer than two days

2. Jerry Thomas is a 26-year-old type 1 diabetic. He was originally diagnosed

at the age of 14, and currently manages his disease with an intensive
regimen of insulin injections. Jerry is employed as a schoolteacher and soccer
coach. He presents today with a 2-day history of vomiting and diarrhea. He
has been closely monitoring his blood glucoses, and is using regular insulin
for high blood glucose levels. He has only been able to tolerate liquids such
as Gatorade, but today he is unable to even tolerate that, and comes to the
clinic for evaluation of possible diabetic ketoacidosis (DKA). (Learning
Objective 9)
 a. Describe the pathophysiology of DKA and why it occurs in patients with
type 1 diabetes.
- Diabetic ketoacidosis (DKA) is an acute metabolic complication
of diabetes characterized by hyperglycemia, hyperketonemia, and
metabolic acidosis. Hyperglycemia causes an osmotic diuresis with
significant fluid and electrolyte loss. DKA occurs mostly in type 1
diabetes mellitus. It occurs in type 1 diabetes patients as this is an
autoimmune dysfunction that involves the destruction of beta cells,
which produce insulin. Type 1 diabetes often results in a lack of
sufficient insulin due to it being undiagnosed or untreated. It can also
happen as a result of non adherence to a diabetic regimen.

b. Based on the diagnosis of DKA, what assessment findings does the

nurse correlate to this disorder?

- Polyuria
- Polydipsia
- Polyphagia
- Weight loss
- GI effects
- Blurred vision, headache and/or weakness
- Orthostatic hypotension
- Fruity breath odor
- Kussmaul respirations
- Metabolic acidosis
- Mental status changes

c. The physician orders a complete metabolic panel, and Jerry’s blood

glucose is 425. Other lab values include a serum sodium of 152, serum
potassium of 3.0, and BUN of 64. What is your assessment of these
results?
- Blood glucose is high which indicates Hyperglycemia and Serum
sodim potassium and BUN indicates Dehydration-
d. Explain why it is important for Jerry to continue to take his insulin
even though his oral intake is decreased.

First is it help regulates the blood sugar in his body next is it prevents
complications of diabetes
 Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Subjective: Deficient Before Assess the Patients who are After nursing
““What should I do if I knowledge discharge, patient’s and recently intervention:
am sick and can’t eat; related to patient will be family’s diagnosed with Patient is able to
should I still take my unfamiliarity able to readiness to diabetes often go demonstrate
medicine for the with insulin demonstrate learn before through various knowledge of
diabetes?” as stated injection knowledge of initiating an stages of the insulin injection,
by the patient insulin injection, education plan. grieving process. symptoms, and
symptoms, and Provide treatment of
Objective treatment of reassurance to hypoglycemia
- Requests of hypoglycemia the patient and and diet.
information and diet. family that these
- Statements feelings are
of concern normal.
- Inadequate
follow-
through of Encourage the
instructions Assess the patient to discuss
- Development patient’s fears feelings and
of and major fears related to
preventable concerns about complications of
complications diabetes. diabetes.
Providing simple
and direct
information can
help clear out
any
misconceptions
about diabetes
that may
contribute to
 their anxiety.

Contributing
Assess the factors may
patient’s social include the
situation for patient’s literacy
factors that may level, financial
affect diabetes resources, lack
treatment and of health
education plan. insurance,
patient’s daily
schedule,
presence or
absence of family
support, learning
disabilities, or
neurologic
deficits or
conditions.

Monitoring
Verify that the provides data on
patient the degree of
understands and glucose control
demonstrates and identifies the
the technique need for changes
and timing of in insulin dosage.
home monitoring
of glucose.

Teach the Systematic

 patient to rotate rotation of
insulin injection injection sites is
sites. recommended to
prevent
lipodystrophy.

Explain that nsulin dosage

insulin dosages should be
may need to be reduced when
adjusted. fasting for
surgery, when
not eating, or
when
hypoglycemia
occurs. Illness or
infection may
increase insulin
requirements.

