16 Case study of a patient living with diabetes mellitus
Introduction
This chapter provides you with an example of the nursing care that a patient with type 1 diabetes might require. The case study has been written by a diabetes nurse specialist and provides you with a patient profile to enable you to understand the context of the patient. The case study aims to guide you through the assessment, nursing action and evaluation of a patient with type 1 diabetes together with the rationale for care.
Being in this community of practice has also enlightened me about diabetes as we come across many patients with diabetes. I have since learnt different ways of diabetes management. I can also give advice to patients suffering from diabetes bearing in mind that this is evidence based.
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?
The following paper outlines the latest guidelines for the care of patients with diabetic ketoacidosis (DKA). It would be useful to read these guidelines before you read the case study:
Joint British Diabetes Societies Inpatient Care Group (2010). The management of diabetic ketoacidosis in adults. NHS Diabetes, London. Online. Available at: http://www.bsped.org.uk/professional/guidelines/docs/DKAManagementOfDKAinAdultsMarch20101.pdf (accessed July 2011)
Patient profile
Lucy is an 18-year-old university student in her first year and is living in student accommodation. Lucy has had type 1 diabetes since the age of 13. Her parents are very supportive but naturally worried about her leaving home.
Lucy had a take-away chicken meal 2 days ago and since then she has been vomiting and has diarrhoea. She stopped taking her insulin as she is not eating. She has been admitted with DKA.
Assessment on admission
Lucy is apyrexial and has not vomited for 6 hours. Her vital signs are: pulse 96 beats per minute, blood pressure 130/80 mmHg, respiratory rate slightly raised at 18 per minute. Due to her diarrhoea and vomiting, she is dehydrated. Ketones are + 2 on a standard urine stick, her blood glucose is 16 mmol/L and her venous pH is 7.2.
See Appendix 4 in Holland et al (2008) for possible questions to consider during the assessment stage of care planning.
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)
The most important therapeutic intervention for DKA in the acute stage is appropriate fluid replacement followed by insulin administration.
Problem: Due to DKA, Lucy is dehydrated and has electrolyte imbalance.
Goal: Lucy will maintain urine output > 30 mL hour. Lucy will have elastic skin turgor and moist, pink mucous membranes.
| Nursing action | Rationale |
|---|---|
| Measure and record urine output hourlyReport urine output < 30 mL for 2 consecutive hoursCatheterise LucyProvide catheter care | Lucy may undergo osmotic diuresis and have excessive urine outputMeasure fluid output accuratelyMaintain 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 dehydrationAssess 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 stateObserve and document how awake Lucy isAssess 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 continuesRemember 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 oedemaIntravenous 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 potassiumInsulin therapy results in intracellular movement of potassium resulting in low potassium levels |
| Lucy may have signs of hyperkalaemiaAssess Lucy for any weakness or irritability, ECG changes such as tall, peaked T waves, QRS and prolonged PR intervals may suggest thisPotassium levels should be kept between 4 and 5 mmol/L | As ketoacidosis resolves, potassium levels can rise quickly causing hyperkalaemiaEnsure 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 acidosisLucy 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 meterCheck ketones 4 hourly | Blood glucose should be checked by a hand-held ketones meterThis provides direct results for DKA to be resolvedKetonaemia has to be suppressed |
| Lucy will need intravenous insulin during the acute stageLucy will require fixed-rate intravenous infusion of insulin calculated on 0.1 units/kgThe 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/hourInsulin has the following effects:
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