Type II Diabetes Mellitus Group Case Study
By: Dusty Evernden, Natalie Keiller, Tiffany Sefton, & Lacy Stone
- Measure and record intake & output
- Weigh patient at same time each day
- Document characteristics of current ulcers to provide a baseline
- Implement prone positioning 3x/day for 30 minutes
- Maintain aseptic technique with sterile dressing changes
- Culture and sensitivity labs before beginning abx therapy
- Monitor temperature and WBC count
- Excess fluid volume r/t decreased renal function
- Impaired skin integrity r/t impaired physical mobility
- Infection r/t impaired primary defenses
- Ineffective peripheral tissue perfusion r/t decreased arterial blood flow
- Initial interview
and assessment (ABCDE)
- Vital signs
- Assess A&O's concurrently
- RBCs 3.1 (4.3-5.7)
- Hgb 8.5 (13.2-17.3)
- Hct 26% (39-50%)
- WBCs 15,500 (4,000-11,000)
- pH 7.2 (7.35-7.45)
- PaCO2 53 (35-45)
- HCO3- 10 (22-26)
- K+ 7.3 (3.5-5.0)
- Cl- 110 (96-106)
- Mg 1.3 (2.4-4.4)
- CO2 10 (23-30)
- PO4 12 (2.4-4.4)
- Glucose 586 (<200)
- HgbA1C 10.4% (<6.5)
- BUN 194 (6-20)
- Creatinine 3.6 (0.6-1.3)
Potential MI?
- O2 via nasal cannula (2L/min)
- Cardiac monitor/EKG
- 18 gauge IV
- Send for labs & cultures
- Report to MD within 5 minutes (sinus tachy)
- 5-minute head-to-toe assessment
- ABG
- CXR
Natalie Keiller, RN, BSN, CCRN
ICU Nurse
Tiffany Sefton, RN, BSN
ED Nurse
A Night in the ED
- Defect in insulin production leads to insulin resistance & inadequate secretion to compensate
- Clinical Manifestations include:
- 3 P's (polydipsia, polyuria, polyphagia)
- Fatigue
- Malaise
- Increased frequency of infections
- Slow onset (months)
- Usually asymptomatic 1st 5-10 years
- Visual disturbances
- Weight gain
- Patient arrived via ambulance from his home
- C/O:
- Chest pain
- Nausea
- Weakness
- SOBOE
Pathophysiology
- Medication Reconciliation
- Case Management
- Referrals
- Patient Teaching
Meet Jose Guiterrez
- Hyperkalemia
- Possible sepsis
- Respiratory distress
- Renal failure
Give Report
Accompany patient during transfer
- 41 y/o Hispanic male
- Married to Rosa and has 2 school-aged children (Cristina age 9 & Antonio age 13)
- On permanent disability
- Wife works small paying job with health insurance
- Family lives in the area
Long Term Complications
- DKA (mostly type I; sometimes type II)
- HHS (type II) (BG >600 mg/dL)
- Angiopathy
- Cerebrovascular disease
- Coronary artery disease
- Delayed gastric emptying
- Hypertension
- Infections
- Nephropathy
- Neuropathy
- Retinopathy, cataracts, glaucoma
Medications & Treatment Options
Diagnostics
“…the nurse case manager coordinates the clinical care of the patient across care settings, from admission through discharge from the hospital, through other community agencies as needed, and back home in an effort to achieve optimal outcomes”
- Social Work
- Financial Counselor
- Physical Therapy
- Occupational Therapy
- Registered Dietician
- Pastoral Care
- Assess the home for hazards. Make a plan for addressing hazards & re-evaluate same.
- What are the patient’s expectations for treatment?
- What are barriers as identified by pt to effectively managing his therapeutic regimenl; address same.
- Medication Education
- Plan of action for managing side effects
- Set-up goals with patient both short-term and long-term.
- Home health aide to visit 3X week to relieve spouse
- Set up schedule for future visits.
- Set up telephone coaching schedule with pt
- Bilateral lower extremity prosthetics
- RT-CGM
- Telephone coaching with CDE to improve diabetic self-management.
- New medication regimen (diuretics, aspirin, new oral antihyperglycemic, antidepressants, d/c metformin, lisinopril, nisoldipine)
- Psychotherapy
- CRRT --- > hemodialysis --- > renal transplantation?
- TENS unit, other nonpharm pain control measures
- 2 or more test results with 2 or more abnormal values
- Fasting blood glucose >126 mg/dL (normal is <100)
- Oral glucose tolerance test (GTT): 2-hr values >200 mg/dL
- Random glucose >200 mg/dL + Sx (3P's)
- HgbA1c is high (good control in DM is <6.5%). Used to check control, not for Dx.
Lacy Stone, RN, BSN, CNS
Case Manager
Dusty Evernden, RN, BSN, CDE
Home Health Nurse
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- Joslin Diabetes Center. (2010). Continuous glucose monitoring system. Retrieved from www.joslin.org
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- Lewis, S.L., Schumacher, L., Howard, V., & Weberg, D. (2011). Nursing Management: Diabetes Mellitus, Medical-Surgical Nursing, with media. (8th ed.). St. Louis, MO: Mosby-Elsevier
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- MacLean, L., White, J., Broughton, S., Robinson, J., Shultz, J., Weeks, D., & Wilson, M. (2012). Telephone coaching to improve diabetes self-management for rural residents. Clinical Diabetes, 30(1), 13-16.
- National Limb Loss Information Center. (2006). Pain management and the amputee. Retrieved from http://www.amputee-coalition.org/fact_sheets/painmgmt.html
- Pagana, K. D., & Pagana, T. J. (2010). Mosby’s manual of diagnostic and laboratory tests. St. Louis, MO: Mosby
- Ralph, S. S., & Taylor, C. M. (2014). Sparks & Taylor’s nursing diagnosis reference manual. Philadelphia, PA: Lippincott Williams & Wilkins. Retrieved from http://online.statref.com.ezproxy.baylor.edu/Document/Document.aspx?docAddress=wm2i1FmNWpU5ig0Y2CAapg%3d%3d&offset=7&SessionId=1339423CHLIJLGLQ
- Return to re-evaluate safety of home.
- Re-evaluate effectiveness of new medication regimen.
- Meet with paternal & maternal grandparents and set-up a childcare schedule so JG and wife can have time to themselves, meet with pastor in order to seek counseling.
- Meet with pastor and set-up schedule for weekly visits with J.G. and his wife.
- Pastor has arranged for transportation to pick up the G family every week for church in a handicap accessible van with wheel-chair lift.
- Referring patient to home health
- Acquiring medical equipment
- Ensuring continuity of care