Mrs. Guadalupe Hernandez, age 65, has been hospitalized for complications of her diabetes. She was diagnosed with adult onset diabetes mellitus (AODM) since age 51. She takes glyburide 10 mg q.d. She does not have a home glucose monitor. Last week she developed an ulcer on her left great toe, which she has been treating at home. She is unable to visualize her feet well, but she thinks it’s getting worse. She noticed some red streaks on her ankle yesterday. The previous day at home she reports being very thirsty and needing to urinate frequently. Last evening she began feeling nauseated and vomited twice. When she came to the emergency room this morning she reported feeling very fatigued and had vomited once more. On physical exam, she has a fruity breath odor. Her vital signs are: T=100.1, P= 102, R= 28, BP= 96/62. Her BMI is 32. Initial nursing assessment reveals a tired-looking woman with little ability to answer questions. She states that she has not eaten or taken her medication since yesterday morning. Her breakfast that morning was two corn tortillas with cheddar cheese and refried beans, and two cups of coffee with milk and sugar. Her left great toe has a 5cm round ulcer that involves the full depth of the skin and is bright red in color with a small amount of yellow-green exudate. The surrounding area is indurated and hot to the touch. Red streaks are present from her ankle to mid-calf. She has little feeling in her feet, and admits that the ulcer may have been present for some time.
Tests done in the emergency department indicate:
Blood glucose: 480 mg/dL
Serum bicarbonate: 12 mEq/L
Serum positive for ketones
Potassium: 3.7 mEq/L
Sodium: 140 mEq/L
Calcium 10 mg/dL
Leukocyte count is 22,000 U/L, with a shift to the left
POINTS TO PONDER:
1. Which lab values are abnormal?
2. What clinical manifestations correspond to the abnormal values?
3. Describe the changes (pathophysiology) in the body causing each abnormal value and link the value to a clinical manifestation present in the patient?
4. Which values are within normal limits?
5. What nursing care needs to be implemented?
6. Provide one nursing diagnosis appropriate to this patient.