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
-Diarrhea Risk for fluid After few hours Assess These will After few hours
-Vomiting volume deficit of nursing precipitating provide baseline of nursing
-Dysphagia related DKA intervention: factors such as data for intervention:
- Patient will other illnesses, education once Patient remains
remain new-onset with resolved normovolemic as
normovolemic as diabetes, or poor hyperglycemia. evidenced by
evidenced by compliance with Urinary tract urinary output
urinary output treatment infection and greater than 30
greater than 30 regimen. pneumonia are ml/hr, normal
ml/hr, normal the most skin turgor, good
skin turgor, good common capillary refill,
capillary refill, infections normal blood
normal blood causing DKA and pressure,
pressure, HHNS among palpable
palpable older clients. peripheral
peripheral pulses, and blood
pulses, and blood glucose levels
glucose levels Assess skin To provide between 70-200
between 70-200 turgor, mucous baseline data for mg/dL
mg/dL. membranes, and further
thirst. comparison. Skin
turgor will
decrease and
tenting may
After 1 Week of occur. The oral
nursing mucous
intervention: membranes will
Patient will be become dry, and
able to manage the client may
and know the experience
signs and extreme thirst.
symptoms of
DKA
Monitor hourly Oliguria or anuria
intake and results from
output. reduced
glomerular
filtration and
renal blood flow.

Acetone breath is
Monitor due to the
respirations, breakdown of
e.g., acetone acetoacetic acid.
breath, Kussmaul’s
Kussmaul’s respiration (rapid
respirations. and shallow
breathing)
represent a
compensatory
mechanism by
the respiratory
buffering system
to raise arterial
pH by exhaling
more carbon
dioxide.

Diagnostic
Monitor criteria:
laboratory DKA: blood
studies: glucose level
greater than 250
Blood glucose mg/dL.
levels
HHNS: blood
glucose level
greater than 600
mg/dL with
serum osmolality
>320 mOsm/kg.

Elevated ketones
Serum ketones is associated with
DKA.

Initially,
Potassium hyperkalemia
occurs in
response to
metabolic
acidosis. As the
fluid volume
deficit
progresses,
potassium level
decreases. Both
DKA and HHNS
result in
hypokalemia.
 Increased blood
Sodium sugar causes
water to shift
from intracellular
into extracellular,
resulting in
serum sodium
depletion.

Elevated BUN
Blood urea and creatinine
nitrogen and indicate cellular
creatinine. breakdown from
dehydration or a
sign of an acute
renal failure.

Initial goal of
Administer fluid therapy is to
as indicated: correct
Isotonic solution circulatory fluid
(0.9% NaCl). volume deficit.
Isotonic normal
saline will rapidly
expand
extracellular fluid
volume without
causing a rapid
 fall in plasma
osmolality.
Clients typically
need 2 to 3 liters
within the first 2
hours of
treatment.

Regular insulin
Administer an IV has a rapid onset
bolus dose of and therefore
regular insulin, immediately
followed by a helps move
continuous glucose
infusion of intracellularly. IV
regular insulin. route is the initial
route because
subcutaneous
injection of
insulin may be
absorbed
unpredictably.
While a
continuous
infusion is an
optimal way to
consistently
administer insulin
to prevent
hypoglycemia.
 GENERIC THERAPEUTIC INDICATIONS CONTRA- ADVERSE EFFECTS NURSING CONSIDERATION
NAME ACTIONS INDICATIONS

Insulin Insulin is a  Treatment of  Contraindicated Hypersensitivity: Ra Assessment

