NURSING Assignment 1 Case Study
Answer1:
Pathophysiology of the given signs and symptoms from case study
The Signs and symptoms of Ms. Gladys Liu can be described as dehydration, tachycardia,
hyperventilation and hypotension. The more pronounced form of symptoms can include nausea
and vomiting like sensation, frequent and excessive urination along with mild to severe pain in
the lower abdominal region. The physical examination with shows cracked lips, sunken eyes
provides clinical evidence of dehydration. This will also be associated with the turgor in skin,
dry skin, faint and ill physical appearance and dry mucous membrane. One of the most common
and early symptom associated with be increase in thirst that is polydipsia. It should be noted that
the owing to the problem of dehydration, there will be a decrease in blood volume in the
circulation. Furthermore the decrease in the blood volume in the circulation leads to fastening of
the heart rate as well as low blood pressure. This is evidenced with the clinical data suggesting
decreased blood pressure of 100/65 mmHg and heart rate of 125 beats per minutes. Such
situation often leads to confusion (altered consciousness) and mild disorientation in the behavior.
Diabetic ketoacidosis arise due to lack of insulin in body. Sepsis in the present case may arise
from infections (Lewis, 2013). Since as the patient has a long history of Type II Diabetes
Mellitus; the pathophysiology may be as follows:
 Lack of insulin and abundance of glucagon raises the blood sugar level. Once glucose
level rises above urinary threshold, it causes dehydration by osmotic diuresis.
 Lack of insulin also elevates the free fatty acid in blood, furthermore which will be
converted into ketone bodies in liver.
 The ketone bodies in blood lower the pH of blood. Bicarbonate buffer system, in this
situation often fails to maintain fluid pH of body. In order to compensate acidosis
hyperventilation in such as case, it is necessary to remove CO2 from body.
Rationale of symptoms:




Dehydration – Due to osmotic diuresis.
Tachycardia and Hypotension - Due to dehydration and acidosis.
Hyperventilation- Compensatory mechanism to raise the pH of blood.
Elevated Body Temperature- Due to acute infection.
Management aspects
In the present case, Ms. Gladys has lost a huge amount of fluid and may have very high level of
blood sugar; the following urgent steps should be undertaken for as a part of treatment regime in
order to manage the medical condition (Pickup & Williams, 1991):
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NURSING Assignment 1 Case Study
 Fluid replenishment: Rapid infusion of saline approximately 1 liter per day is
recommended in order to restore the circulatory volume.
 Potassium replenishment: It is a general fact that insulin decreases the potassium level in
the physiological condition by virtue of redistribution inside the cells. Moreover there
will be a huge loss of potassium in the urine because of osmotic diuresis. A regular
assessment of body potassium level is needed in this case and the potassium should be
administered by intravenous route in case the level of potassium in blood decreases
below 5.3 mmol. Liter-1.
 Insulin: Bolus dose of Insulin after attaining normal potassium levels. In general if the
potassium level of the body is higher than 3.3 mmol. Liter-1 a prescribed dose of insulin
(0.1 unit per kg of body weight) is recommended for administration. The administration
of insulin should be carefully monitored with respect to the blood sugar level. It should
be noted that the insulin administration will help in recusing the blood sugar level as well
as for suppression of ketone body production.
 Bicarbonate: The increase of blood pH because of high level of ketone is also necessary
to maintain. A prescribed dose of sodium bicarbonate is thus required to compensate
(increase) the pH level of acidic blood.
 Blood pH, Blood glucose, Blood potassium level and heart rate to be monitored at regular
interval.
 Immediate broad spectrum antibiotic treatment. Sepsis with respect to urinary tract
infection should be confirmed after test and antibiotics oriented for management in this
respect should be thus attempted only after confirmation.
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NURSING Assignment 1 Case Study
Question2:
Investigation and test
A brief of the necessary investigation and/or test that is required to be ordered for Ms. Gladys are
explained in Table 1 (Provan, 2010). The justified normal levels of specific attributes in each of
the investigation and/or test have been mentioned as normal level. A brief of the rationale for
each of the individual investigation has been provided in the table.
Table 1: Relevant investigation and/or test that should be addressed in context of Ms. Gladys.
Sl.
No.
1
Investigation
2
Blood
Ketone < 0.6mmol/L
Bodies Measurement
Arterial Blood Gas pH 7.34-7.44
Measurement
PaO211-13kPa
PaCO24.7-6.0kPa
Venous
Blood PaO2 30-40 mmHg
Measurements
PaCO2
40-50
mmHg
Urine Ketone Bodies 0.5-3.0 mg/dl
Measurement
Blood
β- 0.4-0.5 mmol/L
hydroxybutyrate
Serum Creatinine/ Urea- 20-40 mg/dL
Urea
Creatinine- 0.7-1.2
mg/dL
Complete
Blood Normal Cell counts
Count
C-reactive Protein Below
1.0
Test
milligram
per
deciliter
Culture of blood and NA
urine sample
3
4
5
6
7
8
9
10
Normal Level
Blood Glucose Level 80-110 mg/dl
Rationale
To check the level of hyperglycaemia and
determine the dose of insulin
To determine the mode of administration of
anti-hyperglycaemias medication
To determine the lungs efficacy in gaseous
exchange and buffering capacity of blood
To determine the lungs efficacy in gaseous
exchange and buffering capacity of blood
To justify the associated investigation of
Diabetic Ketoacidosis.
