Describethepathophysiologythatleadsto thelong-term(chronic)complicationsofdiabetes
Macrovascular Cardiovascular
DIABETES MELLITUS Case Study (Add-On Clinical Case Study)
DIABETES MELLITUS Case Study (Add-On Clinical Case Study)
Simon Cowell Patient #: 1234567History 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 HistoryAppendectomy in 1972. No chronic illnesses. Last dental visit 6 years ago.Family HistoryBoth 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 HabitsHe 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 RevealsNKDAWt. 217 lbs., ht. 5′ 11″ (BMI 30), P 76, regular, BP 142/78Obese.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 TestsDay 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/dL2 hour OGTT – 407 mg/dLHospitalization 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 2Orders:Diet 2000cal ADA dietActivity: BRPIV Fluids: 1L NS at 75 mL/hrAccucheck AC & HSMedication Orders:Ancef 1 g IVPB every 8 hoursGlyburide 5 mg PO daily Metformin 500 mg PO BIDSliding Scale AC & HS Insulin with Regular Humulin insulin as follows:BS 141-170 3 units 171-210 4 units 211-250 6 units 251-290 8 units 291-320 10 units 321-350 12 units > or equal to 351 14 units and call MD if recheck is greater or equal to 351CASESTUDY 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 AdministrationofInsulin
a.IfSimon’sBSbeforelunchis265,how muchinsulin willyouadministerbasedonthe slidingscaleorder?21
b. Iflunchtraycomesat1200, what timewillyouadministertheinsulin?11.45
c. WhatinsulinreactionwouldyoubemostconcernedaboutafteradministeringtheRegularinsulintoSimon?
d. Specifythesignsandsymptomsofthisacutecomplication?
e.AtwhattimewouldSimonbeatmostriskforthisadversereaction?
Thenextmorning,theMDchangedSimon’sinsulinslidingscale orderto Insulinlispro.
f. IfSimon’sBSat0700is208mg/dL.Howmuchinsulin willyouadministerbasedon theslidingscaleorder(UsesameslidingscaleforRegularinsulinandchangeRegular insulinto Insulinlispro) 7 unitg.Ifbreakfasttraycomesat0800,whattimewillyouadministertheinsulin?
h. AtwhattimewouldSimonbeatriskfors/s/orhypoglycemiaafteradministrationofInsulinLispro?
1. Whatoral antidiabeticmedicationwasprescribedfor Simon?Discusstheir action andnursing implications.
C.ReadtheCaseStudyagain &answerthefollowingquestions.
1. Whatsymptomsis Simonexperiencing?
Tingling and numbness, weight gain, polyuria, blurry vision,
Pain in lower extremities
2.WhichtypeofDiabetesdoestheSimonhave?2
3. I. Whatdiagnostictest/sdid Simonhaveinitially?Explainwhatthetestare and whatit 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.Whatdiagnostictestdid Simonhavethenextday?Forwhatpurposedidthephysician orderthistest?Explainwhatthetestentailsandwhatitreflects.
III.Listwhat diagnosticdataprovided supportsthatSimonhasDiabetes.
4.Onthepatient’s3monthfollow-upvisit,heforgotto bringhisbloodsugarlogbutstates thathisBSlevelshavebeengood.Toevaluatehisbloodsugarcontrolin thepast,what testwilltheMDorderandwhy?
5. DiscusstheacuteandchroniccomplicationsofDiabetesMellitus
AcuteComplications:DifferentiateDiabeticKetoacidosisandHyperosmolarHyperglycemicNonketoticSyndrome
DKA HHNS No insulin No glucoseLiver breaks down fat KetonuriaDehydration
Not enough insulinCells get minimal glucoseProfound dehydrationDry mucous membranesPoor skin turgorBG> 600
6. Describethepathophysiologythatleadsto thelong-term(chronic)complicationsofdiabetes
Macrovascular Cardiovascular
Cerebrovascular
PeripheralVascular
Microvascular Retinopathy
Sudden vision loss, rupture retina blood vessels,
NephropathyDisease because the kidney’s filtration mechanism is stressed and thickening in glomerulus
NeuropathyAffects the distal portions of the nerves, especially the nerves of the lower extremities (peripheral neuropathy)
7. Diabetes management:BScontrolthroughDiet,Exercise,andMedications a. Whatisthefrequencyformonitoringbloodsugarlevels?
b. HowoftenshouldSimonmonitorhisbloodsugarandhowoftenyouhebeseenbyhis physician?
c. WhatisSimon’stargetFBSrange andHgbA1Crange?
d. What modifications in diet and teaching does Simon need to achieve optimal BSlevels?
8. Simon wrote down what he usually eats for dinner.
3 oz lean steak or 2 oz chicken1 cup milk1 cup steamed broccoli1 cup winter squash3 oz baked potato1 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
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