Help!! Case Scenario 45 y/o M w/diabetes post op revascularisation (PAD)

bribreeze87 · Mar 27, 2014

Just wondering is the glucose a typo? 21? Anyways priority wise i would say potassium is the priority. Think about what is gonna kill him first?! His past history of MI and the potential problems related to hyperkalemia?

Nurse_Sian84 · Mar 27, 2014

Hi bribreeze87,

Cheers for your response. Its not a typo the case study given states 21mmol/L, so he is elevated. The potassium level is only slightly raised where as if his insulin levels were >34mmol/L then you would class that as possible HHNS. This is where it gets confusing. Most signs and symptoms of dehydration are also similar of HHNS. As soon as I mentioned dehydration may not be first priority I was shut down immediately.

bribreeze87 · Mar 27, 2014

Hi bribreeze87 Cheers for your response. Its not a typo the case study given states 21mmol/L, so he is elevated. The potassium level is only slightly raised where as if his insulin levels were >34mmol/L then you would class that as possible HHNS. This is where it gets confusing. Most signs and symptoms of dehydration are also similar of HHNS. As soon as I mentioned dehydration may not be first priority I was shut down immediately.[/quote'] were you shut down by your professor or fellow students?

schnookimz · Mar 27, 2014

His potassium is more than just "slightly" raised.

Nurse_Sian84 · Mar 27, 2014

were you shut down by your professor or fellow students?

fellow students. I'm still awaiting a response from my tutor (australian term)

Nurse_Sian84 · Mar 27, 2014

His potassium is more than just "slightly" raised.

Hi Schoonookimz,

thank you for your input, according to Lewis's Medical Surgical Nursing - Assessment and Management of clinical problems it states on page 357 that the normal level is 3.5-5.0mmol/l I guess when you do look at it like that it is elevated...I take back 'slightly'

Esme12, ASN, BSN, RN · Mar 27, 2014

First an easy way to make the conversion from mg/dl to mmol/L is to divide by 18. To convert mmol/L to mg/dl, multiply by 18.

The glucose is 380.

CASE SCENARIO

Mr George Brown, a 45-year-old male, has been admitted to a ward and has undergone a limb revascularization procedure following experiencing severe leg pain on his anterior right lower leg. The following data were obtained on admission: Subjective data: (reported by Mr Brown’s friend) - Diagnosed with type 2 diabetes mellitus 2 years ago - Diagnosed with peripheral arterial disease (PAD) 1 year ago - 2 year history of hypertension - 10 year history of smoking - Taking oral hypoglycaemic medications and anti-hypertensive medications Reported by Mr Brown: -
Feeling ‘weak’ with nausea and vomiting 2 days prior to admission (don’t know what has caused him to feel like this) - Extremely thirsty (caused by the dehydration which in turn caused by vomiting and also hyperglycaemia would be aggravating his fluid loss) Could this be from his elevated glucose from his arterial occlusion causing stress aggravated by the dehydration caused by his elevated glucose?
Foot and leg ache continually –( better at rest) (Dehydration causing hypotension which decreases blood flow to the periphery, aggravating the effects of his PAD) Could this be caused by the arterial occlusion from the PAD?
Objective data: - Drowsy but can be roused (dehydration) - Dry mouth (dehydration) - Skin dry and warm with decreased turgor (dehydration) - Weight 132 kgs - Height 170 cms - Blood glucose level 21mmol/L (will be increased due to reduced volume of water in his blood – hence increased concentration of all elements in the blood) Could this be from his diabeties that is poorly controlled?- Serum potassium level 6mmol/L (as above) normal range 3.5-5.0 mmol/l - Lipid profile: total 253 mg/dl; LDL 91 mg/dl; HDL 25 mg/dl; triglycerides 423 mg/dl (as above) - Diminished peripheral pulses (aggravated with hypotension which accompanies severe dehydration) and severe PAD- Ankle-Brachial Index 0.4 (severe PAD) normal 0.90-1.30, decreased peripheral blood flow due to severe hypotension in a patient with PAD.
Previous hospital admission for: - Hyperosmolar Hyperglycaemic Nonketotic Syndrome (State) 2 months ago (>34mmol/l) - ST-segment elevation myocardial infarction 12 months ago

Social: - has 3 children visiting, who live with ex-wife - has been working as a real estate agent 20hrs/wk ASSESSMENT Mr Brown presents with multiple clinical problems.
Five of Mr Brown’s problems are: 1. Altered serum potassium level 2. Dehydration 3. Decreased level of consciousness 4. Altered blood glucose level 5. Paraesthesia (abnormal feelings i.e. pins and needles) and paralysis (loss of ability to move one or all limbs)

CASE SCENARIO

Mr George Brown, a 45-year-old male, has been admitted to a ward and has undergone a limb revascularization procedure following experiencing severe leg pain on his anterior right lower leg. The following data were obtained on admission:

Subjective data:

reported by Mr Brown’s friend - Diagnosed with type 2 diabetes mellitus 2 years ago - Diagnosed with peripheral arterial disease (PAD) 1 year ago - 2 year history of hypertension - 10 year history of smoking - Taking oral hypoglycaemic medications and anti-hypertensive medications

