Case study - Hyperosmolar hyperglycemic syndrome (HHS): Nursing

Nurse Juana works on the medical unit and is caring for Ralph, a 76-year-old with a history of type 2 diabetes mellitus and osteoarthritis, who was transferred from the intensive care unit after being admitted for hyperosmolar hyperglycemic syndrome, or HHS, also known as hyperosmolar non-ketotic syndrome or hyperglycemic hyperosmolar non-ketotic coma.

After settling Ralph in the room, Nurse Juana goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Ralph’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Juana recognizes important cues, including Ralph’s vital signs, which are temperature 98.9 F, or 37.2 C, heart rate 92 beats per minute, respirations 22 breaths per minute, blood pressure 110/65 mmHg, and oxygen saturation 98% on room air. He also states he’s having pain in his hands and fingers and rates his pain as a 5 on a 0 to 10 numeric scale.

Upon physical assessment, Nurse Juana notes Ralph has IV fluids infusing into a peripheral IV, and a moderate amount of light-yellow urine in his catheter bag.

Nurse Juana: Tell me more about how this pain is affecting you, Ralph.

Ralph: It’s my arthritis. It’s been okay if I take ibuprofen, but I ran out. My hands and fingers have been hurting so I haven't wanted to cook. I’ve just been getting fast food. This past week, I was having trouble taking my insulin, too. It’s just too difficult to draw it up with the syringe and vial, even when my hands feel okay.

Next, Nurse Juana analyzes these cues. She reviews the electronic health record, or EHR, and notes that before being stabilized in the ICU, Ralph was confused and his initial lab results were blood glucose 624 mg/dL or 34.7 mmol/L; serum osmolality 345 mOsm/kg, or 345 mmol/kg; hemoglobin A1C 8%; arterial blood gas, or ABG, revealed no acidosis; and his urine was free of ketones. She also notes that Ralph is prescribed metformin and a long-acting injectable insulin at bedtime using a syringe and vial when at home.

Nurse Juana knows that HHS is a complication typically associated with uncontrolled type 2 diabetes mellitus. It occurs when blood glucose levels become elevated, typically over 600 mg/dL, or 34 mmol/L, due to lack of sufficient insulin, like when Ralph was unable to take his nighttime insulin as prescribed.

Nurse Juana knows that without insulin, glucose can’t move from the blood into the body’s cells. As blood glucose increases, this creates a hyperosmolar state, where there is a high concentration of certain substances, like glucose, in the blood; and can be identified with an elevated serum osmolality. This hyperosmolality draws water from the cells into the blood, leaving the cells dry, shriveled, and starving. The extra water in the blood is then eliminated via urination, leading to polyuria, or excessive urination.

Nurse Juana recognizes Ralph needs help with self-administering his insulin and obtaining healthy foods to prevent another occurrence of HHS.

Now, using the information she has gathered, along with Ralph's medical history, Nurse Juana chooses a priority hypothesis of self-care deficit.

Next, she generates solutions to address Ralph’s self-care deficit that will include pharmacologic and non-pharmacologic interventions; and she establishes the expected outcome that after intervening, Ralph will be able to self-administer his insulin and have access to healthy foods by the time he’s discharged.

Nurse Juana then takes action to implement these solutions. First, Nurse Juana collaborates with Ralph’s healthcare provider and the pharmacist to explain Ralph’s difficulty with insulin vials and syringes. She also discusses with the social worker about setting up meal services and grocery delivery to ensure Ralph has access to fresh, healthy foods and other items he may need, like over-the-counter medications such as ibuprofen. Nurse Juana then enters Ralph’s room to explain the plan of care.