N512-19A Module 7 Discussion 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. 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 mg/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 a 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.

Sample Approach

Hyperglycemia occurs when “elevated glucose levels exceed the renal threshold for glucose reabsorption” (Hammer & McPhee, 2019), leading to polyuria, polydipsia, and polyphagia (Hammer & McPhee, 2019). Diabetic ketoacidosis is a metabolic state that occurs when there is a “loss of insulin activity leading to an increase of glucose levels due to an increased hepatic glucose output and decreased glucose uptake by insulin-sensitive tissues” (Hammer & McPhee, 2019).

When insulin is not present, the body begins to break down fat for energy causing acidic ketones to be released into the body (NHS Choices, 2019), and “acidosis occurs when ketone levels exceed the body’s buffering capacity” (Misra & Oliver, 2015). L.M.’s changes in mental status can be attributed to the combined factors of being in DKA, fever, and low sodium levels.

A deep, rapid breathing pattern is indicative of Kussmaul respirations due to L.M. being in DKA. The pathophysiology of Kussmaul respirations is the build of acidic ketones in the blood and the respiratory system responds by increasing the rate and depth of breathing to help expel carbon dioxide (Nall, 2020).

The plan of care while hospitalized for L.M. would be to correct the loss of fluids with intravenous fluids, correct his hyperglycemia with insulin, correct any electrolyte imbalances, and the treatment of the infection in his right lower extremity (Hamdy, 2018). In addition to medical treatment, L.M. would need cardiac monitoring, routine labs to monitor glucose and electrolyte levels, and patient education on diet, diabetes, and care of lower extremity.

L.M.’s plan of care, once he is discharged to the medical floor of the homeless shelter, can be complicated due to the possibility of L.M. not maintaining compliance. While on the medical floor, L.M. would be monitored for continued resolution and care of his infected lower extremity, glucose levels would be monitored, and continued education on the importance of routinely checking his feet for sores/infection, maintaining a balanced diet, follow-up care, medication compliance, and resources that are available to him. With access to medical services at the homeless shelter, L.M. has the potential to effectively maintain and control his diabetes.