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Please help with diabetes scenario/case study!

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by LiLStephRN LiLStephRN (New) New

Here is the case study:

A 45 y.o male brought to the ED with C/O dizziness, weakness, polyuria and polyphagia. He has a history of DM on 70/30 insulin 25 units in am & 15 units pm.

V/S: T95, P88, BP160/92, Pain 3/10, BGM critical high!!!!!!!!!

Lab Values:

Chem 7: Glu 700, BUN 43, Creat 1.2, Cl 108, CO2 20, NA 132, K 4.8

CBC: WBC 12.6, Hgb 10.7, Hct 32, Plt 200

Coag: PT 13.6, INR 1.2, PTT 30

Acetone Trace present

ABG: pH 7.33, pCO 38, pO 96, HCO 21

The doctor's orders are"

(1) NaHCO3 1amp in NS 1000 ml to infuse @ 42 ml/hr.

(2) Regular insulin 10 units IVP X 1 dose

(3) Insulin 25,000 units in D5W 250 ml to infuse @ 10 ml/hr.

The nurse received the orders and changed the insulin drip to a heparin drip without notifying the doctor.

Can anyone help me identify the medication errors in this case study? I am a brand new nursing student and was given this assignment to do ... we haven't covered the diabetes chapters yet and I am going nuts with reading about insulin, the different strengths, etc. I do see that changing the heparin drip was a problem! But i am stuck on the NaHCO3 ... wouldn't that bring down the patient's K levels? His K levels are resting at a normal value right now. Can anyone explain the combo insulin therapy to me? I am going to hit the books and see what i can find. I'll be checking back frequently.

~ Desperate for help

Hey Thanks for taking a look :)

It's 25,000 units of insulin in D5W 250 ml to infuse at 10ml/hr.

and NaHCO3- sodium bicarb

I thought that was bicarb. The bicarb is to prevent/treat acidosis. Look at his values and see if he's in it and then check how much should be given and by what route.

The IV insulin. Is it regular? And break down how much he's getting per hour. Does that sound reasonable to you? It sure doesn't to me. 25,000u over 25 hours = 1,000u per hour.

And the initial insulin. Enough? Is that usual?

The guy is dehydrated. Would you be running a liter of fluids in that slowly?

Start there.

:)

Maybe I am having a bad day but there are a few questions that still remain. Where does it indicate that this patient is in any sort of acidosis. Wouldn't the bicarb put the patient at risk by decreasing his K value when it is at a normal value already? Another thing, by looking at the lab values here is what i see as abnormal: Glucose 700: critically hyperglycemic, his BUN is elevated (can be an indicator of malfunctioning kidneys or dehydration), WBC slightly elevated, both his Hgb and Hct are low (anemic?) ... all other values appear to be in normal ranges including the patient's pH, pCO, and HCO3 levels.

I'm really stuck here.

The medication error that i can point out is the heparin ... This patient has a normal platelet count and a normal coagulation values. By delivering 25000 units of heparin instead of insulin would put the patient at risk. The patient's h&h values are low to begin with and he is already experiencing dizziness and weakness... This would worsen his symptoms? And if the nurse actually followed through with the doctor's order would the insulin be given with D5W since the patient is hyperglycemic or would the insulin work enough to bring the sugar down to normal. This insulin therapy is being delievered over a 25 hour period.

I looked in the drug book for insulin therapy and it seems those are normal doses ...

What on earth am i missing????

Please help!!!!

Wait i think i misread :

Insulin: usual dosing: 10 units/day ... so the 25000 units of insulin would be overdoing it if his order reads for 1000u/hr. Too much? The drug book also says that sodium bicarb is incompatible with the insulin. Does that mean do not mix together or do not give together?

If the order was in fact for heparin the 25000u would be an appropriate dose?

Conrad283, BSN, RN

Specializes in SICU, MICU, CICU, NeuroICU.

Here is the case study:

A 45 y.o male brought to the ED with C/O dizziness, weakness, polyuria and polyphagia. He has a history of DM on 70/30 insulin 25 units in am & 15 units pm.

V/S: T95, P88, BP160/92, Pain 3/10, BGM critical high!!!!!!!!!