Reported by Mr Brown: - Feeling ‘weak’ with nausea and vomiting 2 days prior to admission - Extremely thirsty Foot and leg ache continually –( better at rest)

Objective data: - Drowsy but can be roused - Dry mouth - Skin dry and warm with decreased turgor - Weight 132 kgs - Height 170 cms - Blood glucose level 21mmol/L - Serum potassium level 6mmol/L normal range 3.5-5.0 mmol/l - Lipid profile: total 253 mg/dl; LDL 91 mg/dl; HDL 25 mg/dl; triglycerides 423 mg/dl - Diminished peripheral pulses - Ankle-Brachial Index 0.4 (severe PAD) normal 0.90-1.30,

. Previous hospital admission for: - Hyperosmolar Hyperglycaemic Nonketotic Syndrome (State) 2 months ago (>34mmol/l) - ST-segment elevation myocardial infarction 12 months ago Social: - has 3 children visiting, who live with ex-wife - has been working as a real estate agent 20hrs/wk

ASSESSMENT
Mr Brown presents with multiple clinical problems. Five of Mr Brown’s problems are:
1. Altered serum potassium level
2. Dehydration
3. Decreased level of consciousness
4. Altered blood glucose level
5. Paraesthesia (abnormal feelings i.e. pins and needles) and paralysis (loss of ability to move one or all limbs)

Ok...first...where have you documented that he has paralysis?

You prioritize according to what is going to kill him first. So looking here what is most important?

Potassium. An elevated K can cause lethal cardiac arrythmias. Why is this patients glucose elevated? How does and elevated glucose impact the elevated K? http://www.elsevierhealth.com/media/us/samplechapters/9780443071973/9780443071973.pdf

The next would be dehydration....why is he dehydrated? Well he stated he had nausea and vomiting prior to admission. Why was he vomiting? Well....he has a history of HHNK. The chances this has reoccurred are high. Is his elevated sugar causing nausea and vomiting due to the stress his body being stressed from an occlusion of his lower leg? I think his compliance might be an issue as well.

Altered blood glucose. The elevated glucose will affect healing and contributes to his overall health picture.

Decreased LOC. Patients with elevated glucose that are dehydrates with nausea and vomiting and dehydration will have a decreased LOC and an elevated K

Now looking at these symptoms what disease process causes these symptoms? the hint is in his PMH

Pain. Your patient has pain.

He is at risk for further peripheral circulatory occlusions and infection due to his disease process, poorly maintained health (still smoking), and fresh post op

What are your thoughts? Do you use NANDA I? What semester are you? What did your instructor say?

bribreeze87 · Mar 28, 2014

Yeah what did you professor (tutor) say? I wanted to think about the potassium and how it connects to the patient and what could potentially happen? In prioritization always think what will

bribreeze87 · Mar 28, 2014

I tried to edit my reply and it sent

It unfinished! Sorry bout that. Let me know :-)

l1234567 · Mar 30, 2014

Hey I'm doing this case study too!

It's dehydration from what I've found out so far and that is what my tutor said as well. From starting him on a sodium chloride infusion it will prompt diuresis and also the blood level will be higher so the ratio to potassium will be lower. Also you need to start a sodium chloride infusion as this is done before a attacking his bsl (journals). His circulation will also be improved and loc. His paralyiss will be improved as well.

I have a question too!

the second question of the case study is

"Mr Brown has a further problem of an orally taken temperature of 39o C. He is complaining of general

discomfort related to his body temperature. Identify the best management for the above problem in

Mr Brown’s case. Using an academic writing style, justify your decision for Mr Brown’s body

temperature management in this admission with a synthesis of evidence-based literature. (approx.

750 words). "

Apparently he has an infection and we have to find out what sort of infection it is (via my tutor) is osteomylitis a good one? why/ why not?

Esme12, ASN, BSN, RN · Mar 30, 2014

Where is this paralysis? Paresthesias are NOT paralysis.

Paresthesia is a sensation of tingling, tickling, prickling, pricking, or burning of a person's skin with no apparent long-term physical effect. The manifestation of a paresthesia may be transient or chronic. The most familiar kind of paresthesia is the sensation known as "pins and needles" or of a limb "falling asleep".

Paralysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling (sensory loss) in the affected area if there is sensory damage as well as motor. Paralysis is most often caused by damage in the nervous system, especially the spinal cord or brain.

Mr Brown has a further problem of an orally taken temperature of 39o C. He is complaining of general discomfort related to his body temperature. Identify the best management for the above problem in Mr Brown’s case. Using an academic writing style, justify your decision for Mr Brown’s body temperature management in this admission with a synthesis of evidence-based literature. (approx. 750 words). "

What else information were you given? Has the patient has a CXR? They just had surgery...how is the wound? Do they have a cough? Did they have a foley when admitted after surgery? Can severe dehydration cause a temp? Was the leg surgery recent this admission? Any other information were you given?