Question

P.W. Is a 40-year old disabled man who recently lost his wife to metastatic breast cancer. His brother has taken him into his home. P.W. has a 22-year history of insulin-dependent diabetes mellitus (Type-1). Until recently, he has taken responsibility for the management of his disease and has been actively involved in the local chapter of the American Diabetic Association.

PMH includes 2 amputated toes on his R foot, retinopathy and visual impairment in both eyes, and angina on exertion from coronary artery disease that severely restricts his activity. Since he began treatment with an Ace-inhibitor 2 years ago, his blood pressure has gone from 182/128 to 126/78 mm Hg. Currently, he is 71” tall and weighs 135 lb. P.W.’s sister-in-law, who is an LPN says P.W. has lost about 12 lbs in the past 3 weeks. Over the past few years, P.W. has been administering a multidose (3 injections) regimen of regular Humulin insulin to himself before meals and at night. Recently his BG levels have been increasingly inconsistent and labile, and he has been labeled “noncompliant.” It is Monday. You are the home care nurse assigned to visit P.W. 3 times per week for teaching and evaluation. P.W.’s brother and sister-in-law express concern that P.W. seems to be indifferent about his nutritional and pharmacologic regimens.

As you start to review the above measures with P.W., you notice he already seems aware of what he should do to control his blood glucose. You are concerned that he seems too distracted and drifts off in the middle of a discussion; his affect also appears flat.

You ask P.W if he has been taking all his medications. He says “yes” but adds that he discovers “extra” blood pressure pills left over at the end of each week. He seems to be confused about the reason for the “leftover” pills. You decide to do a glucose stick. He registers 348 mg/dl.

P.W.’s provider says she wants to hospitalize him for evaluation and stabilization; this also would give the opportunity for a psychiatric consult. P.W. says he refuses to go to “that hospital where my wife died.” In discussion with P.W. and the physician, it is decided that you will check his progress daily; someone from the home care agency will call q8h for a progress report on his progress daily. P.W.’s sister-in-law agrees to monitor his BG and vital signs and see that he takes all his medications. If P.W.’s condition does not improve or becomes worse, he must enter the hospital for treatment. The provider is concerned that P.E. may be depressed and starts him on Sertraline 50 mg qd to be taken with his bedtime snack.

PLEASE ANSWER THIS QUESTION:

The next day, during your midafternoon visit to P.W.’s home, he tells you he has a headache and is feeling “fidgety” His pulse is 124, his gait is unsteady, speech is slightly slurred, and blood glucose is 48 mg/dl. What will you do?

Answer 1

His symptoms suggest that the presence of hypoglycemia .Hypoglycemia is the main problem in patient with diabetes mellitus with antidiabetic treatment. The hypoglycemia in terms the blood sugar levels less than 70mg/dl.

If we notice the symptoms of hypoglycemia suddenly check the blood sugar levels and give quickly acting carbohydrates followed by long acting carbohydrates.quick acting carbohydrate include 10 to 20gm of glucose or 2 teaspoon of sugar and recheck the blood glucose levels if it is again low repeat this for three times. After that the condition is not progressed give inj.glucogon 1mg IM because the patient is at  home.

After that immediately shift the patient to hospital because the effect of hypoglycemia may last to 12 to 24 hours. It may cause unconscious to fits.