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92934 Clinical Management in Diabetes

Question

Answered

Task:

Case 1: Managing the diabetic patient

Past and present medical/surgical history

Kenny Ng aged 63, a financial analyst, is admitted to the emergency department at 1500hrs via ambulance with nausea, vomiting and abdominal pain. His wife reports that he has been drinking excessive amounts of water during the past several weeks, and has been urinating frequently, more so at night. Kenny has a 10-year history of hypertension, 15-year history of Type 2 diabetes, obesity (145kg) and abnormal cholesterol and triglyceride levels. He was also diagnosed with hypothyroidism 12 years ago. Kenny’s eyesight has declined significantly in the last five years, where he has complained of ‘floaters’ and shapes moving within his vision field, and nyctalopia. There is an old, peeling dressing (comprised of 4 Band-Aids overlapping) on the sole of Kenny’s right foot, and when removed there is a 2cm long x 2mm deep laceration that is across the fat pad over the calcaneus, that has a small amount of purulent exudate on the Band-Aid. Kenny’s wife Ann explains he was gardening last week, when he cut his foot on a spade. Kenny is non-compliant with his diabetic medications. His wife states he only takes them when he “feels like his sugar is up”. Kenny monitors his blood glucose levels via glucometer only a few times per week.

Signs and symptoms

On admission to the hospital, Kenny appears confused and disoriented, is lethargic, his skin warm, dry and flushed, pulse rapid at 98 beats per minute. Kenny appears dyspneic with a respiratory rate of 24 respirations per minute. He has an acetone smelling breath and polydipsia. Blood pressure is 166/95. Temperature 37.3 C. Kenny’s initial plasma glucose level is 39 mmol/L, his arterial blood pH is 7.30 (normal 7.35-7.45) and serum bicarbonate is 16 mmol/L (normal 22-26 mmol/L). ECG has recorded:

  1. Critically analyse the case study and identify the two most important actual nursing problems for the patient at the commencement of the shift and state these as nursing diagnoses. A two- or three-part NANDA statement is utilised as appropriate. (4 marks)

  2. Analyse the case study and rationalise in no more than 150 words the pathophysiological basis for TWO signs/symptoms observed in the chosen case study (5 marks)

  3. Explain with rationale, three nursing interventions associated with the safe administration of three of Kenny’s admission medications (9 marks)

  4. Discuss how you would assess Kenny’s right foot wound and justify how would this inform your decision to identify one actual and two potential problems. Then, choose one problem (out of the three identified) to discuss one independent nursing intervention aimed at addressing that problem. (8 marks)

  5. From the table above, what blood test result(s) would be the most significant to monitor, in relation to insulin infusions, and why? (1mark)

  6. You have just been notified by the doctor that the insulin infusion will be ceased and a Actrapid insulin sliding scale will be charted. When you inform Kenny, he becomes extremely agitated and refuses to have the insulin infusion removed. Explain how you would manage this situation. (2 marks)

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