Purdue University Northwest

College of Nursing

Online RNBSN Program


DIRECTIONS: Please answer all of the questions within the case study with comprehensive answers. You need to include at minimum two references: one can be your textbook and the other is your choice whether it be an article or another textbook. You must include in text citations as well as a reference list. Both should be in APA format.

Chief Complaint: Hyperglycemia

History of Present Illness: This is a 66 year old female that had labs drawn after a routine follow up visit with her primary care provider today. She received a call from the nurse practitioner telling her to go directly to the hospital for a glucose of 520mg/dl.

Past Medical History: Diabetes Mellitus Type II diagnosed at age 45. Emphysema diagnosed at age 55, Hypertension diagnosed at age 46, Hyperlipidemia diagnosed age 65.

Family History: +Hypertension- mother and father; +Lung cancer- mother; +diabetes- mother / sister

Social History: Tobacco dependence 1 pack per day for the last 46 years. Last cigarette this morning at 9am. Denies alcohol use. Denies illicit drug use.

Allergies: Penicillin

Medications: Glucophage 500mg po bid; Lisinopril 10mg po daily; Hydrochlorothiazide 50mg po daily; Aspirin 325mg po daily; Albuterol inhaler 2 puffs qid prn; Combivent 2 puffs qid; Advair 1 inhalation bid;

Review of Systems:

Constitutional Symptoms: +Weight loss 5 pounds in in the last month; +obese, +fatigue, +poor appetite Integumentary: +Color changes in lower extremities.

HEENT: Eyes: +Vision changes within the last week with +blurriness, +wears glasses; Ears: No hearing changes. Nose: Denies any problems. Throat: Denies sore throat or dysphagia.

Cardiovascular: +occasional chest pain with exertion, +hypertension well controlled – compliant with medications, swelling lower extremities for the last month; +varicose veins

Respiratory: +Dyspnea, +sputum, +wheezing, Emphysema – uses as needed albuterol inhaler once a day, and is compliant with Combivent and Advair, continues to smoke 1 pack per day of cigarettes.

Musculoskeletal: Denies joint pain, swelling, arthritis.

Gastrointestinal: +poor appetite; +nausea, +heartburn; +occasional abdominal pain lower quadrants.

Genitourinary: +polyuria, +polydipsia, denies polyphagia, + frequency, Denies dysuria, hematuria, burning, urgency

Neurological: Denies memory loss, tremors, numbness

Endocrine: +Diabetes compliant and well controlled – patient states her am fasting accucheck is 100-120mg/dl, +excessive thirst over the last 2 days.

Psychiatric: Denies Depression, anxiety, substance abuse.

Physical Exam

Vital Signs: T: 98.2; HR: 84; R: 24; B/P: 148/89; O2 sat: 90% on room air; Ht: 5’6’; Wt: 278; Waist circ: 48

Constitutional: Alert, Appears older than stated age.

Integumentary: Pink, warm, dry, and intact. Bilateral lower extremities with stasis dermatitis, +clubbing.

HEENT: Normocephalic, PERRLA, moist mucus membranes, neck supple, no thyromegaly. Cardiovascular: Reg rate /rhythm, no murmur/rub/gallop, S1/S2, edema 2+ pitting B/L lower extremities.

Respiratory: Tachypnea, slightly labored with expiratory wheezes.

Musculoskeletal: Normal and equal motor/strength/ROM.

Gastrointestinal: Abdomen soft, obese, nontender, nondistended, obese with active bowel sounds.

Genitourinary: Urine is clear, pale yellow.

Neurological: Awake, alert, oriented x 3. No tics. Hematologic/Lymphatic: Lymphadenopathy

Psychiatric: Calm, cooperative

Labs and Diagnostics: Table 14.2 Laboratory Blood Test Results


Appearance: Pale yellow / clear (-) Nitrate (-) Bilirubin (+) Protein (-) Microalbuminuria

pH 5.8 Specific gravity 1.015 (+) Ketones (+)Glucose (-) Microscopy


Na 133 meq/L WBC 16.8 x 103/mm3 Alb 3.2 g/dL

K 3.1 meq/L Hb 10.6 g/dL Protein, total 6.8 g/dL

Cl 109 meq/L Hct 45% Total Chol 266

HCO3 16 meq/L Plt 155 x 103/mm3 LDL 170mg/dl

BUN 40 mg/dL AST 14 IU/L Mg 2.5 mg/dL HDL 32mg/dl

Cr 1.28 mg/dL ALT 31 IU/L Triglycerides 356mg/dl

Ca 8.8 mg/dL Alk phos 78 IU/L

Glu, nonfasting 420 mg/dL Bilirubin, total 0.3 mg/dL

PO4 4.8 mg/dL PT 14.2 sec

CXR = Hyperinflation of the lungs with flattened diaphragm, no evidence of consolidation or atelectasis


Answer the following questions based on the information above:

1) Explain the pathophysiology of diabetes type 2. (3 points)

2) What medication(s) is the patient taking for diabetes mellitus type II? (1point)

3) In understanding metabolic syndrome – explain what results support a diagnosis of metabolic syndrome. (3 points)

4) What are the similarities and differences between diabetes mellitus type I and diabetes mellitus type II. (8 points)

5) What complication of diabetes does this patient have? Explain the process of the complication. What lab results/UA results support this diagnosis? (5 points)


Clinical Course: The patient is admitted to the telemetry floor for diabetic ketoacidosis and becomes your patient. The patient has been given potassium replacement orally and started on IV fluids and an insulin drip. After 6 hours of being under your care the patient complains of increasing shortness of breath and believes her swelling of lower extremities is worsening. You obtain vital signs:

Vital Signs: T: 99.8; HR: 110; R: 32; B/P: 172/98; O2 sat: 86% on 2 Liters O2 per NC

Stat labs and chest x-ray are obtained and an echocardiogram and EKG has been ordered.

