16 Case study of a patient living with diabetes mellitus
Introduction
Chapter 1 gives a brief definition of diabetes and asks you to revise the normal anatomy and physiology of the endocrine system (see Montague et al 2005). How can diabetes affect the body and what happens within the body when a person’s blood sugars become unstable?
Lucy’s problems
Based on your assessment of Lucy, the following problems should form the basis of your care plan:
Lucy’s nursing care plan – acute stage (first hour)
Problem: Due to DKA, Lucy is dehydrated and has electrolyte imbalance.
| Nursing action | Rationale |
|---|---|
| Measure and record urine output hourly Report urine output < 30 mL for 2 consecutive hours Catheterise Lucy Provide catheter care | Lucy may undergo osmotic diuresis and have excessive urine output Measure fluid output accurately Maintain catheter hygiene at all time to prevent infection |
| Administer intravenous therapy as prescribed and ensure that a cannula care plan is in place for this | To prevent infection/complications around the cannula site |
| Assess Lucy for signs of dehydration Assess Lucy’s skin turgor, mucous membranes and complaints of thirst | Testing the skin; dry membranes and thirst are all signs of dehydration |
| Continuous measurement of Lucy’s vital signs during this acute stage of DKA | As Lucy has DKA and is dehydrated, compensatory mechanisms take place that may result in peripheral vasoconstriction which is characterised b a weak thready pulse, hypotension and Lucy may look pale |
| Monitor Lucy’s neurological state Observe and document how awake Lucy is Assess how alert and orientated Lucy is to time and place | Mental status in DKA can be altered due to severe volume depletion and electrolyte imbalance |
| Monitor Lucy’s blood glucose levels every 15 minutes, then hourly as long as the insulin infusion continues Remember to wash Lucy’s hands to remove any contaminants that might alter the results | Glucose levels need to be reduced gradually to prevent the risk of cerebral oedema Intravenous insulin therapy needs to continue until ketoacidosis is resolved |
| Assess Lucy for signs of hypokalaemia, for example muscle weakness, shallow respirations, cramping and confusion | DKA can cause excretion of potassium Insulin therapy results in intracellular movement of potassium resulting in low potassium levels |
| Lucy may have signs of hyperkalaemia Assess Lucy for any weakness or irritability, ECG changes such as tall, peaked T waves, QRS and prolonged PR intervals may suggest this Potassium levels should be kept between 4 and 5 mmol/L | As ketoacidosis resolves, potassium levels can rise quickly causing hyperkalaemia Ensure that the ECG leads are connected correctly and that the pads are not causing discomfort to Lucy’s skin |
| Assess Lucy for signs of metabolic acidosis Lucy may show signs of being drowsy, she may have Kausmaul respirations, confusion and her breath may smell of pear drops | Lucy may have metabolic acidosis due to a build up of ketones in her blood |
| Measure Lucy’s serum ketone levels using a hand-held ketones meter Check ketones 4 hourly | Blood glucose should be checked by a hand-held ketones meter This provides direct results for DKA to be resolved Ketonaemia has to be suppressed |
| Lucy will need intravenous insulin during the acute stage Lucy will require fixed-rate intravenous infusion of insulin calculated on 0.1 units/kg The fixed rate of insulin may have to be adjusted in insulin resistance if the ketone concentration does not fall fast enough | Aim for a reduction of blood ketone concentration by 0.5 mmol/L/hour Insulin has the following effects:  Stay updated, free articles. Join our Telegram channel
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