N512-19A Module 7: Disorders of the Endocrine System Across the Life Span
N512-19A Module 7: Disorders of the Endocrine System Across the Life Span
Discussion 7 Question 1
Leonard Mays, a 58 y.o., Caucasian, homeless man with long-standing insulin-treated type 2 diabetes has been diagnosed with right lower extremity cellulitis. He has taken a prescribed oral antibiotic for the past week but has not noticed much improvement. For the last 2 days, he has complained of intermittent fevers and chills, nausea with poor oral intake, and proximally spreading erythema over his right leg. N512-19A Module 7: Disorders of the Endocrine System Across the Life Span. On the evening of admission, a worker at the homeless shelter notices that he is markedly confused and calls 911. In the emergency room, he is oriented only to his name. The patient is tachypneic, breathing deeply at a rate of 24/min. He is febrile at 38.8°C. He is normotensive, but his heart rate is elevated at 112 bpm. On examination, this patient is a delirious, unkempt man with a fruity breath odor. His right lower extremity is markedly erythematous and exquisitely tender to palpation. Serum chemistries reveal glucose of 488 mg/dL, potassium of 3.7 mg/dL, and sodium of 132 m/dL. Urine dip-stick is grossly positive for ketones.
In this discussion:
- Describe and discuss with your colleagues the pathophysiology of ketoacidosis in this diabetic patient. What is causing his altered mental status?
- Describe the pathogenetic mechanism of his respiratory pattern.
- Describe and discuss a plan of care for this patient during his first few days in the hospital.
- Describe a plan of care for him at discharge (he will likely be admitted to the “medical floor” of the homeless shelter, which has the services of an Nurse Practitioner three times per week and a registered nurse four times per week). Include plans for at least one population-focused intervention.
Include citations from the text or the external literature in your discussions.
Remember to respond to at least two of your peers. Please refer to the Course Syllabus for Participation Guidelines & Grading Criteria.
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Sample Approach and Responses
Ketoacidosis is a severe complication in diabetes and can be life threatening. Ketoacidosis is when is when the body has more sugar then insulin and acid substances called ketones are released. This occurs when the body starts breaking down fats at a past faster than normal. The liver turns the fat into a fuel called ketones, which causes the blood to become acidic (Rebar, Heimgartner, & Gersch 2019). Patients with severe DKA can experience confusion, headaches, and altered mental status due to dehydration or severe acidosis. Mr. Mays labs show’s he is dehydrated with hyperglycemia. On exam Mr. Mays was oriented to self only and experiencing delirium.
Symptoms of fruity breath odor is call Kussmaul breathing. It’s expected to have deep rapid respiration’s that may occur in DKA patients with a pH level lower than 7.20 (Hammer & McPhee, 2019). Mr. Mays was tachypneic, breathing deeply at a respiration rate of 24/min with a fruity breath odor. This is not due to respiratory distress, but rather is a respiratory compensation for the metabolic acidosis. It’s the body’s way to breathe off carbon dioxide to neutralize the pH.
During the first two days of hospitalization, the goal is to hydrate Mr. Mays and to regulate his glucose levels. Mr. Mays would receive normal saline IV until glucose levels were under 250 and on an insulin scale. The goal is to balance pH through fluid replacement and insulin. The treatment of acute DKA includes restoration of fluid deficits in the first 24 to 36 hours through electrolyte replacement and insulin therapy, which is administered slowly to decreased plasma glucose (Mendez, Surani, & Varon, 2017).
Discharge care of plan for Mr. Mays would to be monitor sugars, rest, push fluids, and eat a health diet. Residing in a homeless shelter these discharge instructions may be difficulty to stick to. If Mr. Mays is admitted to the “medical floor” of the homeless shelter, then he will be provided with follow up visits from a Nurse Practitioner three times a week and a nurse four times a week. This medical support will monitor his glucose levels and insure accurate hydration and diet.
References
Rebar, C., Heimgartner, N., & Gersch, C. (2019). Pathophysiology Made Incredibly Easy (6th ed.). Wolters Kluwer.
Hammer, G., & McPhee, S. (2019). Pathophysiology of disease: An introduction to clinical medicine (8th ed). McGraw-Hill
Mendez Y, Surani S, Varon J. Diabetic ketoacidosis: Treatment in the intensive care unit or general medical/surgical ward?. World J Diabetes. 2017;8(2):40-44. doi:10.4239/wjd.v8.i2.40
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In reply to Helen
Re: Discussion 7 question 1 – N512-19A Module 7: Disorders of the Endocrine System Across the Life Span
Hi Diane,
Thanks for your post. Often, diabetic ketoacidosis is associated type 1 diabetes. However, our patient is type 2 diabetic. What are the pathophysiological processes involved in the development of diabetic ketoacidosis in patients with type 2 diabetes?
-Dr. Reynaldo
41 words
In reply to Helen
Re: Discussion 7 question 1
According to Axon, et al. (2016), homelessness is a risk factor for increased hospital admissions for diabetic ketoacidosis in individuals who have type 2 diabetes mellitus. The mortality of a person who is homeless is three times higher than one who is not homeless (Axon, et al., 2016). Furthermore, 66% of homeless individuals have at least one chronic medical issue and 38% have more than one (Axon, et al., 2016).
In the case of our patient, L.M., he not only has had diabetic ketoacidosis, but he is also having to deal with cellulitis of his leg. As a homeless individual, L.M. has limited access to appropriate food, difficulty obtaining and storing his insulin, and an increased amount of physical and/or emotional stress (Axon, et al., 2016). Above all, gaining access to a primary care provider is much more difficult for a homeless person (Axon, et al., 2016). In order for L.M. to manage his chronic medical condition as well as his acute medical issues, he will need support in order to find services that are able to help him to at least have access to care on a regular basis. I think that while in the medical unit at the homeless shelter, this would be the best place for him to be educated on the things that he can do on a daily basis to improve his health as well as setting him up with a care provider on a regular basis.Reference
Axon, R.N., Gebregziabher, M., Dismuke, C.E., Hunt, K.J., Yeager, D., Santa Ana, E.J., and Egede, L.E. (2016). Differential impact of homelessness on glycemic control in veterans with type 2 diabetes mellitus. Journal of General Internal Medicine, 31;1331-1337, https://doi.org/10.1007/s11606-016-3786-z
297 words N512-19A Module 7: Disorders of the Endocrine System Across the Life Span