Lab Values:

Chem 7: Glu 700, BUN 43, Creat 1.2, Cl 108, CO2 20, NA 132, K 4.8

CBC: WBC 12.6, Hgb 10.7, Hct 32, Plt 200

Coag: PT 13.6, INR 1.2, PTT 30

Acetone Trace present

ABG: pH 7.33, pCO 38, pO 96, HCO 21

The doctor's orders are"

(1) NaHCO3 1amp in NS 1000 ml to infuse @ 42 ml/hr.

(2) Regular insulin 10 units IVP X 1 dose

(3) Insulin 25,000 units in D5W 250 ml to infuse @ 10 ml/hr.

The nurse received the orders and changed the insulin drip to a heparin drip without notifying the doctor.

Can anyone help me identify the medication errors in this case study? I am a brand new nursing student and was given this assignment to do ... we haven't covered the diabetes chapters yet and I am going nuts with reading about insulin, the different strengths, etc. I do see that changing the heparin drip was a problem! But i am stuck on the NaHCO3 ... wouldn't that bring down the patient's K levels? His K levels are resting at a normal value right now. Can anyone explain the combo insulin therapy to me? I am going to hit the books and see what i can find. I'll be checking back frequently.

~ Desperate for help

It looks like the patient is in DKA (Diabetic KetoAcidosis), but that's not important.

The NaHCO3 (sodium bicarb), is being used to treat the metabolic acidosis. pH:7.33|HCO3:21 - it's a slight metabolic acidosis.

The med error may be that he's on the wrong insulin to begin with. If he was compliant (no way to know, that'd be reading into the question), then his insulin needs to be adjusted. If he weren't compliant he would maybe need to be switched to a longer acting insulin so that he would only need to take it once a day instead of twice.

And yes the nurse did change the drip from insulin to heparin which is REALLY a bad thing.

He is slightly acidic ph 7.33. The bicarb is to bring the ph up a bit. I don't think the concern with bringing down the potasssium is warranted because the patient is on the high side of normal. The insulin will cause the potassium ecf value to go dwon because it will cause potassium to influx into the cells at a greater rate. But the sodium value is slightly low so the exchange can be beneficial up to a point. In any case the major issue is heparin substitution. Check the dosages of the Insulin infusion too because that seems wrong 1000 units per hour for 25 hours?

Nrs_angie, BSN, RN

Specializes in Med-Surg, Tele, Vascular, Plastics. Has 2 years experience.

looks like DKA to me

1) initial therapy begins with IV insulin bolus dose of 0.1 u/kg followed by an IV drip of 0.1 u/kg/hr.

2) figure THAT THIS GUY maybe weighs about 220 lbs... which converts to 100 kg... so he should be getting around 10 units of insulin per hour...

3) the 2nd med order is correct, a bolus of 10 units one time.

4) but the 3rd order is lethal... because that would be giving him 25,000 units per hour...

5) the 1st med order is WRONG... because Bicarb therapy is only indicated for SEVERE acidosis... a pH of 7.33 is only slightly acidotic... there is a danger of hypokalemia if acidosis is reversed too rapidly.

6) Sodium Bicarb IV infusion is only indicated when the blood pH is 7.0 or less.

7) Also the patient is somewhat dehydrated so, some fluid raplacement of isotonic solution is probably advised.

HOPE THIS HELPS

ANGIE

Here is the case study:

A 45 y.o male brought to the ED with C/O dizziness, weakness, polyuria and polyphagia. He has a history of DM on 70/30 insulin 25 units in am & 15 units pm.

V/S: T95, P88, BP160/92, Pain 3/10, BGM critical high!!!!!!!!!

Lab Values:

Chem 7: Glu 700, BUN 43, Creat 1.2, Cl 108, CO2 20, NA 132, K 4.8

CBC: WBC 12.6, Hgb 10.7, Hct 32, Plt 200

Coag: PT 13.6, INR 1.2, PTT 30

Acetone Trace present

ABG: pH 7.33, pCO 38, pO 96, HCO 21

The doctor's orders are"

(1) NaHCO3 1amp in NS 1000 ml to infuse @ 42 ml/hr.

(2) Regular insulin 10 units IVP X 1 dose

(3) Insulin 25,000 units in D5W 250 ml to infuse @ 10 ml/hr.

