Question

Case Study: The Patient with 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 (38.7o C); 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.

During the first 24 hours, what complications should the nurse monitor for in this patient? Why?

The patient eventually becomes normoglycemic, regains consciousness, and begins a 1500- calorie diabetic diet. Develop a teaching–learning plan for her about this diet.

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?

Answer 1

The Patient has developed diabetic ketoacidosis which is triggered by the infectious process and insufficient amount of insulin in the body.It is one of the most serious complication of Type I diabetes mellitus.The intensive monitoring of patient is essential as if left untreated it can cause fatal outcomes.The possible inmediate complications includes

- Acute renal failure which occurs as a result of severe dehydration.The patient will be having marked glycosuria.Along with glucose water and electrolyte losses will be higher leading to severe dehydration.As a result there will a temporary cessation of renal function.The waste products may accumulate within the blood stream.Also there may be accumulation of fluid in the tissues leading to edema.So it is important to monitor the intake and output of the patient as well as Renal function test.Dialysis has to be done if indicated.

- Cerebral edema which occurs as a result of fluid accumulation within brain cells,it has to early identified and treated to prevent neuronal damage.It may manifest as seizures or dizziness.Close monitoring of blood glucose levels and serum electrolyte levels,urine output,mental status,and neurological signs is essential.

-Acute respiratory distress syndrome may occur due to accumulation of fluid within the lung tissues.Pulmonary edema may manifest as severe respiratory distress and hypoxia.Adult respiratory distress syndrome may require ventilator support to manage it.

- The fluid overload may also lead to heart failure. So cautious use of IV fluids to manage blood volume is essential.Initiate CVP monitoring and hemodynamic monitoring to assess fliud status.Focus on physical examination of skin turgor,cardiac rate and rhythm,breath sounds,veno ve distension and urine output

- Hypokalemia may occur as the IV insulin administering for managing hyperglycemia will bind with circulating potassium.It may results in cardiac arrhythmias.

-Hypoglycemia may occur due to continuous infusion if insulin .So hourly monitoring of blood glucose as well as administration of concentrated dextrose solutions if blood sugar suddenly below 200 mg/ dl

Teaching learning plan for 1500 calories diabetic diet

Diet has an important role in the management of diabetes.The type of food consume,amount of food consume and the timing of food has influence in the blood sugar.A 1500 calories diet helps to manage the blood sugar as well as treat obesity.

In this diet plan all food items are grouped into different categories and we ensures that the total intake contains all the required nutrients and also required calories.An ideal plan include 3 main servings and 3 snacks.A balanced 1500 calories diabetic diet plan includes 6 serving of starch,6 serving of meat ,3 serving of fruits 3 serving of milk and 4 serving of non- starchy fruits and 4 serving of fat per day.

That is;

Break fast- Include starch,meat,milk and fat, fruit

Eg:Two Bread, cheese,banana one glass of milk,half boiled egg

Mid morning-Fruits eg: Oranges

Lunch - Two serving of starch and meat,one serving of fat and vegetables

Eg: Two cup rice,fish curry ,vegetable salad and curd.

Afternoon snack- It may include one serving of milk.Eg.Sugar free cappuccino

Dinner- It should contain twotwo serving starch,three serving meats,three serving vegetables,one seving fruit and two seving fat

Eg:Two dosa, chicken curry,low fat salad,vege vegetable soup.

Evening snack- It may include 1 serving of starch and 1 serving of milk

Eg: oats boiled in milk

Blood sugar testing is recommended over urine testing.Because the presence of sugar in urine can be detected only after the blood sugar is above the renal threshold ,that is above 160-180 mg/dl.But through blood sugar test even the slight deviation sugar can be identified.Hence early detection and prompt actions such as dosage adjustment of insulin can be possible through blood sugar analysis.It also prevents complications like hypoglycemia also.