case study help - page 3

I am currently working on the following case study and need a little guidance on which way to go with the info. Any ideas? I think the patient is possibly septic r/t her leg??? I am not sure... Read More

  1. Visit  Esme12} profile page
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    Quote from laurensummers
    I would hardly say a BGM of 550 is an emergency over the fact that this patient is in SEPTIC SHOCK. ..there is no resson in this stem that would indicate this patient was hypovolemic...and not to mention the K is high but not that high...but the Na is low..135-145 is norm
    There absolutely was evidence given that this patient is dehydrated......Integ:skin dry with tenting present over sternum, lips and oral mucus membranes dry and cracked. Hypotensive with tachycardia.
    BUN 82
    CR 2.3

    pH of 7.30- what does this indicate? Acidosis, right?

    PCO2 47- what does this mean? CO2 is an acid with normal range of 35-45. So you have too much acid which produces an acidotic state.

    HCO3 20- what does this mean? HCO3 is a base with a normal range of 22-26, so you have lost base which also gives you an acidotic state.
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  3. Visit  Esme12} profile page
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    Quote from laurensummers
    There are no ketones in HHS because there is insulin so how can the ACIDOTIC STATE be explained. ..Septic shock-!!!.we cannot say this is HHS without Osmolarity and urine output.
    Anerobic acidosis.....Lactic acidosis
  4. Visit  Esme12} profile page
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    Quote from laurensummers
    The point is the labs dont match what your going for and Shock causes AKI
    HHS most commonly occurs in patients with type 2 DM who have some concomitant illness that leads to reduced fluid intake. Infection is the most common preceding illness, but many other conditions can cause altered mentation, dehydration, or both. Once HHS has developed, it may be difficult to differentiate it from the antecedent illness. The concomitant illness may not be identifiable.

    HHS has also been reported in patients with type 1 DM, in whom DKA is more common.

    HHS usually presents in older patients with type 2 DM and carries a higher mortality than DKA, estimated at approximately 10-20%.

    HHS is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis. Most patients present with severe dehydration and focal or global neurologic deficits.In as many as one third of cases, the clinical features of HHS and DKA overlap and are observed simultaneously (overlap cases); this suggests that these 2 states of uncontrolled DM differ only with respect to the magnitude of dehydration and the severity of acidosis.

    HHS most commonly occurs in patients with type 2 DM who have some concomitant illness that leads to reduced fluid intake. Infection is the most common preceding illness, but many other conditions can cause altered mentation, dehydration, or both. Once HHS has developed, it may be difficult to differentiate it from the antecedent illness. The concomitant illness may not be identifiable.

    HHS has also been reported in patients with type 1 DM, in whom DKA is more common.

    HHS usually presents in older patients with type 2 DM and carries a higher mortality than DKA, estimated at approximately 10-20%.

    HHS is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis. Most patients present with severe dehydration and focal or global neurologic deficits.In as many as one third of cases, the clinical features of HHS and DKA overlap and are observed simultaneously (overlap cases); this suggests that these 2 states of uncontrolled DM differ only with respect to the magnitude of dehydration and the severity of acidosis.
  5. Visit  MendedHeart} profile page
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    Yea I believe so..just because you been a nurse for so many years really doesnt mean you know everything..open any text book..this case matches Septic shock to capital T. At every hospital the sepsis and SIRs screening criteria is the SAME..and this matched..not to mention I explained the tenting as septic shock begins the capillary hydrostatic pressure drops resulting in fluid shift from interstial space to vesseks to compensate. .it is hypoperfusion..then when it gets to the progressive stage it reverses and the capillary pressure changes and vessels get LEAKY..please look this up because sometimes one myst humble themselves..
  6. Visit  MendedHeart} profile page
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    Lactic acidosis from shock. .yes
  7. Visit  Esme12} profile page
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    Quote from laurensummers
    There are no ketones in HHS because there is insulin so how can the ACIDOTIC STATE be explained. ..Septic shock-!!!.we cannot say this is HHS without Osmolarity and urine output.
    Sepsis or septic shock is systemic inflammatory response syndrome (SIRS) secondary to a documented infection. Detrimental host responses to infection occupy a continuum that ranges from sepsis to severe sepsis to septic shock and multiple organ dysfunction syndrome (MODS). The specific clinical features depend on where the patient falls on that continuum.

