In this Ihuman Case Study, there is a diagnosis on a patient with suspicion of having Diabetes Mellitus 2. It is categorized as one of the two types of Diabetes that is defined as the body's inability to give adequate response to the body sugar levels thus causing the body to have increased amount.
Below is the Ihuman Case Study on Maria
CC: Maria
Primary Diagnosis:
Diabetes Mellitus type II
Status/Condition:
Guarded
Code Status:
Full
Allergies:
NKDA
Admit to Unit:
Intensive Care
Activity Level:
Up as tolerated with assist
Diet:
Diabetic Diet
IVF:
0.45 NS at 125 ml/hr: Patients should be given intravenous 5% dextrose for acute hypernatremia or half-normal saline (0.45% sodium chloride) for hypernatremia (Kim, 2006). Given that the patient has elevated blood glucose of 566, D5W should be avoided at this time.
Critical Drips:
Regular Insulin IV drip: Carefully monitored continuous insulin infusions produce the greatest stability in blood glucose levels (Lilley & Levine, 2008).
Respiratory:
None at this time, monitor O2 saturations
Medications:
- Regular Insulin IV drip: Begin at 1mg/ml and titrate. Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients (American Diabetes Association, 2016).
- D50 IVP PRN: Give ½ amp D50 for blood glucose70 or less, hold insulin drip and repeat blood glucose check in 15 minutes.
- Potassium Replacement Protocol: IV insulin leads to a dose-dependent decline in serum potassium levels (Li & Vijayan, 2014).
- Atorvastatin 40 mg PO daily. In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age, it is reasonable to use a statin to reduce the LDL-C level by ≥50% (American Heart Association, 2018).
- Miconazole 2% powder: Under bilateral breasts BID.
- Tylenol 650 mg PO PRN for pain
- Zofran 4mg IVP Q6H PRN for nausea
Nursing Orders: vital signs, skin care, toileting, ambulation etc.
- Q1H blood sugar checks
- Notify if there is change in mental status
- Q1H VS: Notify is BP <100, HR >120
- Up as tolerated with assist
- Cleanse folds under the breasts bilaterally with soap and water. Dry well prior to using miconazole powder as prescribed BID.
Follow Up Lab tests:
- BMP: Monitor Na, Creatinine and BUN
- Thyroid function
- Q1H blood glucose levels while on Regular insulin drip
- Lactic acid
Diagnostic testing:
- BMP: to evaluate electrolytes as the patient complains of polyuria and polydipsia
- Elevated serum Na 148
- Elevated blood glucose 566
- Elevated BUN 86
- Elevated Cr 1.5
- Elevated anion gap 30
- CBC WNL: rule out infectious etiology or anemia
- EKG: Sinus Tachycardia, no evidence of ischemia, left ventricle hypertrophy possibly to longstanding HTN – evaluate for cardiac relation to fatigue
- HbA1c: 10.3% - evaluate blood sugar control
- UA: rule out urinary tract infection
- Pale yellow urine
- >800 osmolarity
• +4urine glucose
- Lipid profile: The patient has obesity with poor dietary choices
- Cholesterol 250
- HDL 40
- LDL 165
- Triglycerides 200
Consults:
- Dietician: Assist the patient with dietary modifications with diabetes type 2 diagnosis
- Endocrinology: New diagnosis of diabetes mellitus type 2 and diabetes pharmacological management for discharge.
- Diabetes nurse educator: Assist the patient with medication importance of medication, appointments and blood sugar check compliance as she has had issues with compliance in the past.
- Social work: The patient has lost her medical insurance and needs assistance.
Patient Education and Health Promotion:
- Diet: The patient needs to be educated on the importance of maintaining the diabetic diet after discharge.
- Exercise and weight loss: The patient needs to be educated on the importance of exercise to help her achieve a healthy weight. The patient is morbidly obese at this point and losing weight will help in the prevention of complications of diabetes.
- Foot care: The patient is experiencing neuropathy in her feet. The patient needs to be educated on diabetic foot care to prevent possible complications such as non-healing sores or infection. The patient should be told to seek a podiatrist for routine checkups and nail trimming.
- Medications: Educate the patient on the importance of medication compliance with her new diagnosis.
- Laboratory Studies: Speak with the patient about making sure to have routine ordered blood work done such as A1C to monitor medication compliance and efficiency.
- Checking blood glucose levels at home: Ensure the patient knows how to properly check her blood glucose level at home and to keep a log to bring with her to appointments.
- Smoking cessation: According to the CDC (n.d.) smokers who have diabetes are more likely to have serious health problems, including heart and kidney disease, poor blood flow in the legs and feet that can lead to ulcerations, infections, and possible amputation of toes or feet, retinopathy and peripheral neuropathy.
- Monitor BP at home: The patient has a history of HTN, which is common in patients with diabetes type 2. She should be educated on the importance of keeping track of her BP and keeping it within a healthy range to prevent complications.
Discharge planning and required follow-up care:
- Follow up with PCP within 1 week of discharge
- Follow up with endocrinologist per their recommendations.
- The patient will need to have her HgA1C rechecked in 3 months.
- The patient will need to have follow up lipid profile in 6 weeks. Assess adherence and percentage response to LDL-C-lowering medications and lifestyle changes
- with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed (American Heart Association, 2018).
References(minimum of 3, timely, that prove this plan follows current standard of care).
American Diabetes Association. (2016, January01). 13. Diabetes Care in the Hospital. Retrieved from https://care.diabetesjournals.org/content/39/Supplement_1/S99
American Heart Association. (2018). Cholesterol Management Guide. Retrieved from https://www.heart.org/-/media/files/health-topics/cholesterol/chlstrmngmntgd_181110.pdf
Centers for Disease Controland Prevention. (n.d.).Smoking and Diabetes.Retrieved from https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/pdfs/fs_smoking_diabetes_508.pdf
Kim S. W. (2006).Hypernatemia : successful treatment. Electrolyte& blood pressure: E & BP, 4(2), 66–71. doi:10.5049/EBP.2006.4.2.66
Li, T., & Vijayan,A. (2014, June). Insulin for the treatment of hyperkalemia: A double-edged sword? Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4377764/
Lilley, S. H., & Levine, G. I. (2008, March 01). Management of Hospitalized Patientswith Type 2 Diabetes Mellitus. Retrieved from https://www.aafp.org/afp/2008/0301/p1079.html
