Question

Bill Hughes is a 26 year-old man who lives with his wife. He has a history of type one diabetes and is overweight. He presented to the emergency department, complaining of feeling foggy in the head and sleepy. His wife reports that he became very drowsy and confused after dinner. Bill has high blood sugar levels which were managed in the emergency department and he has been transferred to the medical ward. You are the nurse assigned to care for Bill for the afternoon shift. Following handover you go to introduce yourself to Bill you find he has tachypnoea, and his skin is flushed and dry. You can smell his breath which has an acetone scent. From his medical history you gather the following data;

Subjective data (provided by his wife)

•           Was diagnosed with Type 1 diabetes mellitus 2 years ago

•           Is taking 48 U of insulin daily: 12 U of regular insulin plus 20 U of isophane (NPH) before breakfast, 8 U of regular insulin before dinner and 8 U of NPH at bedtime

•           Has a history of flu-like symptoms for 1 week with vomiting and poor appetite

•           Stopped taking insulin 2 days ago when he was unable to eat

•           Lethargic but responding appropriately

Objective data

Physical examination

•           Kussmaul breathing

•           BP 95/65, HR 93 bpm, Temp 35.6 ⁰Celsius, Resp 22 bpm

•           Acetone smell on breath

•           Skin flushed and dry

•           GCS 14

Diagnostic studies

•           Blood glucose level: 38.5 mmol/L

•           Blood HbA1c: 9%

•           ABG’s: pH 7.24, HCO3 18 mmol/L

•           U&E’s K 4.1 mmol/L Na 154 mmol/L

•           Urinalysis - ketonuria

(A).Demonstrate your knowledge of the pathophysiology of Type 1 diabetes mellitus and the development of diabetic ketoacidosis (DKA) in this patient (300-word limit)

(B)Examine the clinical manifestation demonstrated, establish why they are occurring, and outline the medical and nursing management Bill requires.(400-word limit)

Answer 1

A. Type 1 Diabetes Mellitus and its pathophysiology

Diabetes Mellitus( DM) is a  group of metabolic diseases where by a person has high blood sugar due to an inability to produce , or inability to metabolize, sufficient quantities of the hormone insulin. Type 1 Diabetes Mellitus is type of Diabetes Mellitus, in which the body is unable to  produce insulin due to the destruction of pancreatic cells. It is also known as Juvenile diabetes. It is characterised by increased blood glucose level, increased thirst, hunger, fatigu and frequent urination.

Pathophysiology

An infection, or Auto immune disorders

? ( leads to)

body produces antibodies against Beta cells of Pancreas, in which the insulin production occurs.

?

Destruction of Beta cells of Islets of Langerhans in Pancreas

?

Beta cells are unable to produce/ produces no insulin or little insulin

?

Blood glucose is unable to take up by muscles and tissues as there is no insulin ( Insulin hormone is responsible for the metabolism of Glucose, transportation of Glucose to cells and tissues from blood )

?

Increased Glucose level in the blood

?

Body's compensatory system tries excrete out the excessive glucose through urine along with extra urination

?

Glycosurea, polyurea, Dehydration, Polydipsia( increased thirst) etc.

Diabetic ketoacidosis and its pathophysiology

Diabetic ketoacidosis is a severe form of ketosis seen as a complication of Diabetes , in which so much ketone is produced that acidosis occurs. Ketosis is a metabolic state in which the body produces ketones to be used as a fuel in response to low glucose availability . As a result of this ketonebodies level may increase in the blood and urine .

During type 1 Diabetes Mellitus, due to the insufficient production of Insulin leads to peripheral glucose resistance, Dehydration and hyper glycemia. Body cells are unable to use glucose for energy due to insulin insufficiency. Lipolysis or fats accumulated in the body tissues and muscles are utilized for energy production. End product of fat metabolism are ketone bodies. Due to increased lipolysis, ketonebodies get accumulated in the blood, which are highly acidic in nature. This increases the acidic nature of blood. This condition of accumulation of ketone bodies in the blood due to Diabetes Mellitus is calling Diabetic ketoacidosis.

B. Clinical manifestations

Mr. Bill Hughes manifests the symptoms such as :

* Confusion

* drowsiness

* tachypnoea

* acetone smell in breath

* Dry and flushed skin

Confusion and drowsiness are may be due to cerebral edema that may affect the brain or and acidosis, that affects brain .

Tachypnoea is indicating hyperventilation. Hyperventilation is a mechanism of body to expell extra Carbon dioxide from the body there by reduces HCO3 in the blood, that is acidic in nature. So that acidosis may decrease.

Ketonebodies involves acetone and aceto acetic acid. So in Diabetic Ketoacidosis, ketnobodies are accumulating in the blood and body. This leads to avetone smell in patient's breathing .

Dry skin is due to Dehydration.

Medical and nursing management

Medical management for Diabetic ketoacidosis can be:

* Insulin therapy : Correction of Hyperglycemia with insulin : After an administration of intravenous fluids to correct dehydration,

Short acting insulin can be infused through IV ( 0.1 U/ kg/ hr.

* Correction of fluid and electrolyte imbalance  loss and maintain acid base balance: Isotonic Sodium chloride solution or balanced electrolyte solution .

10 mEq / hr if hypokalemia is present

* Correction of acid- base balance.

Sodium bicarbonate administration ( if indicated)

Nursing management

* Careful monitoring of blood Glucose level

* Frequent checking of vital signs

* Physical examination to detect other complications of Diabetic ketoacidosis

* Administer Medications as per physician's order

* Provide the patient an environment for adequate rest and sleep

* Reorient the patient if he is having a confusion.

* Teach the patient and family for the home management of type 1 Diabetes.