Physiological Concepts of Critical Care Nursing A Case Study - The Patient with Diabetes

ASSIGNMENTS - 1

Mr. Lawrence Secord, a 23 year old male, was brought to the emergency department of the hospital at 2215 h via ambulance. Larry was found by his landlady, in the hallway of his apartment building. He was in semiconscious state when she found him. Mr. Secord's landlady reported that Larry is known to have Diabetes Mellitus. He usually takes NPH insulin 25 u and Rapid insulin 10 u ac breakfast, Rapid insulin 15 u ac lunch, Rapid insulin 34 u ac supper, and NPH 45 u hs daily. She also states Larry seems to have been unusually stressed lately and she thinks he has not been eating properly, plus she has heard him tell his neighbour he hasnt been taking his usual insulin because his upset stomach prevents him from eating. On admission Larry was semiconscious. His stat blood work revealed the following: pH 7.32 Na K CI 132 mmol/l 6.6 mmol/l 101 mmol/l Blood sugar WBC Hgb Hct Temp. 36.7oC p.o. BP 96/58 Heart rate 140 Respiration 30 Dyspneic 37 mmol/l 32.6 185 .60

PCO2 23.5 PO2 103.8

Bicarb 9.8 Vital signs:

In emergency, Larry had an I.V. started in his left arm. A 1000 cc 0.9% N/S was hung and infused over one hour. Then another 1000 cc 0.9% N/S was hung and infused at 250 cc/hr. A Foley catheter was inserted and put to hourly drainage. Larry's urine tested 2% sugar and large for ketones initially. Larry's foley catheter drained 1200 cc of dilute urine in the following four hours. Larry was transferred to ICU via stretcher with O2 support and I.V. infusing. Regular insulin was given I.V. q4h according to a sliding scale, starting in emergency and continuing in ICU. Blood sugar testing was done q4hr. Larry's ketoacidosis was resolved over the next few days and a further week on a medical floor, saw Larry stabilized on his previous insulin regime.

Physiological Concepts of Critical Care Nursing A

ASSIGNMENTS - 2

a) Based on pathophysiology give reasons for Larry's reported admission symptoms of muscle weakness, decreased skin turgor, tachycardia and hypotension. b) Discuss how this situation can be corrected. (3 marks)

a) Larry experience muscle weakness because of dehydration and hyperkalaemia, as he forgot to take insulin dose potassium shifted from cells to blood and leads to increased plasma potassium level, this causes muscle weakness .Decreased skin turgor is because of dehydration due to polyuria, caused by osmotic diuresis. This is because of the presence of excess glucose in the blood. Due to dehydration, large amount of fluid lost from the body leads to hypovolemic state and cause hypotension. As a result of hypotension heart has to increase its rate to maintain normal cardiac output. This leads to tachycardia. b) The primary goal of treatment is rehydration with isotonic fluids such as (0.9%or 0.45% sodium chloride) for initial two hours and subsequent fluid replacement according to blood pressure of the patient. In case of severe hypotension and hypervolemia bolus of fluid is administered. Hyperkalaemia is corrected by administering insulin and monitor the patients ECG, cardiac status and blood glucose level. 2. Discuss the role of the stress hormones during the stress of his illness. (3 Marks) Stress hormones, because of its hyperglycaemic effect also known as counter regulatory hormones. Different stress hormones which have an effect on glucose metabolism are Acetylcholine, Norepinephrine, Epinephrine, cortisol, Beta-endorphin and Growth hormone. Acetylcholine stimulates both insulin and hepatic glucose production thus increases blood glucose. Norepinephrine and epinephrine enhanced glucose production by decreasing insulin level, glucose utilization and increasing lypolysis and hepatic glucose production. Beta endorphin raise glucose level by decrease insulin while growth hormone did it by reduced

Physiological Concepts of Critical Care Nursing A

ASSIGNMENTS - 3

utilization of glucose. The mechanism by which Cortisol increases blood glucose level is by increase glucose production and lypolysis. 3. What is the effect of Larry's elevated blood sugar on his urine output, urine composition, and fluid/electrolyte balance? Describe the physiologic basis for this, including the excretion of glucose by the kidneys. (4 Marks) Larry experience polyuria, because of hyperglycaemia due diabetic mellitus. Presence of excess glucose increases the osmotic pressure of the urine and causes osmotic diuresis. This leads to excretion of large amount of urine. Urine composition changes due to the presence of glucose, ketone bodies. Electrolytes such as sodium, potassium, and phosphorous can also be seen in the urine due to his disease condition. Glycosuria occurs when blood glucose level exceed the renal threshold. The excess glucose, filtered at the glomeruli, cannot be reabsorbed at the renal tubule and spills in to urine. Ketone bodies is due lipolysis because of severe hyperglycaemia and due to osmotic diuresis ketones appear in the urine. As results of osmotic diuresis, lots of electrolytes excrete through the urine especially sodium, potassium, and phosphorus lead to fluid electrolyte imbalance and patient may experience hypokalaemia, hyponatremia and hypophosphatemia

4.

Larry's admission temperature is 36.7oC p.o and his white blood count is 32.6. (1 mark) What is the most likely cause of this condition? 1. This condition mainly occurs because of stress, dehydration and hypovolemia.

5.

Larry's temperature has increased to 38.0oC. a) What is the mechanism by which fever or infection affect blood sugar? b) How would this affect insulin therapy during the acute stage of his illness and then as he recovers?

Physiological Concepts of Critical Care Nursing A (5 Marks)

ASSIGNMENTS - 4

_a) Larry may experiences hyperglycaemia due to fever and infection; this is because body needs more energy to fight with infection so body releases hormones called counter regulatory hormones such as epinephrine and cortisol and it stimulates liver to produce extra glucose. b)___In initial stage patient needs high dose of insulin because of severe hyperglycaemia ,then as he recovers the need for insulin declines. ______________________________________________________________

6.

Give 4 reasons for altering the dose, route, frequency and type of insulin during Larry's ketoacidosis. (4 marks). _In this scenario it is best to give regular insulin by continuous infusion after an IV bolus has given .The reason for altering the type of insulin is regular insulin is rapid acting and will assist in movement of glucose in to cells. IV method is preferred as it helps in, reducing hyperglycaemia, acidosis and optimise carbohydrate metabolism. The rate is 5-10 units per hour until glucose level decrease. 7. Larry's urine specimen tests large for ketones. On admission his nurse detected his fruity

breath. Explain. (3 marks). When insulin is insufficient to allow glucose in to cells ,cells begin to starve and liver increase its production of glucose .due to cell starvation body break down fat that stored in the adipose tissues of the body. Fatty acids develop rapidly and are converted in to a substance called ketones. Presence of ketones leads to a condition called ketoacidosis .Body attempts to compensate acidosis by depending respiration to blow off excess carbon dioxide.

Physiological Concepts of Critical Care Nursing A

ASSIGNMENTS - 5

This deep sighing respiration is called kussmauls respiration and the expired breath has a fruity odour due to presence of ketones.

8. What patient education would you provide to Larry in terms of recognizing the potential for the development of DKA to decrease his risk of critical care admissions in the future? (2 marks) 1) Contact doctor if vomiting more than once, in case of stomach pain, diarrhoea, trouble breathing. 2) If the blood glucose level is more than 250 mg/dl avoid food and drinks high in carbohydrate and test the urine for ketones. 3) Patient must drink lots of sugar free and caffeine free liquids. 4) Patient should not stop insulin completely even if not taking having foods. 5)Patient should watch their glucose level every 3-4 hour if in case of any sickness.

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