Question

endocrine case study 3 CJ

You are working in an outpatient clinic when a mother brings in her 20-year-old daughter, C.J., who has type 1 diabetes mellitus (DM) and has just returned from a trip to Mexico. She has had a 3-day fever and diarrhea with nausea and vomiting. She has been unable to eat and has tolerated only sips of fluid. Because she was unable to eat, she did not take her insulin as directed. You note C.J. is unsteady, so you take her to the examining room in a wheelchair. While helping her onto the examination table, you note her skin is warm and flushed. Her respirations are deep and rapid, and her breath is fruity and sweet smelling. C.J. is drowsy and unable to answer your questions. Her mother states, “She kept telling me she’s so thirsty, but she can’t keep anything down.”
C.J.’s mother tells you the following:
“Blood glucose monitor has been reading ‘high.’”
“C.J. has had sips of ginger ale, but that’s all.”
“She has been vomiting about every other time she drinks.”
“When she first got home, she went [voided] a lot, but yesterday she hardly went at all, and I don’t think she has gone today.”
“She went to bed early last night, and I could hardly wake her up this morning. That’s why I brought her in.”

Vital Signs
Blood pressure
90/50 mm Hg
Heart rate
124 beats/min
Respiratory rate
36 and deep
Temperature
101.3° F (38.5° C) (tympanic)

Laboratory Test Values
Glucose
677 mg/dL (37.6 mmol/L)
Potassium
6.3 mEq/L (6.3 mmol/L)

Interpret C.J.’s VS and laboratory results, relating them to the pathophysiology.
After assessing C.J., the ED resident on call writes the following orders. please Review each order and Indicate which of these orders are appropriate, also indicate corrections for those which are inappropriate.

____ 1000 mL lactated Ringer’s IV stat
____ 36 units NPH and 20 units regular insulin subQ now
____ CBC with differential; CMP; blood cultures × 2 sites; clean-catch urine for UA and C&S; stool for ova and parasites, Clostridium difficile toxin, and C&S; serum lactate, ketone, and osmolality; ABGs on room air
____ 1800-calorie, carbohydrate-controlled diet
____ Bed rest
____Acetaminophen 650 mg rectal suppository                      q4h as needed
____Furosemide 60 mg IV push now
____Urinary output every hour
____VS every shift

All orders have been corrected and therapies started. C.J. receives fluid resuscitation and sliding-scale insulin drip via infusion pump. After several hours, her latest laboratory findings are as shown in the chart.

Laboratory Test Results
Na
149 meq/L (149 mmol/L)
K
3.0 meq/L (3.0 mmol/L)
Cl
119 meq/L (119 mmol/L)
Total CO₂
21 meq/L (21 mmol/L)
BUN
12 mg/dL (4.28 mmol/L)
Creatinine
1.2 mg/dL (106 mcmol/L)
Glucose
307 mg/dL (17 mmol/L)

The attending changes the insulin drip infusion, decreasing it from 6 units to 4 units per hour. Is it acceptable for the nurse to make this change alone, or should it be verified by another nurse? please Explain answer.

Answer 1

patient's vital signs indicate she is having hypotension, tachycardia, tachypnea, and fever. patient
respiration deeper and severe. patient's diabetic level is uncontrolled and it is too high, the potassium level is high. the patient is suffering from diabetic ketoacidosis that occurs when the plasma glucose level is high. it is a fatal metabolic complication due to uncontrolled diabetes. it causes ketonemia, high glucose levels, and metabolic acidosis. when there is insulin define, increased insulin overload due to high intake or increased concentration of counter-regulatory hormones like cortisol, glucagon, catecholamines, and growth hormone. when there is peripheral insulin resistance that causes dehydration, ketosis, electrolyte imbalance, and hyperglycemia.
The infusion of RL solution 1000ml stat increase the glucose and could exacerbate the hyperglycemia in the diabetic ketoacidosis.it must be replaced with NS 0.9% administration to restore the extracellular fluid volume.
The patient should receive regular insulin 0.1unit per kg per hour until the blood glucose is normal. consider reducing NPH less.
CBC differential finds out the patient WBC count in diabetic ketoacidosis there is a chance for high WBC count.
comprehensive metabolic panel(CMP) finds the patient metabolic complications due to uncontrolled diabetes.
Blood culture help to find the infection in the infection.
patient need urine analysis and culture and sensitivity. a urine sample is usually collected using the clean catch method for the sterile procedure.
stool for ova and parasites for diabetic patients influence diabetic complications and intestinal parasitosis. high frequency of parasites can be present in Type 2 diabetes.
the patient needs Clostridium difficile toxin and culture and sensitivity to find the type of infection because a patient with uncontrolled diabetes develops with c.diffcicle infection.
serum lactate is an important diagnosis to find lactate acidosis due to inadequate tissue perfusion and oxygenation, metabolic derangements in diabetic ketoacidosis due to high lactate level.
the patient blood sugar level is high, there will be a high level of ketones in the blood.
osmolality will be high in diabetic ketoacidosis.
it is important to obtain ABG check-in room air, it usually shows metabolic acidosis, low bicarbonate, and low ph in diabetic ketoacidosis.
patient need not more than 1800calosirs each day.
A low carbohydrate diet improves glycemic control, but a low carbohydrate level can increase the risk of ketoacidosis.
the patient needs strict bed rest
oral or suppository for the diabetic ketoacidosis patient reduce the fever.
avoid furosemide 60mg IV push in diabetic ketoacidosis patients to prevent hypovolemia.
regular monitoring of patient urine output is important because the patient will be hemodynamically unstable.
Vital signs measurement for the patient is important to find the tachycardia, hypotension, tahcypena and hypothemria.