Nursing Case Study for Type 1 Diabetes
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Outline
Michael is a 14-year-old male brought into a small ER by his mother. They were driving a long distance after he competed in a wrestling tournament. He had not felt well on the bus ride with the team so his mother decided he should ride with her. His mother denies a history of chronic illness but did say he had “like a cold but with a stomachache” about 3 months ago.
She also says that he has been very thirsty, and they had to stop several times for him to urinate. She is also worried because he almost missed his wrestling “weight class” parameters because he was significantly lighter this past weekend than he has been in the past. And that is even with him eating more than usual.
What symptoms are most worrisome to the triage nurse?
In triage, the nurse obtains a point-of-care blood glucose (BG) level and the machine gives no value. Instead, an error message indicating “hi” displays on the machine.
Why did the nurse do this test? What should they do next?
Michael is AAO x 4. He complains of a “stomachache” and reports he has nausea and experienced vomiting shortly before arrival. His skin is warm and dry, but his face is flushed. When asked about pain, he says he has a headache, and his vision is blurry. The nurse notices a fruity odor on his breath when obtaining vital signs.
BP 90/54 mmHg SpO2 98% on Room Air
HR 122 bpm and regular
RR 26 bpm at rest
Temp 37°C
The patient and his mother are placed into an exam room immediately and the triage nurse verbally reports this to the accepting nurse.
How does the nurse interpret these symptoms?
What orders does the accepting nurse anticipate?
The provider orders stat labs, urinalysis and ABGs then examines the patient.
Why stat orders?
Lab results are as follows:
CBC
WBC 15000 cells/mcL
HbgA1c 9%
BMP
Glucose 420 mg/dl
K 5.8
BUN 21 mg/dl
Creatinine 0.77 mg/dl
Anion gap 12
ABG
Ph 7.25
HCO3 15
PaCo2 35
PaO2 88
Urine
Glucose positive
Ketones positive
What do these results mean?
What medication orders should the nurse anticipate?
The provider tells Michael and his mother that he suspects diabetic ketoacidosis which is not uncommon for new type I diabetics. He plans to transfer Michael to a nearby city via helicopter for a higher level of care. The patient’s mother asks why he has to be transferred.
How does the nurse explain the transfer to the mother and patient?
The flight team arrives and assesses the patient. The ER completes a report using SBAR format at the bedside. The patient and his mother are given the chance to ask questions.
What are the transport team’s priorities as they move this patient?
Upon arrival to the higher level of care, Michael is admitted to the ICU overnight. By the morning he is transferred to a pediatric floor for further observation. His mother remains at his bedside. They plan to return to their home after discharge.
How should the pediatric medical unit prepare this family for discharge? What specific teaching should be provided?
References:
from uptodate: Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents-
Authors:Lynne L Levitsky, MDMadhusmita Misra, MD, MPH, updated Oct, 2021; Overview of the management of type 1 diabetes mellitus in children and adolescents
Authors:Lynne L Levitsky, MDMadhusmita Misra, MD, MPH, updated Nov, 2021; Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis
Authors:Irl B Hirsch, MDMichael Emmett, MD, updated Mar, 2020
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Transcript
Hey everyone. My name is Abby. We’re going to go through a case study for type one diabetes together. Let’s get started. In this scenario, Michael is a 14-year-old male brought into a small ER by his mother. They were driving a long distance after he competed in a wrestling tournament. He hadn’t felt well on the bus ride with the team, so his mother decided that he should ride with her. His mother denies a history of chronic illness, but did say he had a, like a cold, but with a stomachache, about three months ago. She also says that he’s been very thirsty, and they had to stop several times for him to urinate. She is also worried because he almost missed his wrestling weight class parameters because he was significantly lighter this past weekend than he had been in the past. Even though he’s been eating more than usual, we’re seeing polyuria and polydipsia from this scenario. Now let’s take a look at critical thinking check number one below.
Great job! In triage, the nurse obtains a point of care blood glucose level on the machine, but it gives no value. Instead, an error message indicating high displays on the machine. Now that we have these results, let’s take a look at critical thinking check number two below.
Excellent. Michael is still alert and oriented times four, but he complains of a stomachache and reports that he has nausea and has been experiencing vomiting shortly before arriving. His skin is warm and dry, but his face is flushed. When asked about pain, he says he has a headache, and his vision is blurry. The nurse notices a fruity odor on his breath when obtaining vital signs. Let’s take a look at those vitals; his blood pressure, 90 over 54 with a saturation of 98% on room air, and a heart rate of 122 beats per minute with a regular rhythm. His respiratory rate is 26 breaths per minute at rest with a temperature of 37 degrees Celsius. The patient and his mother go into an exam room immediately and the triage nurse verbally reports these findings to the accepting nurse. Now that we have some more information, let’s take a look at critical thinking check number three and number four below.
Great job. The provider orders stat labs, a urinalysis, and an arterial blood gas, and then examines the patient. With all of this in mind, let’s take a look at critical thinking check number five below.
Great job. Let’s look at those lab results. According to his CBC, he has a white blood cell count of 15,000. His hemoglobin A1C is 9%. In a look at his BMP, now we can see that his blood glucose is 420, yikes! A potassium of 5.8. again, outside of parameters, a BUN of 21, creatinine of 0.77 with an anion gap of 12. His ABG resulted with a pH of 7.25. Definitely acidotic. A bicarb of 15 PaO2 of 88 and a PaCO2 of 35. When we looked at his UA, it ended up showing that he was positive for glucose in the urine, as well as ketones. I bet you know what all of this is going to indicate. Let’s take a look at our critical thinking check number six and number seven below.
Great job. The provider tells Michael and his mother that he suspects diabetic ketoacidosis or DKA, which is not uncommon for new type one diabetics. He plans to transfer Michael to a nearby city by a helicopter for a higher level of care. The patient’s mother asks, why does he have to be transferred? With this in mind, let’s take a look at critical thinking check number eight below.
Well done! The flight team arrives and assesses the patient. The ER completes a report using the SBAR format at the bedside. The patient and his mother are given a chance to ask questions with all of this in mind. Let’s take a look at critical thinking check number nine below.
Great job! Upon arrival to the higher level of care, Michael is admitted to the ICU overnight. By the morning, he is transferred to the pediatric floor for further observation. His mother remains at the bedside. They plan to return to their home after discharge. Okay. Let’s wrap up with critical thinking check number 10 below.
Great job guys. This wraps up the case study on type one diabetes. Please take a look at the attached study tools and test your knowledge with a practice quiz. As always, we love you guys, now go out and be your best selves today, and, as always, happy nursing!
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