case study help - page 3

by ckirkpa

3,075 Views | 41 Comments

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 though. There is so much going on.... Read More


  1. 0
    I do agree with the insulin drip however
  2. 0
    Quote from laurensummers
    If this patient was dehydrated the Na would NOT be low ..it would be high becsuse of concentration. ..
    and the creatinine would not be as high..not to mention ...skin tenting is indicative in this case of the decrease in hydrostatic capilkary pressure initially in septic shock which causes fluid to shift from interstial space into vasculature as a compensatory mechanism initially until it gets worn out. I have seen this clinical ly in the icu. I pretty sure about this
    But is the Na really that low? Plus, hypovolemic hyponatremia does exist.

    Plus, the high Cr and high BUN are indicative of AKI, most likely resulting from dehydration (secondary to both DKA/HHS and sepsis). No one is denying that there is infection/sepsis, but there is definitely a diabetic emergency at work too...it may be secondary to the sepsis, but treatment of the pt is going to be treating both the sepsis and the diabetic issues.
  3. 0
    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
  4. 0
    The point is the labs dont match what your going for and Shock causes AKI
  5. 0
    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.
  6. 1
    I completely understand that you are studying this in school.....I have been a nurse and educator for 34 years. An argument can be made for both but which needs immediate attention......acidosis, glucose, severs dehydration. The labs do match

    While most shock like states require volume (except certain cardiogenic shock) The question is does Septic shock cause severe dehydration AEB tenting of the skin over the sternum.....lab values aside.....it's all about the patient assessment to complete the picture....does Septic shock cause severe clinical dehydration?

    HHS "starts" at a glucose of 600....550 is good enough for me. A WBC if 17,000 doesn't scream sepsis. Sepsis usually cause the capillarity beds to leak causing edema and anasarca.....not severe dehydration that causes tenting of the skin over the sternum. It's the whole picture that needs to be looked at......everything you are saying is right about partially compensated metabolic acidosis and that the patient as an elevated WBC......We are saying the same thing....I just believe the acidosis is from the glucose induced HHS caused by a raging infection which isn't necessarily SIRS. And you believe the acidosis is from SIRS

    We will have to agree to disagree.
    psu_213 likes this.
  7. 0
    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.
  8. 0
    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
  9. 0
    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.
  10. 0
    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..


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