hormone secreted type 1 (insulin- with allergy to sh, anaphylaxis
Insulin  History: Allergy to pork products; pregnancy; lactation
by the beta cells dependent) pork products or angioedema
injection:  Physical: Skin color, lesions; eyeball turgor; orientation, reflexes,
of the pancreas diabetes (varies with  Local: Allergy—local
Humulin R, peripheral sensation; P, BP, adventitious sounds; R, adventitious
that, by receptor-  Treatment of preparations; reactions at injection
Humulin R sounds; urinalysis, blood glucose
mediated effects, type 2 (non– human insulin site—redness,
Regular U-500  
promotes the insulin- not swelling, itching;
(concentrated) Interventions
storage of the dependent) contraindicated usually resolves in a
, Novolin ge  Ensure uniform dispersion of insulin suspensions by rolling the
body's fuels, diabetes that with pork few days to a few
Toronto vial gently between hands; avoid vigorous shaking.
facilitating the cannot be allergy). weeks; a change in
(CAN),
Novolin R, transport of controlled by  Use cautiously type or species  Give maintenance doses subcutaneously, rotating injection sites
Novolin R metabolites and diet or oral with pregnancy source of insulin regularly to decrease incidence of lipodystrophy; give regular
PenFill, ions (potassium) agents (keep patients may be tried; insulin IV or IM in severe ketoacidosis or diabetic coma.
Regular Iletin through cell  Regular insulin under close lipodystrophy;   Monitor patients receiving insulin IV carefully; plastic IV infusion
II, Velosulin membranes and injection: supervision; pruritus sets have been reported to remove 20%–80% of the insulin;
Human BR stimulating the Treatment of rigid control is Metabolic: Hypoglyc dosage delivered to the patient will vary.
synthesis of severe ketoacid desired; emia; ketoacidosis   Do not give insulin injection concentrated IV; severe
Regular insulin glycogen from osis or diabetic following   anaphylactic reactions can occur.
glucose, of fats coma delivery,   Use caution when mixing two types of insulin; always draw the
– It has an from lipids, and  Treatment requirements regular insulin into the syringe first; if mixing with insulin lispro,
onset of proteins from of hyperkalemia  may drop for draw the lispro first; use mixtures of regular and NPH or regular
action amino acids. with infusion of 24–72 hr, rising and Lente insulins within 5–15 min of combining
(begins to   glucose to to normal levels them; Lantus insulin (insulin glargine) cannot be mixed in solution
reduce produce a shift during next 6 with any other drug, including other insulins.
blood sugar) of potassium wk); lactation   WARNING: Double-check, or have a colleague check, the
within 30 into the cells (monitor mother dosage drawn up for pediatric patients, for patients receiving
minutes of  Highly purified carefully; concentrated insulin injection, or patients receiving very small
injection, and insulin doses; even small errors in dosage can cause serious problems.
reaches a human insulins  requirements  Carefully monitor patients being switched from one type of insulin
peak effect promoted for may decrease to another carefully; dosage adjustments are often needed.
at 1-3 hours, short courses of during Human insulins often require smaller doses than beef or pork
and has therapy lactation). insulin; monitor cautiously if patients are switched; lispro insulin
effects that (surgery, intercu is given 15 min before a meal.
last 6-8 rrent disease),  Store insulin in a cool place away from direct sunlight.
hours. newly Refrigeration is preferred. Do not freeze insulin.
diagnosed Insulin prefilled in glass or plastic syringes is stable for 1 wk
Intermediate patients, refrigerated; this is a safe way of ensuring proper dosage for
Insulin patients with patients with limited vision or who have problems with drawing up
poor metabolic insulin.
control, and   Monitor urine or serum glucose levels frequently to determine
– It has an patients with effectiveness of drug and dosage. Patients can learn to adjust
onset of
gestational insulin dosage on a sliding scale based on test results.
action
diabetes   Monitor insulin needs during times of trauma or severe stress;
starting
 Insulin injection dosage adjustments may be needed.
about 2
concentrated:  WARNING: Keep life support equipment and glucose readily
hours
Treatment of available to deal with ketoacidosis or hypoglycemic reactions.
following
diabetic patients
 with marked  
injection. It insulin Teaching points
has a peak resistance  Use the same type and brand of syringe; use the same type and
effect 4-12 (requirements of brand of insulin to avoid dosage errors.
hours after > 200 units/day)  Do not change the order of mixing insulins. Rotate injection sites
injection,  Glargine regularly (keep a chart) to prevent breakdown at injection sites.
and a (Lantus):  Dosage may vary with activities, stress, diet. Monitor blood or
duration of Treatment of urine glucose levels, and consult physician if problems arise.
action of 18- adult patients   Store drug in the refrigerator or in a cool place out of direct
26 hours. with type 2 sunlight; do not freeze insulin.
diabetes who  If refrigeration is not possible, drug is stable at controlled room
require basal temperature and out of direct sunlight for up to 1 month.
insulin control  Monitor your urine or blood for glucose and ketones as
Drug classes: of prescribed.
Antidiabetic hyperglycemia  Wear a medical alert tag stating that you have diabetes and are
Hormone  Treatment of taking insulin so that emergency medical personnel will take
  adults and proper care of you.
Pregnancy children > 6 yr   Avoid alcohol; serious reactions can occur.
Category B who require  Report fever, sore throat, vomiting, hypoglycemic or
baseline insulin hyperglycemic reactions, rash.
control