The nurse received the orders and changed the insulin drip to a heparin drip without notifying the doctor.

Can anyone help me identify the medication errors in this case study? I am a brand new nursing student and was given this assignment to do ... we haven't covered the diabetes chapters yet and I am going nuts with reading about insulin, the different strengths, etc. I do see that changing the heparin drip was a problem! But i am stuck on the NaHCO3 ... wouldn't that bring down the patient's K levels? His K levels are resting at a normal value right now. Can anyone explain the combo insulin therapy to me? I am going to hit the books and see what i can find. I'll be checking back frequently.

~ Desperate for help

Nrs_angie, BSN, RN

Specializes in Med-Surg, Tele, Vascular, Plastics. Has 2 years experience.

Wait i think i misread :

Insulin: usual dosing: 10 units/day ... so the 25000 units of insulin would be overdoing it if his order reads for 1000u/hr. Too much? The drug book also says that sodium bicarb is incompatible with the insulin. Does that mean do not mix together or do not give together?

If the order was in fact for heparin the 25000u would be an appropriate dose?

you should read my last post it will clear this up for you big time... i noticed some errors in some of the other posts as well...

sodium bicarb not being compatible with insulin means that you should NOT run them together into the same line... if he has a second IV access or a PICC with multiple lumens, then it is fine to give together.

BUT, BUT, BUT, if you read my last post you will understand why the BICARB order is WRONG, WRONG, WRONG.

it doesnt matter if the order was for heparin or not... the patient doesnt need heparin... and that is a lethal dose of insulin... so its just WRONG...it means you call the MD and get a NEW order

please read my post about the insulin dosing... its right from my Med-Surg book

Nrs_angie, BSN, RN

Specializes in Med-Surg, Tele, Vascular, Plastics. Has 2 years experience.

I'm really stuck here.

The medication error that i can point out is the heparin ... This patient has a normal platelet count and a normal coagulation values. By delivering 25000 units of heparin instead of insulin would put the patient at risk. The patient's h&h values are low to begin with and he is already experiencing dizziness and weakness... This would worsen his symptoms? And if the nurse actually followed through with the doctor's order would the insulin be given with D5W since the patient is hyperglycemic or would the insulin work enough to bring the sugar down to normal. This insulin therapy is being delievered over a 25 hour period.

I looked in the drug book for insulin therapy and it seems those are normal doses ...

What on earth am i missing????

Please help!!!!

Ok... not to be rude... please dont take this the wrong way... but you are way off

get yourself a Med-Surg book.... look up DIABETIC KETOACIDOSIS or DKA

Good Luck,

Angie

bookworm1

Specializes in Critical Care: Cardiac, VAD, Transplant.

Wouldn't the fact that the NURSE changed the order to heparin be a problem? "The nurse received the orders and changed the insulin drip to a heparin drip without notifying the doctor" Unless the nurse is an APN or NP, they would not likely have prescriptive powers. And why would you infuse insulin with dextrose (D5W)? I believe that dextrose is only added if the patient's blood glucose drops too quickly in response to the insulin. I know that only regular insulin should be infused via IV but I do not see any information about mixing it for IV administration. 10ML/H doesn't sound right because (if I'm doing my math correctly) that would be 1000 u/h which would be unsafe if the safe range is .5-1u/kg/day (3) Insulin 25,000 units in D5W 250 ml to infuse @ 10 ml/hr.

Seems like that are many errors in this scenario! But as a new student myself, I am probably missing something!

Nrs_angie, BSN, RN

Specializes in Med-Surg, Tele, Vascular, Plastics. Has 2 years experience.

Wouldn't the fact that the NURSE changed the order to heparin be a problem? "The nurse received the orders and changed the insulin drip to a heparin drip without notifying the doctor" Unless the nurse is an APN or NP, they would not likely have prescriptive powers. And why would you infuse insulin with dextrose (D5W)? I believe that dextrose is only added if the patient's blood glucose drops too quickly in response to the insulin. I know that only regular insulin should be infused via IV but I do not see any information about mixing it for IV administration. 10ML/H doesn't sound right because (if I'm doing my math correctly) that would be 1000 u/h which would be unsafe if the safe range is .5-1u/kg/day (3) Insulin 25,000 units in D5W 250 ml to infuse @ 10 ml/hr.

