Need help with case study

[WLBarter]

I am just having one of those days where I can't seem to function and I am getting really confused about the difference between 2 questions on a case study. Can someone please offer some advice?

Mr. Edward Berns is a 62 year old African American male that was admitted to the hospital with an exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and hyperglycemia.

In the emergency room, Mr. Berns presented with severe dyspnea, tachypnea and was noted to be using accessory respiratory muscles to breathe. O2 sat on room air was 82% per pulse oximeter. Blood glucose level returned at 324mg/dl. The emergency room physician orders sq Reg insulin and placed the patient on a glycemic protocol. Mr. Berns was also placed on 40% O2 per non-rebreather mask. He was stabilized in the Emergency Department and admitted to the floor for further treatment.

The admission nursing history revealed the following:

Height 6'0; Weight 151 lbs., BP 160/94-118-28. Diminished breath sounds were noted throughout all lung fields w/ rhonchi noted posterior bases bilaterally. The client was pleasant and cooperative and affirmed a history of "breathing problems" and "sugar in my blood". The client denied any other significant health history or surgeries. Mr. Berns' wife died 2 years ago and he stated that his kids live in different areas of the state. His oldest daughter has been talking to him about moving to Paducah with her. She does not like the Smoketown neighborhood he lives in and worries about him being all alone, but Mr. Berns is reluctant to leave.

Mr. Berns is currently not employed. He was recently laid off from work where he worked in a tool and dye shop. He has applied for financial assistance, but cannot afford the COBRA payments to continue his health insurance. His was not aware of what medications he took at home, but after several calls, a friend from church was able to bring in the medications. The following medications were listed as his home medications:

Brethine 5 mg. po tid

Albuterol inhaler 1-2 puffs q 4-26 hrs prn

NPH insulin 15 units q AM

Regular insulin.....dosage/timing schedule unknown

Upon further questioning the nurse is able to determine that Mr. Berns is to be doing finger sticks at home and administering the Regular insulin on sliding scale. However, the doctor's office did not follow up on obtaining a glucometer for Mr. Berns so he has not been adhering to the prescribed regimen. Mr. Berns stated he is not sure he needs the "new fangled contraption" anyway.

Chest x-ray on admission revealed hyperinflation and increased intercostal margins consistent with chronic obstruction pulmonary disease. EKG results: Sinus Tachycardia with low amplitude and right axis deviation which may be consistent with right ventricular enlargement. ABG results: pH 7.35, p02 75, PCO2 48; HCO3 28.

Admission orders:

NS @ 75 ml/hr

O2 @ 40% per non-rebreather

ABGs on 02 in AM

EKG, Chest x-ray & BMP in AM

Albuterol 2.5 mg via nebulizer tid

Brethine 5 mg po tid

Solu-Medrol 40 mg. IV q 6 hrs.

NPH insulin 20 units sq q AM

1200 cal ADA diet

Activity: up as tolerated

1. From the admission orders is there something that might be cause for concern and why? What action(s) as the nurse would you take?

No fast-acting insulin administration scale.

No schedule for blood sugar testing

2. Are there any additional needs the patient might require which are not identified in the orders? If so, what would you as the nurse recommend to be added to the admission orders for Mr. Berns?

[UM Review RN, ASN, RN]

There's a lab test that can tell whether Mr. Berns's blood glucose has been controlled over the past few months. I'd add that.

Also, think about when he goes home. Will he need any supplies or medications? Can he afford them?

[Daytonite, BSN, RN]

1. from the admission orders is there something that might be cause for concern and why? what action(s) as the nurse would you take?

the dose of nph insulin that has been ordered is higher than his home dose.

2. are there any additional needs the patient might require which are not identified in the orders? if so, what would you as the nurse recommend to be added to the admission orders for mr. berns?

his blood pressure was not addressed and he is being placed on steriods. the patient was on sliding scale insulin coverage at home and that has not been ordered for him either. the patient was supposed to be doing no routine blood sugar testing at home, wasn't, it hasn't been ordered, should be, as well as teaching for the patient by the nursing staff.