Question

Jessica is a 13 yr old student who lives with her parents and younger brother Jonathon in a middle-class neighborhood. Jessica has had diabetes type 1 since the age of 7, which has been well controlled by morning and evening injections of NPH insulin, diet and exercise. Recently, she has been staying up later in the evenings studying and is also the pitcher on her school softball team, which is playing in the semi-finals. Her schedule has contributed to a change in eating and sleeping patterns.

Situation:

Jessica developed a cough, nasal congestion and a low-grade fever 3 days ago but told her parents she was well enough to go to school and softball practice. Today she felt worse so her mother called their pediatrician and brought her in to the office. The physician, Dr. Jones, noted that Jessica’s pulse and respiratory rate were elevated and her breath smelled fruity. A blood glucose level with the clinic glucometer showed an elevated blood sugar. Dr. Jones referred the family to the emergency room.

The emergency room diagnostic findings were as follows:

Chemistry Profile
Glucose	480 mg/dL
Sodium	130 mEq/L
Chloride	79 mEq/L
Potassium	3.3 mEq/L
Arterial Blood Gas
pH	7.19
PaCO2	25 mm Hg
HCO3	10 mEq/L
PaO2	92 mm Hg
Oxygen saturation	97%

Questions

• Discuss your impression of Jessica’s situation. (Short and sweet -what's happening?)

• What data indicates that Jessica’s lungs are attempting to compensate for her present condition?

• After Jessica has received 2 L of intravenous fluids and her blood glucose level decreases to 240 mg/dL, the doctor prescribes IVF with 5% dextrose as the insulin is being titrated. Are you comfortable implementing this order? Why or why not? Give your rationale with reference.

• What are your teaching priorities for Jessica and her parents prior to discharge?

Answer 1

#. The impression of Jessica’s situation is that she is having Diabetic Ketoacidosis as a complication of her diabetes mellitus type 1.

#. The data that indicates Jessica’s lungs are attempting to compensate for her present condition is the lower PCO2 than normal range.

#. Yes , I am comfortable with the prescription.

When the blood glucose concentration is approximately 250 mg per dL (13.9 mmol per L), glucose should be added to the hydration fluid (i.e., 5 percent dextrose in hypotonic saline solution). This allows continued insulin administration until ketonemia is controlled and also helps to avoid iatrogenic hypoglycemia.

#) The teaching priorities for Jessica and her parents prior to discharge is to provide them information about the complications of diabetes mellitus and how it can be prevented.

Some of the measures include :-

Drink 2 L fluids daily

Monitor blood glucose every 4 hr when ill

Administer insulin as prescribed when ill

Report ketones in the urine after 24 hr of illness

Consult the physician as soon as possible.