Case study - New-onset diabetes mellitus: Nursing

Nurse Harvey works in a primary care office and is caring for Maru, a 69-year-old female who presents for a well-care visit. In collaboration with the registered nurse, RN Pam, Nurse Harvey goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Maru’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Harvey recognizes important cues, including Maru’s vital signs, which are temperature 98.9° F, or 37.2° C, heart rate 71 beats per minute, respirations 16 breaths per minute, blood pressure 108/62 mmHg, and oxygen saturation 99% on room air. She also rates her pain as 0 on a 0 to 10 numeric scale.

Nurse Harvey also notices Maru has used the restroom twice while waiting and she reports she’s been thirstier lately.

Next, Nurse Harvey analyzes these cues. He reviews the electronic health record, or EHR, and notes that Maru has been seen and treated for recurrent vaginal yeast infections three times in the past couple months. He also notes Maru’s routine lab work shows a fasting glucose of 155 mg/dL or 8.6 mmol/L and her hemoglobin A1C was 7%.

Nurse Harvey suspects Maru is experiencing the effects of an elevated blood glucose level, which could be caused by diabetes mellitus. He knows that diabetes mellitus is a metabolic condition where there’s insufficient insulin to move glucose from the blood into cells for energy.

He knows that as people age, insulin production decreases and insulin resistance increases, placing them at risk for diabetes. With insufficient insulin and increased insulin resistance, blood glucose levels increase, leading to a hyperosmolar state.

This hyperosmolar state pulls water from cells into the blood vessels where it’s then removed through urination. This causes polyuria, or frequent urination.

Lastly, Nurse Harvey knows that diabetes can increase the risk for certain infections because individuals with diabetes have weaker immune systems and extra glucose excreted in the urine can be used as energy for certain microorganisms, like yeast.

Nurse Harvey recognizes Maru needs help managing her blood glucose.

Now, using the information he has gathered, along with Maru’s medical history, Nurse Harvey reports his findings to RN Pam and together they choose a priority hypothesis of impaired glucose regulation.

Next, Nurse Harvey collaborates with RN Pam to generate solutions to address Maru’s impaired glucose regulation that will include pharmacologic and non-pharmacologic interventions; and they establish the expected outcome that after intervening, Maru’s blood glucose will improve at her follow-up.

Nurse Harvey then takes action to implement these solutions. First, Nurse Harvey collaborates with Maru’s healthcare provider to share the information he’s gathered.