A patient with acute pancreatitis is reporting excessive thirst, excessive voiding, and blurred vision. As the nurse, it is priority you:
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A 21-year-old female (A.M.) presents to the urgent care clinic with symptoms of nausea, vomiting, diarrhea, and a fever for 3 days. She states that she has Type I diabetes and has not been managing her blood sugars since she's been ill and unable to keep any food down. She's only tolerated sips of water and juices. Since she's also been unable to eat, she hasn't taken any insulin as directed. While helping A.M. from the lobby to the examining room, you note that she's unsteady, her skin is warm and flushed, and that she's drowsy. You also note that she's breathing rapidly and smell a slight sweet/fruity odor. A.M. has difficulty answering questions but keeps asking for water to drink. You get more information from A.M. and learn: - She had some readings on her glucometer which were reading 'high'. - She vomits almost every time she takes in fluid. - She hasn't voided for a day but voided a great deal the day before. - She's been sleeping long hours and finally woke up this morning and decided to seek care. Current labs and vital signs: What is the pathophysiology for the condition you believe A.M. has? Relate the etiology and clinical manifestations for the condition you identified for A.M. The practitioner at the urgent care facility makes the decision that A.M. needs to go to the hospital by ambulance. Once at the Emergency Department (ED), the ED physician orders these items: - 1000 ml Lactated Ringer's (LR) IV stat - 36 units NPH (Humulin N) and 20 units regular (Humulin R) insulin SQ now - CBC with differential; CMP: blood cultures X2 sites; clean-catch urine for UA and C&S; stool for ova and parasites; Clostridium difficile toxin, and C&S; serum lactate; ketone; osmolality; ABGs on room air - 1800 calorie, carbohydrate-controlled diet - Bed rest - Acetaminophen (Tylenol) 650 mg orally Q4 hrs PRN - Furosemide (Lasix) 60 mg IV push now - Urinary output every hour - VS every shift The orders above -- which are questionable related to her condition and which are appropriate? What are the expected treatments for this condition? Instructions: Summarize the questions above and formulate what may be happening with A.M. and how you would improve her condition. Use two evidence-based articles from peer-reviewed journals or scholarly sources to support your findings. Be sure to cite your sources in-text.
Madhur L.
ENDOCRINE SYSTEM Diabetes mellitus A 14-year-old male is brought to the ER being found unresponsive. The patient's mother, who had not seen the child for over 24 hours, came home to find her son lying on the sofa unresponsive. Copious quantities of black colored vomit were evident. The child is a diabetic and gives himself his own medication. His mother was unsure when her son last took his medication. Blood pressure: 101/72; heart rate: 123; respirations: 32; oral temperature: 34.8°C; pulse oximetry: 100% on room air. General: An approximately 65 Kg, thin male who is, in general, responsive only to very loud or painful stimuli. His oropharynx demonstrates very dry mucous membranes and a moderate amount of dried, black material which is strongly Gastrocult positive. His lungs are clear, but display Kussmaul respiratory pattern. Abdomen exam is negative. There are no other pathological findings. 1. How would you proceed from here? Does this patient need an IV? If so, what types of fluid do you want to initiate and at what rate? 2. What basic lab tests would you order? 3. In addition to saline the patient was given a bolus of 10 units of regular insulin IV while waiting for the lab results, do you find it necessary, too risky? 4. A serum glucose determination (Accucheck) was too high to read. How does this affect your differential diagnosis? What additional care would you now render this patient? 5. The results came back shortly thereafter, and showed an arterial blood gas pH of 6.92, CO2 of 9 and a bicarb of 2. The WBC count was 62.6 thousand (62,600), hemoglobin of 14.4 mg/dL, and hematocrit of 43.5%. His chemistry panel demonstrated a serum sodium of 127, potassium 5.2, chloride of 87, CO2 of less than 5, BUN of 32, creatinine 1.5, and a blood sugar of 1,582. The serum ketones were positive at a dilution of 1:32. What is your interpretation of these results? What additional treatment would you add? a. Blood sugar b. Serum ketones c. Dehydration d. Electrolyte changes; What type of acidosis is this? e. BUN and creatinine f. WBC 6. What might trigger a DKA? 7. Would you administer antibiotics?
Adi S.
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