Assignment: DIABETES MELLITUS
Case Study (Add-On Clinical Case Study)
Simon Cowell Patient.
History of Present Illness:
Simon Chamberlain is a 49 year-old Caucasian male client who had been in good health until about two months ago when he started to feel weak and tired more rapidly than usual. Upon questioning him, he admitted to getting up two or three times a night to urinate. He also is often thirsty at those times and drinks a glass of water each time.
Simon's weight had been average throughout high school, where he had been on the football team. After leaving school, he had gradually gained weight over the years. His appetite remained excellent but he has noticed he is now losing weight and becoming weak.
The pain in his feet was worse at night and sometimes kept him awake. It was burning in character and sometimes his toes felt numb. The tingling and numbness in his fingers was causing him problems at his work as an auto mechanic because he frequently drops small parts or has difficulty making fine manualadjustments to engines.His vision was blurry at times, especially in the afternoon. All other symptoms were negative.
Past History
Appendectomy in 1972. No chronic illnesses. Last dental visit 6 years ago.
Family History
Both parents are deceased. His father died at age 69 from a massive stroke. His mother died at age 62 from end-stage kidney disease. She was found to have diabetes at age 48, and had a course marked by major complications including partial amputation of her right foot. She was on dialysis for three years before her death. Simon was primarily responsible for his mother's care during her later years. He administered her insulin shots twice a day and transported her to and from the dialysis center.
Simon is the youngest of four children and weighed 10 lb 2oz at birth. Both parents were overweight, as are his siblings, two of whom have diabetes.
Social History and Habits
He is married and lives at home with his wife. He has three adult children. He works as an auto mechanic. He does not smoke. He drinks an occasional beer. He takes no medications, nutritional supplements or herbal remedies.
Physical Examination Reveals
NKDA
Wt. 217 lbs., ht. 5' 11" (BMI 30), P 76, regular, BP 142/78
Obese.
Head and neck-mild bleeding of gums reported with tooth brushing. Chest, abdomen and genital examination normal.Feet: skin dry with calluses on the medial side of the big toes. Nails normal.Pulses strong and equal.
Sensation: normal.
Laboratory Tests
Day of Doctor's visit:
Urinalysis: 4+ glucose, negative for ketones and protein. Random blood glucose: 456 mg/dL.
Total cholesterol 243 mg/dL, HDL 20 mg/dL, triglycerides 416 mg/dL.
Glycohemoglobin (HbA1c) 16.4%.
The day after Doctor's visit:
Fasting Blood Sugar: 216 mg/dL
2 hour OGTT - 407 mg/dL
Hospitalization Course:
Simon came in for another doctor's visit with complaints of feeling extremely weak and tired. He also presents with a swollen left leg that is very painful. Upon examination, the nurse noted heat and tenderness to the left lower extremity with 2+ pitting edema. Simon admits to having stubbed his toe three or four days ago but didn't think it was of any concern. When the physician checked his random blood sugar, it was 352 mg/dL. The physician then admitted him to the hospital in the medical surgical floor with the following admitting orders:
Admit to Med-surgical floor: Diagnosis - Left leg cellulitis, DM Type 2
Orders:
Diet 2000cal ADA diet
Activity: BRP
IV Fluids: 1L NS at 75 mL/hr
Accucheck AC & HS
Medication Orders:
Ancef 1 g IVPB every 8 hours
Glyburide 5 mg PO daily
Metformin 500 mg PO BID
Sliding Scale AC & HS Insulin with Regular Humulin insulin as follows:
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BS
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141-170
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3 units
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171-210
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4 units
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211-250
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6 units
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251-290
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8 units
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291-320
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10 units
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321-350
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12 units
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> or equal to 351
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14 units and call MD if recheck is greater or equal to 351
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CASESTUDY Activities
A. Read the Case Study, then analyze the above MD orders and give the rationale for each order.
Order rationale
Diet 2000cal ADA dietto control blood glucose and lose Wight
Activity: BRP
IV Fluids: 1L NS at 75 mL/hr
Accucheck AC & HS
B. Use the Provided Sliding Scale to answer questions for Administration of Insulin
a. If Simon's BS before lunch is 265, how much insulin will you administer based on the sliding scale order? 21
b. If lunch tray comes at 1200, what time will you administer the insulin? 11.45
c. What insulin reaction would you be most concerned about after administering the Regular insulin to Simon?
d. Specify the signs and symptoms of this acute complication?
e. At what time would Simon be at most risk for this adverse reaction?
