Background KeeganSugamoto

Patient History 36 YO M 75 Kg

Past Medical History: Type 1 Diabetes diagnosed one year ago

Allergies: No known drug allergies

Medications: 48 units of insulin daily: 12 units of regular insulin plus 20 units of NPH insulin beforebreakfast; 8 units of regular insulin before dinner; and 8 units of NPH insulin at bedtime.

Code Status: Full Code

Social/Family History: Married, lives in an apartment, spouse at bedside

Handoff Report

Situation: The patient is a 36-year-old male who was brought to the ED by paramedics after his wife found him confused and agitated in their apartment. According to his wife, he was diagnosed with Type 1 diabetes mellitus 12 months ago. She stated he has had “the flu” for five days with vomiting and anorexia and stopped taking his insulin two days ago when he was unable to eat. The paramedics started a saline lock in the right forearm and administered 250 mL of 0.9% NS en route to the hospital.

Background: Since his diagnosis, he has been taking 48 units of insulin daily: 12 units of regular insulin plus 20 units of NPH insulin before breakfast; 8 units of regular insulin before dinner; and 8 units of NPH insulin at bedtime. Prior to the “flu” his wife states that he had been doing well. He is currently confused and agitated. He has no known drug allergies.

Assessment:

Vital signs: HR 130, BP 82/46, RR 32 and deep, SpO 2 92% on RA, temperature 38.5 o C

General Appearance: Agitated, appears stated age

Cardiovascular: Sinus Tachycardia

Respiratory: Breath sounds are clear

GI: Bowel sounds normal, abdomen soft

GU: Voiding dark yellow, hazy urine

Extremities: Pink, warm and with adequate turgor; MAEW

Skin: Flushed and dry

Neurological: Confused; Pupils equal, round, reactive to light and accommodation; unable to assess for neurological deficits

IVs: 20-gauge IV to saline lock in the right forearm, patent and non-reddened, 250 mL of 0.9% NS begun in route to hospital

Labs: Lab to be drawn STAT

Fall Risk: High-risk

Pain: Agitated and confused, unable to assess

Recommendations:

Initial Healthcare Provider’s Orders:

Capillary glucose STAT

Urine dipstick for ketones STAT

CBC, Electrolytes, BUN, Creatinine, Glucose, Phosphate, Magnesium, Calcium and Anion Gap STAT

ABG STAT

Urinalysis STAT

Blood Cultures x 2 now

Urine culture and sensitivity now

Portable Chest x-ray STAT

12-lead ECG STAT

Urinary catheter

Continuous SpO 2 monitoring

O2 per nasal cannula at 2 LPM

Maintain SpO 2 greater than 92%

Continuous cardiac monitoring

Vital signs and level of consciousness every one hour

Intake and Output every one hour

Electrolytes, BUN, Creatinine, Glucose and Anion Gap every one hour

IV #1 0.9% NS at rate of 1 L/hour

Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar Syndrome (HHS)

1. Discuss the differences between type 1 diabetes mellitus and type 2 diabetes mellitus.

2. Describe the pathophysiologic changes that occur in DKA. How does the client present?

3. Describe the pathophysiologic changes that occur in HHS. How does the client present?

4. Describe the management of the client in DKA.

5. Describe the management of the client in HHS.

6. What electrolytes are monitored in the acute stage of DKA?

7. What type of blood gas would be expected in the client with DKA or HHS? Include the clinical manifestations.