Seems like that are many errors in this scenario! But as a new student myself, I am probably missing something!

Hi there.... Im not trying to be rude at all.... but I have already said this several times

WE HAVE ALREADY ESTABLISHED THAT THE NURSE IS WRONG FOR CHANGING THE ORDER TO HEPARIN....

WE GOT THAT.... NO HEPARIN.... NO HEPARIN...NO HEPARIN.... ITS BEEN ESTABLISHED!!!!!!! WHO CARES WHAT ITS MIXED IN.... WE BETTER NOT EVER GIVE HEPARIN TO A PATIENT IN DKA WHO'S COAGS ARE NORMAL.... BAD IDEA.

just because you know the heparin is wrong, doesnt get you off the hook. as the nurse you also need to know that you need an order for a continuous infusion of IV insulin... which means you need to call the Doc and all the orders corrected... and any additional orders you need... but when you call you also need to have an idea of what is an appropriate dose for the situation and the patient... so that when you get the order you know if it correct or dangerous... do some math beforehand and you will be ready to page the MD.

now if you read my post about DKA....

the golden standard of treatment is an initial dose of continuous IV insulin of 0.1 units/kg/hr.... lets assume that the man weighs 220 lbs, which converts to 100 kg which converts to 10 u per hour, which adds to 240 units in a 24 hour period..... THE CORRECT INSULIN DOSE SHOULD BE 10 U PER HOUR INITIALLY. (depends on the patient's weight, but since we don't know, we assume 100 kgs, to get a general idea, the concept still applies even if he doesn't weigh 100 kg)

I have no idea where you get the .5-1u/kg/day... assume the man weighs 100 kg.. at most that would be no more than 4 units per hour. that won't be enough insulin for someone whos SBG is 700.... that would only be enough after initial treatment... when the BG starts to come down and the insulin needs to be tapered down as per protocol.

furthermore.... as I already said if the patient is dehydrated... initial therapy should include an isotonic solution.... but once the BG reaches 250 then fluids should be changed to D5 and 1/2 NSS to prevent hypoglycemia and cerebral edema.

Again, Im sorry if I was rude.... Just trying to get you students to develop your critical thinking skills... Everyone keeps getting hung up on the Heparin.... we already know its wrong... talk about beating a dead horse... You still need to correct the orders which means you need continuous IV insulin. Please either look up DKA in a med-surg book or read my previous posts carefully.

Good Luck and Happy Holidays!

Regular Insulin is 1:1 concentration, regular insulin is given subcutaneous.

Here is the case study:

A 45 y.o male brought to the ED with C/O dizziness, weakness, polyuria and polyphagia. He has a history of DM on 70/30 insulin 25 units in am & 15 units pm.

V/S: T95, P88, BP160/92, Pain 3/10, BGM critical high!!!!!!!!!

Lab Values:

Chem 7: Glu 700, BUN 43, Creat 1.2, Cl 108, CO2 20, NA 132, K 4.8

CBC: WBC 12.6, Hgb 10.7, Hct 32, Plt 200

Coag: PT 13.6, INR 1.2, PTT 30

Acetone Trace present

ABG: pH 7.33, pCO 38, pO 96, HCO 21

The doctor's orders are"

(1) NaHCO3 1amp in NS 1000 ml to infuse @ 42 ml/hr.

(2) Regular insulin 10 units IVP X 1 dose

(3) Insulin 25,000 units in D5W 250 ml to infuse @ 10 ml/hr.

The nurse received the orders and changed the insulin drip to a heparin drip without notifying the doctor.

Can anyone help me identify the medication errors in this case study? I am a brand new nursing student and was given this assignment to do ... we haven't covered the diabetes chapters yet and I am going nuts with reading about insulin, the different strengths, etc. I do see that changing the heparin drip was a problem! But i am stuck on the NaHCO3 ... wouldn't that bring down the patient's K levels? His K levels are resting at a normal value right now. Can anyone explain the combo insulin therapy to me? I am going to hit the books and see what i can find. I'll be checking back frequently.

~ Desperate for help

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