Question

Theme – Endocrine Disorder

Patient profile

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

Q 8. Choose three medications that would be used in the treatment of Mr Hughes, outline the indication for use, mechanism of action, administration method, and nursing care required for each of these medications.                                            (150-word limit)

Answer 1

From the history, we know that bill is a known case of type 1 diabetes and has been on treatment with insulin. He had history of flu like symptoms since one week and right now since dinner he has been showing altered behaviour.

On physical examinationa and workup, he has tachypnea his BP is on the lower side, skin is dry and his blood sugars are high, any shows metabolic acidosis, hba1c reveals inadequate recent control of blood sugars and his urine has tested positive for ketone bodies.

Bill's clinical condition is diabetic keto-acidosis which is characterized by a triad of ketonemia, hyperglycemia and metabolic acidosis. These patients will be severely dehydrated often with a fluid deficit if 6 to 9 liters.

In Bill's case, he had an infection the week before which has increased the counterregulatory hormones like adrenalin, cortisol etc. These create a state of insulin resistance by acting against the action of insulin. Because of inadequate insulin action, blood sugar levels increase and increase the blood osmolality. This drives the intracellular fluid outwards to maintain osmolality. The sugar and water is then passed through urine. Electrolytes are also lost this way, mainly potassium.

the issues here are 1. Hyperglycemia 2. Dehydration 3. Dyselectrolytemia.

Treatment:

1. IV fluids: Usually NS. Ringers is also used

Indication: dehydration

The aim is to expand intravascular and extravascular volume.

Initially 15 to 20 ml/ kg is instituted in the first hour. The rate is halved over the next 4 hours.

Further fluid resuscitation is guided by fluid status, urine output and electrolyte levels.

Fluid overload should be avoided. This can lead to complications like cerebral edema which carries high mortality rates.

2. Insulin therapy

Indication: hyperglycemia and ketosis

Mechanism: It helps the body to utilise the abundant blood sugar and drive it intracellularly so that the blood glucose levels come to physiological range.

Fixed continuous infusion is usually started at rate of 0.1 unit per kg per hour. The aim is to bring blood glucose down by 50mg per hour.

Hypokalemia should be managed before insulin administration as insulin will further drive the potassium into cells which can cause life threatening hypokalemia.

3. Once, blood sugars reach 250mg/DL, dextrose should be added alongside insulin to clear ketosis as well.

4. Electrolyte corrections especially potassium if required.

5. Bicarbonate in case pH less than 7.0 as a temporary protective measure against acidosis