Please help with diabetes scenario/case study!

SuesquatchRN, BSN, RN · Nov 17, 2007

What's NaHCO3?

LiLStephRN · Nov 17, 2007

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

SuesquatchRN, BSN, RN · Nov 17, 2007

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.

:)

LiLStephRN · Nov 17, 2007

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!!!!

LiLStephRN · Nov 17, 2007

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 · Nov 17, 2007

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.

smk1, LPN · Nov 17, 2007

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 · Nov 18, 2007

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 · Nov 18, 2007

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 · Nov 18, 2007

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 · Nov 18, 2007

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!