Diabetes Mellitus Type II is a condition that is associated with the body's lack of producing enough Insulin or may reject the insulin in the body. This is an Ihuman case study on a patient diagnosed with Type 2 Diabetes.
Primary Diagnosis: Uncontrolled diabetes mellitus, type II
Status/Condition: Guarded
Code Status: Full
Allergies: NKA
Admit to Unit: ICU for IV insulin gtt
Activity Level: Up as tolerated
Diet: Diabetic diet
IVF (if ordered, include type and rate ): 0.45%NS at 125mL/hr may be required due to the goal of water repletion in this patient with her sodium level at 148. It is likely that she is chronically hypernatremic and requires slower repletion in order to avoid development of cerebral edema (Sterns & Hoorn, 2018). D5W is another choice that may be considered, but considering the patient’s high glucose level, it is not advised.
The patient also has a high anion gap in which lactic acidosis is likely the cause. We may need to push fluids in order to correct her likely hypovolemic state.
Critical Drips (If ordered, include type and rate. Do not defer to ICU Protocol):
IV regular insulin gtt, start at 1 unit per hour, titrate to hold blood sugar between140 to 180. Requires regular checks to maintain tight control(McCulloch & Inzucchi, 2018).
Respiratory:
Oxygen therapy protocol as needed, monitor for any drops in O2 sat
Medications: (include ALL, tx of primary condition, underlying conditions, pain, comfort needs etc. dose and route)
IV regular insulin gtt 1mL/hr
Miconazole 2% powder under bilateral breasts BID (Brodell & Dolohanty, 2018).
Nursing Orders: Vital signs, skin care, toileting, ambulation etc.
POCT Q30 min blood sugars while sugar is>200 or <100,once stable, Q1hrTitrate insulin gtt to maxof 5mL/hr to keep sugar between 140-180
Q2VS
Cleanse under breast folds with mild soap/water. Dry well. Place miconazole powder. Up as tolerated
Notify of any mental status changes
Follow Up Lab tests :
Lactic acid (check for lactic acidosis), repeat again if high to ensure goes down Blood glucose levels
Check thyroid function
Recheck BMP to ensure levels are improving
Diagnostic testing(CXR, US, 2D Echo, etc…) Include indication for test, for example CXR to evaluate pneumonia):
BMP revealed: Hypernatremia, elevated BUN to Cr ratio (57)
- Elevated serum Na 148
- Elevated blood glucose 566
- Elevated BUN 86
- Elevated Cr 1.5
- Elevated anion gap 30CBC WNL
EKG revealed: S T, no evidence of ischemia, left ventricle hypertrophy
HbA1c: Elevated at 10.3% UA revealed:
- Very pale yellow urine
- >800 osmolarity
- +4 urine glucose Lipid profile revealed:
- Cholesterol 250
- HDL 40
- LDL 165
- Triglycerides 200
Free water deficit = 0.5 x101 / (148/140) -1 = 2.9L
Consults:
Diabetes nurse educator Nutritionist to recommend diets
Social work to help with resources as the patient has no medical insurance
Patient Education and Health Promotion (address age appropriate patient education if applicable):
Education for this patient should focus on what new medications are prescribed to her. With her Hba1c at 10.3%, we should be starting her on medication to help her achieve good glycemic control. As the patient does not have health insurance, it is especially vital to stress to her the importance of good glycemic control as it puts her at risk for many other comorbidities as well as symptoms of poor glycemic control, such as diabetic neuropathy, retinopathy, etc.
Education should also focus on nonpharmacological ways to improve her condition, such as losing weight, exercise, and proper nutrition. We should have the nutritionist guide the patient in which foods to avoid, which foods are great, and what type of diet they should try to remain on.
We should educate the patient about checking her feet on a daily basis also to avoid any infection.
Discharge planning and required follow-up care:
Discharge is anticipated within 2-3 days, once her blood sugar is maintaining between 100-140 with use of only subcutaneous insulin. Follow up care should always follow one week later with her primary care physician, but should also be conducted within 3 months to re-evaluate her Hba1c to ensure it is decreasing and that she is comfortable.
References (minimum of 3, timely references, that prove this plan follows current standard of care).
Brodell, R. T., & Dolohanty, L. B. (2018). Intertrigo. https://www.uptodate.com/contents/intertrigo?search=candida
%20intertrigo&source=search_result&selectedTitle=1~8&usage_type=default&display_rank=1# H332809297
McCulloch, D. K., & Inzucchi, S. E. (2018). Management of diabetes mellitus in hospitalized patients. Retrieved from https://www.uptodate.com/contents/management-of-diabetes-mellitus- in-hospitalized-patients?search=insulin
%20drip&source=search_result&selectedTitle=1~126&usage_type=default&display_rank=1#H4
Sterns, R. H., & Hoorn, E. J. (2018).Treatment of hypernatremia in adults. Retrievedfrom https://www.uptodate.com/contents/treatment-of-hypernatremia-in-adults#H2255537440
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