Case study - Hyperosmolar hyperglycemic syndrome (HHS): Nursing

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

After settling Ralph in the room, nurse, Juana goes to 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 BPM respirations, 22 breaths per minute BP, 1 10/65 millimeters of mercury 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 five 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.

Tell me more about how this pain is affecting you. Ralph.

It's my arthritis. It's been ok if I take ibuprofen, but I ran out my hands and fingers have been hurting so much.

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 ok. Next nurse Juan analyzes these cues.

She reviews the electronic health record or E hr and notes that before being stabilized in the ICU, Ralph was confused and his initial lab results were blood glucose.

624 mg per deciliter or 34.7 millimoles per liter. Serum osmolality.

345 milli osmoles per kilogram or 345 millimoles per kilogram, 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 two diabetes mellitus.

It occurs when blood glucose levels become elevated. Typically over 600 mg per deciliter or 34 millimoles per liter 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's 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, Huana recognizes Ralph needs help with self administering his insulin and obtaining healthy foods to prevent another occurrence of HHS.

Now, using the information she's 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 nonpharmacologic 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, Juan then takes action to implement these solutions.

First, nurse, Juana collaborates with Ralph's health care 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, Huana then enters Ralph's room to explain the plan of care. Hi, Ralph I have some ibuprofen here for your pain.

And then I'd like to discuss your plan of care with you. Nurse Juana administers Ral Ibuprofen using safe medication administration principles.

Ben sits in a chair next to Ralph's bedside. Your healthcare provider changed your insulin from a vial to an insulin pen.

This will make it easier to use and administer, especially when you're having pain in your hands and fingers. Sounds great.

Can you show me how to use it? Nurse Juana then demonstrates how to use the insulin pen?

Well, that looks like it'll be a lot easier for me to use. I'll give it a try.

Nurse Juana checks Ralph's blood glucose and ensures he dials the correct dose of insulin. Ralph.

Then effectively demonstrates use of his insulin pen. Wow, that was a lot easier.

This is something I can do at home. Excellent.

Now let's talk about foods you can eat to help keep your blood glucose under control. Nurse Juan explains how the social worker can help set up meal and grocery deliveries for him.

For times when he might not feel up to cooking or going to the grocery store. Then she reinforces how to choose healthy foods that can support his nutrition while keeping his glucose level controlled.

Two days later, Ralph is preparing to be discharged home and nurse Juana evaluates the outcome of her actions. She reviews the EHR and identifies multiple nursing notes indicating Ralph has been successfully administering his insulin at bedtime.

Ralph also says the social worker has set up biweekly meal deliveries to his home and showed him how to order grocery delivery for fresh, healthy food and other items as needed.

All right, as a quick recap, nurse, Juana recognized and analyzed cues related to Ralph's self care deficit and prioritized hypotheses and generated solutions to address this problem.

She then implemented pharmacologic and nonpharmacologic interventions, evaluated Ralph's outcomes and compared them to the expected outcome since Ralph was able to self administer his insulin and has a plan for maintaining a healthy diet.

Nurse, Juana determines the plan of care was successful.