Appropriate order for diabetic + COPD + pneumonia?

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KatePasa

KatePasa

128 Posts

He's on IV antibiotics, IV corticosteroids. Yes, of course, he has IV fluids to go along with that. Sorry, thought that was a no brainer. He's also dehydrated. Nursing intervention for encouraging fluids would be offering fluids q offering a glass of water or ice chips whenever you walk in the the room really...which is a good intervention no matter if you've been a nurse for 30 years or not quite graduated nursing school. At any rate, with a dehydrated patient, offering fluids not only helps get it into them it helps you assess what they've already taken in...to the end of keeping a good I&O with regard to your fluid balance. Not all problems are solved with an IV.

He's type 2 diabetic so, I'm wondering if he might go into HHNS. I'm going to have to go look at the labs again because I think the Na and K were borderline high. So maybe that is the direction we are heading in. We have an hour for this sim so, a lot can go on!

KatePasa

KatePasa

128 Posts

He's type 2 and managed on combo therapy.

This is the first I've heard of Solu Medrol, so I really don't know how to deal with the stuff. But this time a year ago, I didn't even know what a care plan was. It's fantastic and inspiring how much we grow and learn as little ole nursing students.

I'm not going to add anything new that others haven't already said, however, let me give you a little from a patient's perspective.

I have Diabetes and I am an Asthmatic. When I start to exacerbate, nothing but oral or IV Steroids help. Nothing, not my short acting Albuterol, not my long-acting/inhaled combo. I go on oral Prednisone and can be on it up to two months or longer for each exacerbation. I also get prophylactic ABX.

During one of these exacerbations, I developed Bilateral LL PNA. It was either hospitalize me or I promise to go on strict bed-rest with an increase of my Prednisone and additional ABX. Guess which I choose?

As a Type II Diabetic, when I am on steriods, I monitor my sugars religiously and am especially careful with what I eat. There is really nothing else that I can do. Without the steriods, I can't breathe.

Sometimes, the only thing that is going to help your patient, is the drug that has the high risk to benefit ratio. You monitor your patient for complications, and whether or not they are improving with the treatment. Use your clinical judgement, and provide good nursing care.

I know that this probably didn't help, but I hope it gave a little perspective.

shortnorthstudent

shortnorthstudent

357 Posts

Fluids are not a no brainer. No not everything can be fixed with and IV and in fact, the point I was trying to get at is that you need to consider what problems can come as a result of COPD. What is a frequent comorbidity with COPD? Are you sure you want to throw fluids at this person? With his medical problems, he likely is dehydrated, but you have to be very careful with fluids and COPD. How much fluid, how fast, IV and oral?

Encouraging fluids through refilling water jugs, making sure the water is an appropriate temp for the patient, reminding them to drink, etc. can be a good thing. But, even with something as innocuous as water, we have to be careful. Too much in the wrong places can cause serious problems for the patient.

KatePasa

KatePasa

128 Posts

No cor pulmonale or coexisting heart disease if that's what you mean. Nothing limiting fluid intake. He's only on 75 ml/hr and the sim chart says he's dehydrated.

Also, with pnuemonia you want to increase fluids to 3 L. That leaves a deficit of 1200 mL you have to make up somewhere.

KatePasa

KatePasa

128 Posts

I'm not going to add anything new that others haven't already said, however, let me give you a little from a patient's perspective.

I have Diabetes and I am an Asthmatic. When I start to exacerbate, nothing but oral or IV Steroids help. Nothing, not my short acting Albuterol, not my long-acting/inhaled combo. I go on oral Prednisone and can be on it up to two months or longer for each exacerbation. I also get prophylactic ABX.

During one of these exacerbations, I developed Bilateral LL PNA. It was either hospitalize me or I promise to go on strict bed-rest with an increase of my Prednisone and additional ABX. Guess which I choose?

As a Type II Diabetic, when I am on steriods, I monitor my sugars religiously and am especially careful with what I eat. There is really nothing else that I can do. Without the steriods, I can't breathe.

Sometimes, the only thing that is going to help your patient, is the drug that has the high risk to benefit ratio. You monitor your patient for complications, and whether or not they are improving with the treatment. Use your clinical judgement, and provide good nursing care.

I know that this probably didn't help, but I hope it gave a little perspective.

That DOES help put it into perspective.

Dixielee

Dixielee, BSN, RN

Specializes in ER. Has 38 years experience. 1,222 Posts

This person needs to be in ICU for careful monitoring of respiratory and metabolic status. He probably needs to be on an insulin drip at a minimum. He may very well need bipap or vent support. He also needs careful monitoring of electrolyte status. Is he febrile? He may not be since he is on the steroids. You didn't mention the severity of any respiratory distress, age and mentation of the patient, but he is in big trouble already and can crash in an instant. Yes, solumedrol is important to improving his breathing, but as we all know, steroids are a double edged sword. This guy is way past the need for oral or inhaled steroids only.

KatePasa

KatePasa

128 Posts

I was wondering about the insulin also. I have an order for sliding scale insulin, but it does seem that he'll need IV insulin.

shortnorthstudent

shortnorthstudent

357 Posts

I was going towards heart disease. Many of our COPDer wind up with CHF which is why I was asking about fluids. You certainly want to incease fluids with pneumonia, but you also have to be very aware of output as well as heart sounds, etc. because you don't want to push him in to CHF with all that fluid.

My instructors are always very interested in what we really mean for the patient individually when we say:

encourage fluids

CDB

ambulate

monitor blood sugar

i/o

Those are catch phrases that we learn early on, but we need to make sure we think about it for the patient as an individual.

Dixielee

Dixielee, BSN, RN

Specializes in ER. Has 38 years experience. 1,222 Posts

I was wondering about the insulin also. I have an order for sliding scale insulin, but it does seem that he'll need IV insulin.

While it is more labor intensive for the nurse, IV insulin is the best way to correct and prevent problems in a very sick patient.

KatePasa

KatePasa

128 Posts

My instructors are always very interested in what we really mean for the patient individually when we say:

encourage fluids

CDB

ambulate

monitor blood sugar

i/o

Those are catch phrases that we learn early on, but we need to make sure we think about it for the patient as an individual.

We have to meet those demands for our patients too, by providing specific, measurable, attainable, realistic, time bound interventions, goals, diagnosis, care and the whole nine that are relevant to our patients. I've been a little too informal on here today, so please forgive me! I'm new to coming to allnurses with inquiries, so I'll apply the same principles I do for school next time.

Thank you for the discourse. I like your style of thinking. It's like mine, in that you drive people to go deeper by endless questions.

shortnorthstudent

shortnorthstudent

357 Posts

No need to ask for forgiveness. I was just trying to help you flush out your thinking without giving you the answers.

Very interesting scenario. Not a patient I would want to have on my tele floor this term in my preceptorship.