    Symptoms of sepsis are often nonspecific and include fever, chills, rigors, fatigue, malaise, nausea, vomiting, difficulty breathing, anxiety, or confusion. These symptoms are not pathognomonic for sepsis syndromes and may be present in a wide variety of other conditions. Alternatively, typical symptoms of systemic inflammation may be absent in severe sepsis, especially in elderly individuals.

    Fever is a common symptom of sepsis.

    Chills are a secondary symptom associated with fever, which is a consequence of increased muscular activity that produces heat and raises the body temperature. Sweating occurs when the hypothalamus returns to its normal set point and senses the higher body temperature, stimulating perspiration to evaporate excess body heat.


    Alteration in mental function often occurs. Mild disorientation or confusion is especially common in elderly individuals. Apprehension, anxiety, agitation, and, eventually, coma are manifestations of severe sepsis. The exact cause of metabolic encephalopathy is not known; alteration in amino acid metabolism may play a role.


    Hyperventilation with respiratory alkalosis (this patient has respiratory acidosis) is a common feature of patients with sepsis secondary to stimulation of the medullary respiratory center by endotoxins and other inflammatory mediators.


    This patient is afebrile.
  8. Visit  Esme12} profile page
    1
    Quote from laurensummers
    Yea I believe so..just because you been a nurse for so many years really doesn't mean you know everything..open any text book..this case matches Septic shock to capital T. At every hospital the sepsis and SIRs screening criteria is the SAME..and this matched..not to mention I explained the tenting as septic shock begins the capillary hydrostatic pressure drops resulting in fluid shift from interstitial space to vessels to compensate. .it is hypo-perfusion..then when it gets to the progressive stage it reverses and the capillary pressure changes and vessels get LEAKY..please look this up because sometimes one must humble themselves..
    I have no argument with you....I just disagree.

    I have looked this up and I have no need to do so now.

    I agree sometimes one must humble oneself.

    I wish you all the best
    psu_213 likes this.
  9. Visit  psu_213} profile page
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    Quote from laurensummers
    I would hardly say a BGM of 550 is an emergency over the fact that this patient is in SEPTIC SHOCK.
    I am saying that they both need to be treated. Yes, I agree with septic shock, but there is a degree of hypovolemic shock RT osmotic diuresis.
  10. Visit  MendedHeart} profile page
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    I just do not see any data that states the patient is hypovolemic...sepsis is not always presented with fever...it can be high or low..surely a CVP OR PAWP would be great right about now lol
  11. Visit  psu_213} profile page
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    Quote from laurensummers
    Yea I believe so..just because you been a nurse for so many years really doesnt mean you know everything..
    Was that really called for? Though we were having a pretty intelligent conversation about the case, but it seems to have devolved.

    Yes, the meets checklist items for many aspects of septic shock. However, it certainly appears that there are diabetic issues here to (Esme says HHS, but I think we still need to consider DKA--and we cannot know until we get a UA back, possibly a serum acetone level and serum osmo). You seem to be digging your heels in that this is sepsis and only sepsis. Perhaps the HHS/DKA is secondary to severe infection, but that does not mean that we just treat the sepsis any nothing else.
    Esme12 likes this.
  12. Visit  psu_213} profile page
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    Quote from laurensummers
    Lactic acidosis from shock. .yes
    We know the pt is somewhat acidotic (although I've seen much worse), but there is no evidence that this is (just) a lactic acidosis. Certainly an elevated lactate level would point toward shock, but even that is quite nonspecific.
    Esme12 likes this.
  13. Visit  MendedHeart} profile page
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    I wasnt trying to be rude..but this person is resistant to any FACTS im offering...I truely do not think this sitiation was caused by DM... look at the data..if the patient had poirly controlled DM they would be on SQ insulin..this pt is only on metformin...not saying the is no fluid deficit maybe mild but the The first part if stem clearly shows the pneumonia is the beginning of all the subsequent problems..really. .as they teach in school..the underlying problem must be fixed and treat symptoms I.e. insulin etc...
    Last edit by MendedHeart on Mar 20, '13
  14. Visit  MendedHeart} profile page
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    PaO2=70=anareobic metabolism=lactic acid


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