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Poor Diabetes Management and Hyperglycemia

Student Number: 810 121 269
Date Submitted: Monday, March 16th, 2015
Humber College ITAL

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Introduction
The case that is being presented in this paper is based on a 74 year old male who has a
history of type II Diabetes and COPD. He arrives at the clinic with hyperglycemia as his CBG is
18.6 mmoL and dehydrated. He is confused to place and time and is fatigued. His wife reports
that he drinks a bottle of whisky per day. His heart rate is 55 beats per minute, blood pressure is
110/50, and his oxygen saturation is 92 percent. He has had two episodes of diarrhea in the past
eight hours. Based on the case study details, my pathophysiological priority is altered health
maintenance related to poor diabetes management and my priority clinical manifestation is
hyperglycemia. The most effective nursing interventions are administering insulin IV, providing
fluid and electrolyte replacement, ongoing monitoring for hyperkalemia, ongoing monitoring
cardiac output, intake and output, glucose level, oxygen saturation, dysrhythmias, and ongoing
monitoring neurological status.
Pathophysiological Priority
Centred on the information provided in the case study, my pathophysiological priority is
altered health maintenance related to poor diabetes management due to his chronic alcohol
consumption. According to (Lewis, 2014), Insulin that is produced is either insufficient for the
needs of the body, is poorly utilized by the tissues, or both in type II diabetics. Individuals with
type II diabetes cannot utilize the insulin that is available to them, which may lead to
hyperglycemia if they do not follow a strict diet and have an excessive alcohol intake.
Poor diabetes management and chronic alcohol consumption have been associated with
severe medical emergencies and many people are uninformed of the importance of regulating
their blood glucose level to prevent such complications. According to a study by (Onwudiwe NC

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et al, 2011), the main barrier to diabetes self-management resulted from a deficient
understanding of target blood glucose and blood pressure. If the patient is oblivious of his target
blood glucose level, it is questionable that he will be motivated and take initiative to yield the
necessary steps into altering his own behaviour towards his excessive alcohol consumption. As a
probable result of this excessive alcohol consumption, the patient becomes hyperglycemic.
Primary Clinical Manifestation
A major complication of chronic alcohol consumption is hyperglycemia or an excess of
glucose in the bloodstream and it is evident in this patient as the CBG level is 18.6 mmoL.
Clinical manifestations of severe hyperglycemia are polydipsia, polyphagia, and polyuria which
may lead to dehydration and fatigue as seen in the patient. Chronic alcohol consumption is an
indicator of poor diabetes management and therefore hyperglycemia, in the individual with
altered health maintenance as his wife reports that he consumes a bottle of whisky per day. Type
II diabetics that were drinking had significantly higher HbA1c levels than in non-drinking type II
diabetics. In addition, type II diabetics that were drinking had higher fasting blood glucose
levels than type II diabetics that did not drink on the day of admission to the hospital (Emanuele
et al, 1998).
Regardless of the primary cause of this emergency hyperglycemia episode, it is crucial
that the patient be treated promptly in the event of an emergency to inhibit other serious
complications. According to (Crump, 2004), severe hyperglycemia can lead to HHS or diabetic
ketoacidosis (DKA), another life-threatening condition. Signs of DKA include dehydration,
rapid breathing, and drowsiness, and even diabetic coma which may precipitate if there is not
enough insulin and fluids available for the body.

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Nursing Interventions
To prevent such complications from occurring, swift and appropriate nursing
interventions must be implemented immediately. In this circumstance, administering a bolus
infusion of insulin, followed by a continuous infusion of insulin is critical in reducing the 18.6
mmoL blood glucose to normal levels. Short-acting insulin in a constant, low-dose, intravenous
infusion is the optimal treatment for hyperglycemia (Crump, 2004). Monitoring the blood
glucose level in the process as the insulin infusion may need to be increased or decreased
depending on the effectiveness of the treatment plays a major role in the assessment of the
patient.
Furthermore, monitoring the patients electrolytes, specifically potassium levels, are
imperative to prevent any further decreased cardiac output. The patient with hyperglycemia is
often hyperkalemic because potassium cannot get into the cells without insulin. The
hyperkalemia can lead to bradycardia or asystole (Crump, 2004). The patients pulse rate is 55
beats per minute which is already classified as bradycardia so further decreasing the pulse rate
may cause respiratory distress. If respiratory distress does occur, oxygen therapy may be
required as the patient has a history of COPD which may further exacerbate complications.
Fluid replacement for rehydration is important for the patient that is dehydrated and
hyperglycaemic. Providing fluids that contain electrolytes will not only rehydrate the patient, but
will also reduce his blood glucose levels. Osmosis causes fluid to flow from the intracellular
space to the extracellular space as a result of high blood glucose levels. Electrolyte depletion,
reduced kidney function, hypotension, and dehydration occur as a result of this fluid loss from
the intravascular space (Crump, 2004). As the patient has had two episodes of diarrhea in the
past eight hours, it is crucial to replenish the patient with fluids such as water.

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Continuously monitoring the patients glucose level, cardiac output, oxygen saturation,
dysrhythmias, and intake and output all take an important role in evaluating the effectiveness of
the treatment regime. According to (Crump, 2004), some of the complications that have been
reported are respiratory distress, pancreatitis, pulmonary edema, hypertriglyceridemia,
myocardial infarction, vascular thrombosis, and renal failure. In addition to the patients health
history of COPD, respiratory acidosis could potentially develop. Someone with renal failure and
pulmonary edema requires careful monitoring of urine intake and output due to increased fluid
retention and increased fluid loss could lead to further dehydration.
It is important to constantly monitor his neurological status to determine treatment
effectiveness. He initially presented with confusion to place and time, listlessness and fatigued.
Moreover, this will determine patient safety as he may be at a risk for falls due to fatigue and
confusion. According to (Lewis, 2014), lethargy and weakness are early symptoms of severe
hyperglycemia. Any decrease in LOC could indicate potential complications such as a coma.
Monitoring LOC to person, place, and time is one method to evaluate his neurological status.
Conclusion
To summarize, concentrating on the patients hyperglycemia would be of my utmost
priority in this emergency situation. The consequences of hyperglycemia are severe and must be
addressed immediately as complications can generate rapidly. By addressing his hyperglycemia
by evidence based nursing interventions, it prevents the patients condition from further
deteriorating and may improve his condition considerably. Chronic alcohol consumption is
directly associated with the incidence of hyperglycemia which can be avoided by understanding
the relationship between alcohol intake and poor diabetes management.

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References
Crump, V. (2004). Hyperglycemia Crisis: Regaining Control. 67(4), 4-4. Retrieved March 2,
2015, from http://web.a.ebscohost.com.rap.ocls.ca/ehost/pdfviewer/pdfviewer?
vid=7&sid=a4e4b7ef-5d36-4ed8-881c-741b032a4079@sessionmgr4001&hid=4104
Emanuele, N., & Swade, T. (1998). Consequences of Alcohol Use in Diabetics. Retrieved March
3, 2015, from http://pubs.niaaa.nih.gov/publications/arh22-3/211.pdf
Lewis, Sharon L. Medical-Surgical Nursing in Canada, 3rd Edition. Mosby Canada, 2014.
VitalBook file.
Onwudiwe, N., Mullins, C., Winston, R., Shaya, F., Pradel, F., Laird, A., & Saunders, E. (2011).
Retrieved March 3, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/21462726