Clinical Significance/Impact It is Friday evening (Time 2000), and you are working in a busy Emergency Department. History of present illness: You are caring for Shelly, an 18-year-old female.

Clinical Significance/Impact
It is Friday evening (Time 2000), and you are working in a busy Emergency Department.
History of present illness: You are caring for Shelly, an 18-year-old female. She arrived at the emergency department with her mother. She complains of nausea, vomiting, and abdominal pain. She has gotten progressively more fatigued over the past week. Shelly is thirsty all of the time, but no matter how much she drinks she still feels thirsty. She is afebrile, awake, and alert.
Medical History: Diabetes mellitus type 1, neuropathy, migraines
Surgical history: none

History Details
Clinical Significance/Impact
Social History (from Shelly and mother) Shelly is a high school senior. She hopes to graduate and go to college to become a pediatric nurse. Her mother is involved in her care. Her mom reports that Shelly’s breath has smelled “fruity” lately, which is new. Shelly lives at home with her mother and father. She plays soccer for her high-school team and is active. She eats a healthy low carbohydrate diet. Her current BMI is 18.5. Shelly has had episodes of depression since being diagnosed with DM type 1, three years ago but denies feeling depressed now. She reports sleeping 6-8 hours a night on average, but still feels tired in the morning and throughout the day. She denies illicit drug use, alcohol, or current tobacco use. She is up to date on annual appointments and takes her medication as prescribed.

Subjective History
Clinical Significance/Impact
Subjective History (from Shelly and Mother): Shelly enjoys soccer and reading. When she was diagnosed with DM type 1, initially she was scared, but has become more accustomed to the lifestyle. She has had two episodes of hypoglycemia while at school in the past. She admits she does not eat enough when at school. She received her glucometer from her pediatrician 3 years ago. Recently her glucometer has stopped working and she has been “guessing” the amount of insulin she needs throughout the day. She usually takes a basal dose of 15 units at bedtime and short acting insulin with meals. Based on her blood glucose level she will administer sliding scale insulin from 2-10 units with meals. She did not tell her mother her glucometer was broken because she knows her mother struggles financially and did not want to burden her with another cost. Shelly has felt fatigued for about a week and has missed the last two days of school. She is uncertain about a recent blood glucose reading. She does not get migraines as frequently as she used to. Her last migraine headache was 1 month ago, triggered after a soccer game.
Shelly takes the following RX medications:
Medication
Dose
Last dose taken
Insulin aspart (NovoRapid)
Sliding scale 2-10 units with meals
0800 yesterday
Insulin glargine (Lantus)
15 units HS
2100 yesterday
Eletriptan
20 mg PRN Daily for migraine
1 month ago
Nursing Assessment: What assessment data is important?
Clinical Significance/Impact

Detail
Clinical Significance/Impact
Objective Data
General Appearance: Shelly appears healthy and athletic. She is lying in bed on her right side. She is clean and well groomed. She is weak and lethargic. Her mother is at bedside holding her hand. She complains of severe nausea.
Temp: 37?C (98.6?F)
BP: 128/65 mmHg MAP 86
HR: 100 bpm
RR: 20
SpO2: 99% on RA
NEURO: Alert and oriented to person/place/time/situation. GCS 15. Follows commands. PERRLA intact.
CARDIAC: Mucous membranes are pink. Capillary refill <3 seconds. Apical HRR. Peripheral pulses palpable x4 at +2. No edema. No murmur.
RESP: All lobes clear. No stridor. Respirations are deep, but not labored.
GI: Abdomen flat. Soft and non-tender in all quadrants. NABS x4. Last BM was today- liquid. Positive for nausea and vomiting.
GU: Voids without pain and with frequency. Clear yellow urine.
Musculoskeletal: Moves all extremities with no overt deficits. Ambulates unassisted. Equal grip strength bilaterally.
Integumentary: Scar noted on BLLE shins. Warm and dry. No wounds.
Psychosocial: Flat affect, mother at bedside for social support.
What diagnosis do you suspect and why?
Clinical Significance/Impact

You receive the following orders from the provider.
Clinical Significance/Impact
Serum blood glucose level
Urinalysis
Serum chemistry panel
Serum magnesium
Serum phosphorus
Arterial blood gas
The RN receives the following orders from the provider.
Clinical Significance/Impact
Monitor vital signs
NPO
Intravenous access
Continuous cardiac monitoring

Diagnostic Test Results
Clinical Significance/Impact
Serum blood glucose level
625 mg/dL
Urinalysis
Appearance: clear
Color: pale yellow
Odor: none odorous
PH: 4.8
Protein: 5mg/dL
Specific gravity: 1.005
Leukocyte esterase: negative
Nitrates: negative
Ketones: positive
Crystals: negative
Casts: negative
Glucose: positive
WBCs: 1
RBCs: 250
Current BG (mg/dL) / previous BG (mg/dL) x current infusion rate (mL/hr) x 1.20
181-250
Current BG (mg/dL) / previous BG (mg/dL) x current infusion rate (mL/hr) x 1.10
171-180
Current BG (mg/dL) / previous BG (mg/dL) x current infusion rate (mL/hr) x 1.05
150-170
Current BG (mg/dL) / previous BG (mg/dL) x current infusion rate (mL/hr) x
140-149
Current BG (mg/dL) / previous BG (mg/dL) x current infusion rate (mL/hr) x 0.95
120-139
Current BG (mg/dL) / previous BG (mg/dL) x current infusion rate (mL/hr) x 0.90
100-119
Current BG (mg/dL) / previous BG (mg/dL) x current infusion rate (mL/hr) x 0.80
100 mg/dL, restart the infusion at the previous rate x 0.5 and check BG after 60 minutes.
Answer Choices
A. The nurse will titrate the infusion to 6 units/hour
B. The nurse will titrate the infusion to 7 units/hour
C. The nurse will keep the infusion at 4 units/hour
D. The nurse will titrate the infusion to 5 units/hour

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