case study help

truckinusa, BSN, LPN, RN · Mar 14, 2013

seems like it? Hypotension and Hypothermia?

Esme12, ASN, BSN, RN · Mar 14, 2013

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. Thanks for any input!
48year old Mexican American female admitted with fever,difficulty breathing, pleuritic chest pain, weakness, and shaky chills. Hx of flu like symptoms from approximately one week ago, took over-the-counter medications with moderate resolution of symptoms. On the day of admission, pt sleeping more than usual and seemed confused. In ER, pt's chest x-ray revealed left lower lobe pneumonia.

Health History Data:diagnosed with type 2 diabetes and hypertension about15 years ago and a "thyroid problem" for a year or two.

Prescribed Oral Medications:
Glucophage (Metformin) 500 mg twice a day.
Pravastatin(Pravachol) 40 mg daily at bed time
Levothryoxine100 mcg daily
Vasotec(Enalapril) 5 mg twice a day
Diltiazem(Cardizem) 240 mg daily

Reportfrom ER nurse
Vitals:HR 116, BP 88/56, RR 26, T 96.4°F, Wt 180, Ht 5’4”,
Neuro:lethargic, responds to verbal stimuli and oriented to self
CV:heart tones distant, S1, S2, S4audible, capillary refill 3 > seconds
Pul:lungs clear bilaterally
GI:abdomen protuberant, hypoactive bowel sounds in all 4 quadrants
Integ:skin dry with tenting present over sternum, lips and oral mucus membranes dry and cracked, left lower leg edematous and erythematous with serous fluid oozing from lateral aspect of calf.

AdmissionLabs: SerumChemistry:
Glu 550,
K 5.6,
NA 132,
Cl 80,
Cr 2.3,
BUN 82
ABGS: pH 7.30, Pa02 70, PC02 47, HC0 320mEq/L
Hematologypanel:HCT 30. %, HGB 10.1 g/dL, RBC 3.9 x 10⁶/µL
WBCwith differential: WBC 17,000/mm³, segmented neutrophils 79%, bandneutrophils 10%, monocytes 9%, lymphocytes 30%, eosinophils 4%, basophils 3%

This is going to be a long case study......I think we can agree thispatient has an infection.....are you sure it is from her leg? Poss Sepsis isn't the main thing affecting this patient right now......look at this patients labs....look at the glucose, potassium kidney function and abg's.....what condition caused by diabetes that causes acidosis, lethargy , shock, and coma?

ckirkpa · Mar 15, 2013

DKA???

SleeepyRN · Mar 15, 2013

Close. Look at the hx and medications again. The pt takes metformin which tells me that this pt.'s body does produce insulin. Therefore, are ketones likely to be found? Probably not. Also, you're not in med school so we're not just looking at a diagnosis here. What is the case study for? What do all of those assessments tell you as a NURSE? What's going on with this pt? You typed out the case study, now put it in YOUR words. What are YOU gathering from that info? You're close with DKA, but not quite.

ckirkpa · Mar 19, 2013

hhs? i was told blood sugar needed to be atleast 700

Esme12, ASN, BSN, RN · Mar 19, 2013

I have seen that the glucose needs to be 600....so 550 is close enough in the presence of all the other evidence.

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.
According to the consensus statement published by the American Diabetes Association, diagnostic features of HHS may include the following :
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.
According to the consensus statement published by the American Diabetes Association, diagnostic features of HHS may include the following :
Plasma glucose level of 600 mg/dL or greater
Effective serum osmolality of 320 mOsm/kg or greater
Profound dehydration, up to an average of 9L
Serum pH greater than 7.30
Bicarbonate concentration greater than 15 mEq/L
Small ketonuria and absent-to-low ketonemia
Some alteration in consciousness
Detection and treatment of an underlying illness are critical. Standard care for dehydration and altered mental status is appropriate, including airway management, intravenous (IV) access, crystalloid administration, and any medications routinely given to coma patients. Although many patients with HHS respond to fluids alone, IV insulin in dosages similar to those used in DKA can facilitate correction of hyperglycemia. Insulin used without concomitant vigorous fluid replacement increases the risk of shock. http://emedicine.medscape.com/article/1914705-overviewmedscapeisfree and requires registration....it is an excellent resource and reference

This patient is right on that cusp of deteriorating down the drain. In the presence of your clinical data.....

Vitals:HR 116, BP 88/56, RR 26, T 96.4°F, Wt 180, Ht 5’4”,
Neuro:lethargic, responds to verbal stimuli and oriented to self
CV:heart tones distant, S1, S2, S4audible, capillary refill 3 > seconds
Pul:lungs clear bilaterally
GI:abdomen protuberant, hypoactive bowel sounds in all 4 quadrants
Integ:skin dry with tenting present over sternum, lips and oral mucus membranes dry and cracked, left lower leg edematous and erythematous with serous fluid oozing from lateral aspect of calf.

Admission Labs: Serum Chemistry:
Glu 550,
K 5.6,
NA 132,
Cl 80,
Cr 2.3,
BUN 82
ABGS: pH 7.30, Pa02 70, PC02 47, HC0 320mEq/L

HHS Hyeprglycemic Hyperosmolar Non Ketotic coma.....would be my first thought brought on by illness/infection.

MendedHeart · Mar 20, 2013

Patients vital signs indicate SIRS/septic shock...meets all criteria= HR》90, RR> 22, systolic

MendedHeart · Mar 20, 2013

The ABGs match shock as well..pt need 4-6liters of isotonic fluid resuscitation. .if the vs dont respond..the patient will need vasopressors and of course ABX aggressively.

MendedHeart · Mar 20, 2013

Most of the pts assessment data, signs and symptoms appear to look like compensatory stage of this shock..in addition WBC are high and Also bands @10% which is also sn indicator

Esme12, ASN, BSN, RN · Mar 20, 2013

Most of the pts assessment data, signs and symptoms appear to look like compensatory stage of this shock..in addition WBC are high and Also bands @10% which is also sn indicator

If they remain hypotensive, tachycardic, tachypnic that are not compensating. With the elevated glucose, altered LOC, dry tenting skin my vote is HHS. The WBC is elevated and they have an infection but in leiu of the glucose and renal failure/acidosis I vote HHS.

However...your rationale is correct as well. In the real world these co-morbidities are considered and treated simultaneously

psu_213, BSN, RN · Mar 20, 2013

A minor point...

With hyperglycemia, serum Na levels are artificially lowered. So, with hyperglycemia, it is necessary to get a correct sodium level. While I have found several formulas for this correction one site (there are many) that provides a tool to make such a correction is:

MDCalc | Sodium Correction for Hyperglycemia

This may be beyond the scope of this assignment, but it is important for developing the entire clinical picture. So, is this patient hypo-, hyper-, or eu- natremic?