Question

You are working in the accident and emergency department and have been allocated to assess and care for Jane Ray.

Jane is a 57-year-old man with Type 2 diabetes first diagnosed 2 years ago. Mr. Ray has a past history of heavy alcohol use and obesity. Despite his best efforts he has gained weight slightly over the last two years due to his fondness for take-away food and continued high beer intake. Richard has been feeling increasingly unwell over the last three weeks following an episode of acute gastroenteritis. He says he has been getting more forgetful since his stomach upset and keeps forgetting to take his diabetic medications. He also can’t remember when he last measured his blood glucose level (BGL) or where his glucometer is. Mr. Obrien’s neighbor called an ambulance this morning when he found Jane in the front yard of his house confused and in his underwear.

Your assessment of Ray reveals the following information.

Visually, Ray looks unwell and complains of nausea, blurred vision, headache, abdominal pain, severe thirst, and a strong need to urinate. On physical examination, sunken eyes, dry mouth and thick coating on his tongue, poor skin turgor were noticed.

Neurological assessment: GCS 14 (eye opening spontaneously, confused to time, place & person, obeys commands). His speech is slurred, and he has mild weakness down his left side. Both pupils are size 2 and briskly respond to light. He is very drowsy but is constantly asking to go home.

A set of vital signs and blood and urine tests were taken, which showed:

T 36.8^oC, HR 115 bpm, RR 22 rpm, BP 90/50 mmHg, Height 175 cm Body weight 105 kg.

Blood test & Urinalysis results: BGL 37mmol/L, HbA1c 14%, Ketones absent. Urine glucose +++, Ketones negative.

Medical orders: IVT of 0.9% Saline at 167ml/hr. 1/24 BGL. Sliding scale insulin and commence on an insulin infusion if BGL does not drop quickly enough. Nil orally. Continuous cardiac monitoring.

Medical Diagnosis: Type 2 Diabetes withHyperosmolar/Hyperglycaemic State (HHS)

Question:

.

Describe how each of these aspects of the information presented above has led to the diagnosis of a pre-HHS state.

• Presentation history (2):

• Nursing Assessment (3):

.Physical appearance:

• Vital & neurological signs:

• Diagnostic tests (2): Blood & urine tests:

Question 2

After reading the case study, you are required to identify three (3) priority nursing problems and provide your rationale for making each of these a priority.   

Question 3

After identifying three (3) priority nursing problems in the previous question, you are required to formulate a goal to address each priority nursing problem.

Question 4

After formulating the goal for each priority nursing problem in Question 3, you are required to describe three (3) nursing interventions with rationale that you will implement to achieve each goal.  

Answer 1

1) Presentation history complaining of nausea, blurred vision, headache, abdominal pain, severe thirst, and a strong need to urinate.

Nursing Assessment,Physical appearance.. sunken eyes, dry mouth and thick coating on his tongue, poor skin turgor were noticed ,looks unwell

Vital & neurological signs:GCS 14. His speech is slurred. Both pupils are size 2 and briskly respond to light. He is very drowsy but is constT,36.8oC, HR 115 bpm, RR 22 rpm, BP 90/50 mmHg

Blood & urine tests , BGL 37mmol/L, HbA1c 14%, Ketones absent. Urine glucose present, ketones negative.

2) risk of fall ( neurological disturbance can cause imbalance and risk of fall and injury) dehydration( due to polyuria ca lose dehydration threat ) and overweight ( overweight is more risk for deteriorating diabetes)

3) goals are to prevent injury and correct the dehydation and reduce risk of dehydration in the pt and help the pt to reduce the weight which will help in controlling diabetes

4) risk of fall .... Intervention teach the pt about the exercise that helps in improving balance, gait, and strength..No pychoactive drugs like alcohol ..change in home environment ( all these will help the pt and prevent him from fall)

Dehydration, intervention.... Educate the pt about the signs and symptoms of dehydration, take plenty of fluids, and fruits, avoid stimulants like smoking alcohol ( all these will raise the level of fluid in the body )

Overweight... .. Teach the pt what are the I'll effects of the obesity , help the pt in exercise , get rid of junk food and high calorie diet switch to veggies ,avoid taking alcohol ( these all will help the pt to reduce the weight)