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.

PLEASE ANSWER THIS QUESTION:

1) If P.W. were to become unconscious during a hypoglycemic episode, how would you revise nursing management of his condition in this setting?

2) P.W.’s sister-in-law phones you on Sunday morning stating that P.W. is “very sick”. What questions would you ask her to help you decide the best course of action?

3) Under what circumstances is P.W. likely to experience diabetic ketoacidosis?

Answer 1

hypoglycemia low blood glucose level occurs when the blood glucose falls below 50 t0 60 mg/dL. it can be caused by too much insulin or oral hypoglycemic agents, too little food , or excessive physical activity. . it may occure at any time. If often occurs before meals , especially if meals are delayed or if snacks are ommitted. Middle of the night hypoglycemia may occure because of peaking evening NPH or Lente- insulins, espacially in patients who have not eaten a bedtime snacks.

1) If P.W. were to become unconscious during a hypoglycemic episode, how would you revise nursing management of his condition in this setting?

Nursing Management

• teach the patient to prevent hypoglycemia by following a consistant regular pattern of eating, administering insulin and exercising . Consume between - meal and bedtime snacks to counteract the maximum insulin effect
• Reinforce that routine blood glucose tests are performed so that changing insulin requirments may be anticipated.
• Encourage him taking insulin to wear an identification bracelet or tag indicating they have diabetes
• Instruct him to notify physician after sever hypoglycemia has occured.
• instruct him and family about symptoms of hypoglycemia and use of glucogon
• Teach family that hypoglycemia can cause irrational and unintentional behavior.
• Teach him importance of performing self- monitoring of blood glucose on a frequent and regular basis.

2) P.W.’s sister-in-law phones you on Sunday morning stating that P.W. is “very sick”. What questions would you ask her to help you decide the best course of action?

• Is he conscious?
• did you checked his blood glucose ? if yes what are the values?
• did he have any issues with communicating ?
• signs of palpitation?
• is he sweating?
• dizziness or presence of confusion?
• ask her regarding P.W's diatery pattern for the last days
• did he missed his meals?
• did he reseaved extra dose of insuline?
• is he took his hypertensives?

From this qustions answers nurse can decide what he is experiancing and manage for the illness

3) Under what circumstances is P.W. likely to experience diabetic ketoacidosis?

Diabetic ketoacidosis is a serious complication of diabetes that occures when your body produces high levels of blood acids called ketones. This condition develops when your body cant produce enough insulin

Causes

DKA ( diabetic keto acidosis) is caused by lack of insulin in the body which results in the body breaking down fat for energy . Ketones are relesed in to the body as the fat is broken down . sometimes UTI , any infections or flu also can cause DKA

Symptoms

1. confusion
2. weakness or fatigue
3. shortness of breath
4. Fruity -scented breath
5. abdominal pain
6. nausea and vomiting
7. frequent urination
8. excessive thirst