Question

P.W. Is a 40-year old disabled man who recently lost his wife to metastatic breast cancer. His brother has taken him into his home. P.W. has a 22-year history of insulin-dependent diabetes mellitus (Type-1). Until recently, he has taken responsibility for the management of his disease and has been actively involved in the local chapter of the American Diabetic Association. PMH includes 2 amputated toes on his R foot, retinopathy and visual impairment in both eyes, and angina on exertion from coronary artery disease that severely restricts his activity. Since he began treatment with an Ace-inhibitor 2 years ago, his blood pressure has gone from 182/128 to 126/78 mm Hg. Currently, he is 71” tall and weighs 135 lb. P.W.’s sister-in-law, who is an LPN says P.W. has lost about 12 lbs in the past 3 weeks. Over the past few years, P.W. has been administering a multidose (3 injections) regimen of regular Humulin insulin to himself before meals and at night. Recently his BG levels have been increasingly inconsistent and labile, and he has been labeled “noncompliant.” It is Monday. You are the home care nurse assigned to visit P.W. 3 times per week for teaching and evaluation. P.W.’s brother and sister-in-law express concern that P.W. seems to be indifferent about his nutritional and pharmacologic regimens. As you start to review the above measures with P.W., you notice he already seems aware of what he should do to control his blood glucose. You are concerned that he seems too distracted and drifts off in the middle of a discussion; his affect also appears flat. You ask P.W if he has been taking all his medications. He says “yes” but adds that he discovers “extra” blood pressure pills left over at the end of each week. He seems to be confused about the reason for the “leftover” pills. You decide to do a glucose stick. He registers 348 mg/dl. P.W.’s provider says she wants to hospitalize him for evaluation and stabilization; this also would give the opportunity for a psychiatric consult. P.W. says he refuses to go to “that hospital where my wife died.” In discussion with P.W. and the physician, it is decided that you will check his progress daily; someone from the home care agency will call q8h for a progress report on his progress daily. P.W.’s sister-in-law agrees to monitor his BG and vital signs and see that he takes all his medications. If P.W.’s condition does not improve or becomes worse, he must enter the hospital for treatment. The provider is concerned that P.E. may be depressed and starts him on Sertraline 50 mg qd to be taken with his bedtime snack. The next day, during your midafternoon visit to P.W.’s home, he tells you he has a headache and is feeling “fidgety” His pulse is 124, his gait is unsteady, speech is slightly slurred, and blood glucose is 48 mg/dl.

P.W.’s sister-in-law informs you that his blood glucose is too high for the machine to read. You tell her to dial 911 immediately; advise her to tell them P.W. is diabetic and his blood glucose is over 400 mg/dl

PLEASE ANSWER THIS QUESTION:

1) What can the ED nurse do to prepare for P.W.’s arrival?

2) The nurse does a quick assessment upon arrival. Outline essential components of an abbreviated assessment specific for this situation

3) Laboratory tests reveal the following: Na 135 mEq/L, Cl 92 mEq/L, BUN 38 mg/dl, glucose 682, WBC 15.7 mm3, HCT 53%, pH 7.30, PaCO2 36, HCO3 18 mEq/L. Interpret the lab values in relation to the situation.

Answer 1

Answer :

1)What can the ED nurse do to prepare for P.W.’s arrival?

• · ED nurse should prepare to receive patient with hyperglycemia so she should check for the availability of glucometer and infusion pump in good condition to administer Fluid replacement.
• · Electrolyte replacement. Electrolytes are minerals in your blood that are necessary for your tissues to function properly. ...
• · Prepare for Insulin therapy.- Insulin is the best way to control hyperglycemia in the inpatient setting specially in the critically ill patient. Intravenously administered insulin is the preferred method to achieve the recommended glycemic target.

2)The nurse does a quick assessment upon arrival. Outline essential components of an abbreviated assessment specific for this situation

• · In the Emergency Department, the nurse primary goals are rapid evaluation and stabilization.
• · All patients with severe hyperglycemia should immediately undergo assessment and stabilization of their airway and hemodynamic status.
• · In cases requiring intubation, the paralytic succinylcholine should not be used if hyperkalemia is suspected as it may acutely further elevate potassium.
• · Immediate assessment should also include placing patients on oxygen, measure O₂ saturation and cardiac monitoring as well as obtaining vital signs, a fingerstick glucose, intravenous (IV) access, and a 12-lead electrocardiogram to evaluate for arrhythmias and signs of hyper-and hypokalemia.
• · High blood sugar, can be diagnosed with a blood test such as a fasting blood sugar, a hemoglobin A1C test, or a fructosamine test.

3)Laboratory tests reveal the following:

Normal Range :

• · Na 135 mEq/L(normal values 135-145mEq/L)
• · Cl 92 mEq/L,(normal range 96-106 mEq/L)
• · BUN 38 mg/dl,( normal range 7-20mgdl)
• · glucose 682,( normal range FBS : 70-100 mg/dl PPBS : 70-140 mg/dl)
• · WBC 15.7 mm3,( normal range 6,000-17,000mm3)
• · HCT 53%,(normal range 41-50 %)
• · pH 7.30, (7.35-7.45 )
• · PaCO2 36 (normal range 35-45 mmHg)
• · HCO3 18 ( Normal range 18-24 mEq/l)

Interpretation :

· BUN 38 mg/dl,( normal range 7-20mgdl)

· glucose 682,( normal range FBS : 70-100 mg/dl PPBS : 70-140 mg/dl)