Labs and Diagnostics:


Na 134 meq/L K 2.9 meq/L Cl 109 meq/L HCO3 17 meq/L BUN 44 mg/dL Cr 1.5 mg/dL

WBC 16.8 x 103/mm3 Hb 10.6 g/dl / Hct45% TROP: 0.34 ng/ml CK: 102U/L CKMB: 3ng/mL

BNP 1025pg/ml Glucose 180

CXR = Hyperinflation of the lungs with flattened diaphragm, with new consolidation right lower and right middle lobe

ECHO = EF = 38% EKG = Sinus tachycardia with PVCs


Answer the following questions based on the information above:

6) In reviewing the assessment, lab results and diagnostic testing what do you suspect is the problem? (1 point) What lab results and diagnostic tests support your suspicion? (2 points)

7) What are the contributing factors / assessment findings in the patient’s history and physical above that contribute or relate to this diagnosis? (2 points)

8) The patient is a known hypertensive on medication, but her blood pressure continues to rise. What is the pathophysiology behind her continued BP elevation? (5 points)

9) What physical findings would you look for to differentiate left heart failure from right heart failure? (2 points)


Clinical Course: You call the hospitalist regarding the labs above and he orders: Potassium rider 40meq IV x 1 now, Decreases the IV fluids, D/C insulin drip, Start insulin sliding scale with accuchecks every 2 hours, increases oxygen to 4 Liters O2 per NC with titration to maintain SpO2 >92%, Duonebs every 4 hours and Lasix 40mg IV x 1 now. You inform him that the newest vital signs are: T:100.9; HR: 114; R: 32; B/P: 122/64. Urine output 60cc/

Basic Metabolic Profile, UA, ABG and Lactic Acid ordered:

Labs and Diagnostics:

Na 134 meq/L K 3.0 meq/L Cl 109 meq/L HCO3 17 meq/L BUN 66 mg/dL Cr 3.0 mg/dL

WBC 16.8 x 103/mm3 Hb 7.6 g/dl / Hct 55% TROP: 0.34 ng/ml CK: 102U/L CKMB: 3ng/mL


Clear, pale yellow urine; Microscopy was negative for cells, casts, pigments, and crystals

SG 1.008 (-) bacteria (+) glucose (+) protein (-) Nitrate (+) RBC many (-) WBC

BNP 1025pg/ml Glucose 180

ABG: pH= 7.30; PaCo2=12; PaO2= 89; HCO3: 18 BE: 1



Answer the following questions based on the information above:

10) The patient is noted to have acute kidney injury (AKI) and nephrology is consulted. Based on the patient’s diagnosis and labs, is the patient exhibiting pre-renal, intra-renal or post renal failure? (2points). How did you determine this? (3 points)

11) List the factors and that could be contributing to this patients AKI. ( 3 points)

12) Describe the key differences between pre-renal and intrarenal failure As the nurse, what would you look for on your assessment? (5 points)

13) Comorbidities such as hypertension and diabetes can affect kidney function over and above this patient’s diagnosis. What would be your expected goals for this patient at discharge to prevent a reoccurrence and readmission? (4 points)


Clinical Course: The patient is transferred to the ICU due to the ABG results and elevated lactic acid in order to receive treatment for sepsis. The patient is intubated during the night and received 2 units packed red blood cells. The patient received Lasix 60mg IV and continues on IV fluids. In the morning following the transfer to the ICU, am labs and CXR are done. Patient has the following Vital Signs: T: 101.2; HR: 104; R: 24; B/P: 98/62; O2 sat: 98% on ventilator at 50% O2. Assessment findings: S1/S2 tachycardia regular; Edema 2+ pitting B/L lower extremities. Hyporesonnance right lower lobe, crackles bilateral lower lobes and right mid lobe.

Labs and Diagnostics:


Na 136 meq/L K 3.6 meq/L Cl 118 meq/L HCO3 22 meq/L BUN 42 mg/dL Cr 1.3 mg/dL

WBC 16.8 x 103/mm3 Hb 9.2 g/dl / Hct 58% TROP: 0.20 ng/ml CK: 106U/L CKMB: 2ng/mL

BNP 856pg/ml Glucose 128

CXR = Right lower lobe consolidation, right mid lobe infiltrate consistent with pneumonia, left lower lobe and right lower lobe with small pleural effusion.


Answer the following questions based on the information above:

14) What category of pneumonia is this considered? (1 points)

15) Identify 3 risk factors that predisposed this patient to pneumonia. (2 points)

16) Identify 2 clinical assessment signs and 2 lab/diagnostic results that support the diagnosis of pneumonia. (2 points)

17) Explain the pathophysiologic basis of the patients decreased pH, elevated pCO2, decreased paO2, and decreased HCO3 leading to intubation. (8 points)

18) Identify the type of abnormal breathing pattern the patient presented with when arriving at the hospital. (1 point); Explain this abnormal breathing pattern. (1 points); Why did the patient have this abnormal breathing pattern? (1 point)


APA (5 points)

Scholarly work (5 points)

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