The next morning, the MD changed Simon's insulin sliding scale order to Insulin lispro.
f. If Simon's BS at 0700 is 208 mg/dL. How much insulin will you administer based on the sliding scale order (Use same sliding scale for Regular insulin and change Regular insulin to Insulin lispro)
g. If breakfast tray comes at 0800, what time will you administer the insulin?
h. At what time would Simon be at risk for s/s/ or hypoglycemia after administration of Insulin Lispro?
1. What oral antidiabetic medication was prescribed for Simon? Discuss their action and nursing implications.
C. Read the Case Study again & answer the following questions.
1. What symptoms is Simon experiencing?
Tingling and numbness, weight gain, polyuria, blurry vision, Pain in lower extremities
2. Which type of Diabetes does the Simon have? 2
3. I. What diagnostic test/s did Simon have initially? Explain what the test are and what it reflects.
Urinalysis: 4+ glucose, negative for ketones and protein.
Random blood glucose: 456 mg/dL.
Total cholesterol 243 mg/dL, HDL 20 mg/dL, triglycerides 416 mg/dL.
II. What diagnostic test did Simon have the next day? For what purpose did the physician order this test? Explain what the test entails and what it reflects.
III. List what diagnostic data provided supports that Simon has Diabetes.
4. On the patient's 3 month follow-up visit, he forgot to bring his blood sugar log but states that his BS levels have been good. To evaluate his blood sugar control in the past, what test will the MD order and why?
5. Discuss the acute and chronic complications of Diabetes Mellitus
Acute Complications: Differentiate Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Nonketotic Syndrome
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DKA
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HHNS
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No insulin
No glucose
Liver breaks down fat
Ketonuria
Dehydration
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Not enough insulin
Cells get minimal glucose
Profound dehydration
Dry mucous membranes
Poor skin turgor
BG> 600
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6. Describe the pathophysiology that leads to the long-term (chronic) complications of diabetes Macrovascular
- Cardiovascular
- Cerebrovascular
- Peripheral Vascular
Microvascular
- Retinopathy
Sudden vision loss, rupture retina blood vessels,
- Nephropathy
Disease because the kidney's filtration mechanism is stressed and thickening in glomerulus
- Neuropathy
Affects the distal portions of the nerves, especially the nerves of the lower extremities (peripheral neuropathy)
7. Diabetes management: BS control through Diet, Exercise, and Medications
a. What is the frequency for monitoring blood sugar levels?
b. How often should Simon monitor his blood sugar and how often you he be seen by his physician?
c. What is Simon's target FBS range and HgbA1C range?
d. What modifications in diet and teaching does Simon need to achieve optimal BS levels?
8. Simon wrote down what he usually eats for dinner.
3 oz lean steak or 2 oz chicken
1 cup milk
1 cup steamed broccoli
1 cup winter squash
3 oz baked potato
1 bowl (2 cups) of ice cream (28 g of CHO per serving)
1 can regular soda (45 g of CHO per serving/can)
A. Count the total CHO in his dinner meal.
B. Now modify Simon's meal to total 60-75 g of CHO (for dinner).
9. Considering the symptoms Simon is experiencing, how will you proceed to teach him about exercise? What exercises are appropriate for Simon?
10. Explain to Simon the patient teaching rules for diabetic home management regarding:
- Sick day rules
- Foot care
- Physician visits
- Prevention of complications.