To determine the level of starvation
To determine the renal efficacy
To determine infection, if any.
To determine infection, if any.
To determine UIT or Sepsis, if any.
Expected results:
According to the American Diabetes Association, there are three stages of Diabetic ketoacidosis,
viz. mild, moderate and severe, depending upon the blood pH, bicarbonate level and physical
fitness of patient. Some of the general criteria that are expected from the above investigations of
Ms. Gladys are;
 Plasma glucose will be more than 250 mg.dl-1.
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NURSING Assignment 1 Case Study
 pH of blood will be in a range of <7.0, 7.0 – 7.24 and 7.25 - 7.3 depending upon the
classification system of severe, moderate and mild stages of Diabetic ketoacidosis.
 Similarly, bicarbonate level of serum will be <10, 10-15 and 15-18 depending upon the
classification system of severe, moderate and mild stages of Diabetic ketoacidosis.
 Urine and/or serum ketone will be positive in test.
 Mental status or physiological fitness can be attributed to stupor like condition,
drowsiness and alert as corresponding to severe, moderate and mild stages of Diabetic
ketoacidosis.
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NURSING Assignment 1 Case Study
Question 3:
Pharmacodynamics and pharmacokinetics of Metformin
Form the investigations, the patient may have been detected with sepsis along with Diabetes
Ketoacidosis. Chemically Metformin is a bi-guanide which is used as anti-hyperglycemic agent.
Metformin in any case (both pharmacologically as well as chemically) is not related to any of the
commonly used oral anti-hyperglycemic agents. This is generally recommended for the treatment
of non-insulin-dependent diabetes mellitus (NIDDM). In order to maintain blood glucose level
metformin was administered. Metformin improves the blood glucose level by chiefly acting on
liver glucose production and increasing the peripheral tissue sensitivity to insulin. It is
noteworthy to mention that Metformin as such is not potent for induce hypoglycemia; rather it
potentiates the effect of insulin with respect to the hypoglycemia effects. Additionally it also has
no effect on secretion rate of insulin in body. Along with this Metformin also has a positive
effect in reducing the lipid level of body. It has a bioavailability of around 40 – 60 %. The
duration of action of Metformin lasts for approximately 8 – 12 hours. Excreted through kidneys,
and has a plasma half-life of 4 - 8.7 hours and it has a characteristics of negligible binding with
plasma proteins. Metformin does not produce any metabolite. It has potential to produce drug
interaction (more appropriately said as adverse drug interaction) by interacting with transport
system. The major associated with Metformin side-effect is lactic acidosis (Moses, 2010, p.331).
Pharmacodynamics and pharmacokinetics of Trimethoprim
Trimethoprim in-general is used as for administration for the treatment of Urinary Tract
Infection (UTI) with pathogen susceptible to trimethoprim. Trimethoprim is a pyrimidine
analogue which acts as an antibacterial drug. The mechanism of action of Trimethoprim can be
accounted as by dihydrofolate reductase inhibition (inhibition of reduction of dihydrofolic acid to
tetrahydrofolic acid). It is active against wide range of gram positive and negative bacteria and
hence is often considered as for broad spectrum antibiotics. With the inhibition of enzyme
dihydrofolate reductase, it makes the bacteria starves for nucleotides which in turn hampers
bacterial process of DNA replication and thereby acts as antibacterial agent. It is noteworthy to
mention that the affinity of bacterial enzyme of Trimethoprim is thousand times more compared
to that for human dihydrofolate reductase. It has a fast and nearly complete absorption rate in the
gastro intestinal tract. The peak plasma concentration reaches to 1ug/ml after oral administration
of 100mg, and has half-life of 8-11 hours. The drug has a wide distribution characteristics to
tissues and body build especially in kidney, seminal fluids, lungs, vaginal secretions, bile and
cerebral spinal fluid. Additionally Trimethoprim also have a high percentage (42 – 46 %) of
binding attributes with plasma protein. Metabolism of this drug use to route via hepatic
metabolism; thereby produces secondary metabolites such as oxides and hydroxylated
metabolites. Suitable for renal impairment patient, as it is mostly excreted unchanged in urine
(Close, 2002, p.983).
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NURSING Assignment 1 Case Study
References:
LEWIS, S. L., DIRKSEN, S. R., HEITKEMPER, M. M., & BUCHER, L. (2013). MedicalSurgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier
Health Sciences.
PICKUP, J. C., & WILLIAMS, G. (Eds.). (1991). Textbook of diabetes (Vol. 1). WileyBlackwell.
PROVAN, D. (Ed.). (2010). Oxford handbook of clinical and laboratory investigation. Oxford
university press.
MOSES, R. G. (2010). Combination Therapy for Patients with Type 2 Diabetes: Repaglinide in
Combination with Metformin. Expert. Rev. Endocrinol Metab., 5(3), 331-342. Retrieved from
http://www.medscape.com/viewarticle/722513_6.
CLOSE, S. J., McBURNEY, C. R., GARVIN, C. G., CHEN, D. C., MARTIN, S. J. (2002).
Trimethoprim-Sulfamethoxazole Activity and Pharmacodynamics Against GlycopeptideIntermediate Staphylococcus aureus. Pharmacotherapy, 22(8), 983-989.
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