Health History
• Patient: H.T.
• Age: 30 years old
• Gender: Female
• Ethnicity: Hispanic
• Chief complaint: cold sweats, nausea, vomiting, and disorientation.
• The patient’s history of present illness on admission includes type I diabetes and missing insulin administration.
• Past and current medical history: Type I diabetes, hypothyroidism, hypertension, and asthma.
Laboratory/ Diagnostic Testing
Arterial Blood Gas (ABG)
• Ph: 7.20
• PCO2:50
• HCO3: 12
• PO2: 96%
Basic Metabolic panel (BMP)
• Glucose: 799
• BUN: 23
• Na: 128
• K: 6.5
• Cl: 121
• Creat: 8
• Ca: 8.3
• Phos: 2.1
• Mag: 1.4
Complete Blood count (CBC)
• WBC: 16,500
• RBC: 3.58
• Hgb: 10.9
• Hct: 31.9
• Plt: 233,000
Urinalysis
○ Urine PH: 4.0
○ Protein = 10.0
○ Ketones = 2.8
Here is a list of medications that the patient is currently on:
• Lispro sliding scale
• Lantus 20 units
• Lisinopril 10 mg by mouth daily
• Gabapentin 100 mg by mouth three times a day
• Montelukast
• Levothyroxine 25mcg by mouth daily
• Glucagon PRN per protocol if less than 40 and symptomatic
• Glucometer check every 1 to 2 hours
1 This patient has been diagnosed with type 1 diabetes. The patient stated she needs more education about type 1 diabetes. Since her blood glucose levels have been normal she does not need to take the medication that has been prescribed and what are your rationales?
2 What are some possible treatments for this patient after reviewing his labs and what are your rationales?
3 What important information regarding sick day rules and management of diabetes is required for this patient. Please provide rationales with your response.
4 The dietitian is on maternity leave and this patient needs to be educated on what diet is best for her diabetes, which will help her maintain proper glucose levels. Please provide rationales.
5 In order to improve the patient’s physical strength and educate them on ways to stay active around the house when discharged. What patient teaching is required and your rationale?
6 Family support, relatives, and friends play a big role in inpatient care. They promote rapid healing and support any patient education on how to maintain a healthy condition and knowing when to go to the healthcare provider or in an emergency situation. What teaching should the nurse provide to the patient and her family for emergencies associated with her disease process. Please provide rationales with your answer.
7 What are 4 nursing diagnoses for this patient with your rationales?
8 What patient teaching should the nurse provide on Lispro, Lantus, Lisinopril, Gabapentin, Montelukast, and Levothyroxine.
9 How does the following affect the patient and her disease process, influence compliance with her medical regimen?
– family patterns
– economic issues
– spiritual
– culture
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