Video Case Study - Caring for Patients With Diabetes Mellitus

Nurse Charlotte works on a medical surgical floor and is caring for Jose, a 53 year old with a history of type one diabetes mellitus, who was admitted for diverticulitis and just returned to the unit after a CT scan.

In collaboration with the registered nurse, RN Luke, Nurse Charlotte goes through the steps of the clinical judgment measurement model to make clinical decisions about Jose's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes.

First, Nurse Charlotte recognizes important cues, including Jose's vital signs, which are temperature 98 °F or 36.6 °C, heart rate 87 BPM, respirations 18 breaths per minute, and oxygen saturation 95% on room air.

She also notices that Jose's hands are trembling slightly, and he's diaphoretic. Nurse Charlotte gathers more information from Jose.

Hi, Jose. Welcome back from your scan.

How are you feeling this morning? Jose responds, I'm OK, I guess.

I just feel a little weak and shaky. It started about 10 minutes ago.

Have you had anything to eat today? No, I haven't eaten since last night because of that test I had this morning.

Next, Nurse Charlotte analyzes these cues. She reviews the electronic health record, or EHR and notes that Jose received 5 units of insulin for a blood glucose level of 121 mg per deciliter last evening.

She also sees that Jose was ordered to be NPO after midnight for an abdominal CT scan that he underwent this morning. Nurse Charlotte understands that type one diabetes mellitus is a condition caused by autoimmune destruction of the pancreatic beta cells.

So, they can't produce and secrete insulin, and that treatment typically requires subcutaneous insulin administration. She also knows that hypoglycemia, or blood glucose below 70 mg per deciliter, is likely to occur if insulin is taken when a patient isn't eating, like when a patient is NPO, leading to clinical findings such as weakness, diaphoresis, and tremors.

Nurse Charlotte then checks Jose's blood glucose, which is 60 mg per deciliter. Based on this finding, she recognizes that Jose needs effective management of his hypoglycemia.

Next, using the information she's gathered, along with Jose's medical history, Nurse Charlotte discusses her findings with R and Luke, and they choose a priority hypothesis of altered blood glucose.

Then, they generate solutions to address Jose's altered blood glucose, and they establish the expected outcome that, after intervening, Jose's blood sugar will increase to at least 70 mg per deciliter within 15 minutes.

Nurse Charlotte takes action to implement these solutions. While RN Luke speaks with the healthcare provider who discontinues the NPO order and orders an oral diet for Jose, Nurse Charlotte initiates the facility's hypoglycemic protocol, gathers supplies, and re-enters Jose's room.

Hello, Jose. I've got some orange juice to help you increase your blood sugar.

OK. I hope it makes me feel better.

I'm pretty hungry too. We will also order you a meal tray, but in the meantime, I can bring you some peanut butter and crackers.

How does that sound? That sounds great.

Over the next hour, I'll be checking your blood sugar levels to make sure they're increasing and getting back to normal.

OK. 15 minutes later, Nurse Charlotte evaluates the outcomes of her actions.

She takes Jose's vital signs, which are temperature 98 °F or 36.6 °C, heart rate 85 BPM, respirations 15 breaths per minute, and oxygen saturation 95% on room air.

She then rechecks Jose's blood glucose, which is 78 mg per deciliter. Nurse Charlotte provides Jose with his meal tray and notes that he's no longer shaking or diaphoretic.

All right, there's a quick recap. Nurse Charlotte recognized and analyzed cues related to Jose's altered blood glucose, and in collaboration with RN Luke, prioritized hypotheses and generated solutions to address this problem.

Nurse Charlotte and RN Luke then took action, evaluated Jose's outcomes, and compared them to the expected outcome. Since Jose's blood glucose increased to over 70 mg per deciliter within 15 minutes, they determined that the plan of care was successful.