Integrated Nursing Practice 92445 Case Study Analysis Report

This report analyzes a case study involving a 65-year-old obese female patient, Evelyn Hansen, focusing on the morning shift of her care. The study identifies five key patient health issues: Hyperglycaemia, Hyperosmolar Hyperglycaemic Syndrome (HHS), Impaired Kidney Function, Depression, and Lack of Diabetic Education. The report prioritizes the top three high-risk issues—Hyperglycaemia, HHS, and Impaired Kidney Function—due to their life-threatening potential, supported by current literature. It provides detailed rationales for their ranking, emphasizing the physiological mechanisms and risks associated with each condition. Furthermore, the report outlines the crucial role of nurses in addressing these priorities through continuous monitoring, fluid therapy, insulin administration, and electrolyte management, highlighting the need for careful assessment, coordination of care, and the provision of interventions to stabilize the patient's condition and prevent complications. The report references multiple sources to support the analysis and recommendations.

Running Head: INTEGRATED NURSING PRACTICE
Integrated Nursing Practice
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Answer 1:
The case study involves around Evelyn Hansen, a 65-year old elderly female who is obese.
The assignment is addressing morning shift of the case study.
The five patient issues identified of Evelyn Hansen by the nurse are:
 Hyperglycaemia
 Hyperosmolar Hyperglycaemic Syndrome (HHS)
 Impaired Kidney function.
 Depression
 Lack of diabetic education
These are the five health issues observed in the patient of which three high risk issues
include the hyperglycaemia, hyperosmolar hyperglycaemic syndrome and impaired kidney
function. This is because these health issues are life threatening and if not checked or kept
in the normal range it could lead to cardiovascular complications in the older adults. The
patient showed slight signs of depression that can be considered later on the basis of
priority of the health conditions that needs immediate attention. Physical well-being will
gradual promote the mental health of the patient. The patient has lack of education on
diabetes as she had doughnut and a bottle of juice and complained of blurred vision as
well. This can also be considered as not that high a priority as health issue because while
treating hyperglycaemia the patient will automatically learn about the ways to deal with
high blood sugar. The hyperglycaemia is the prevalence of high glucose level in the blood
that can lead to other comorbid factors and the main contribution is due to the impairment
of the beta cells of the pancreas (Dhatariya and Vellanki, 2017). The kidney impairment
also is the cause of malfunction in the kidney glomerular filtration. The infiltration can
lead to harmful health condition and the dehydration caused due to the hyperosmolar

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hyperglycaemic syndrome plays an important role in deteriorating the health condition of
the older adults. It mainly compromises the consciousness level of the individual
(Fayfman, Pasquel and Umpierrez., 2017).
Answer 2:
The top three health priorities of the case study include:
 Hyperglycaemia
Hyperglycaemia is the condition when the pancreatic beta cells become dysfunctional and
causes insulin resistance in the liver. It is a condition described as excessive amount of
glucose present in the blood (Dhatariya and Vellanki, 2017). Diabetes is one of the leading
chronic medically health compromised condition among the older adults who have other
vascular comorbidities like coronary artery disease, impairment of the physical and cognitive
function and the mortality (Fayfman, Pasquel and Umpierrez., 2017). This is the most
prevalent form of diabetes among the older adults. The risk of acquiring diabetes for older
adults is higher due to the combined effects of genetic factors, the lifestyle and the influence
of aging. It is further complicated by the occurrence of comorbid and functional impairments
that are associated with ageing. The pathology of the syndrome of hyperglycaemia is the
imbalance of the glucose production and the glucose uptake (Umpierrez and Korytkowski,
2016). And several factors contribute to this imbalance of the glucose distribution. With
increase in age the impairment of the beta cells of the pancreas also increases this acts as a
direct impact of pathophysiology of the disease in the older adults.
 Hyperosmolar Hyperglycaemic Syndrome (HHS)
This syndrome is a complication of the disease diabetes mellitus which is characterised by
high blood sugar that results high osmolarity without any significant ketoacidosis (Hirsch and
Emmett, 2018). The essential symptoms involve dehydration, weakness and leg cramps. It

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impacts the level of consciousness of the individual and causes vision problems (Skyler et al.,
2017). The overall mortality rate of patients with acquired HHS is higher comparatively and
it mostly affects the elderly adults. The symptoms of the HHS are the metabolic
derangements that result from cumulative factors that include insulin deficiency and elevated
levels of counter regulatory hormones like glucagon, catecholamines, cortisol and the growth
hormones. The increased gluconeogenesis and the rapid rate ate which glycogen is converted
to glucose, inadequate absorption of the glucose molecule by the peripheral tissues add up to
the pathogenesis of HHS. The major contribution is due to the elevated production of glucose
by the hepatic cells. The osmolar gradient is created by the elevated glucose concentration
and the osmolarity of the extracellular fluid causes the water to be drawn out of the cells. Due
to increase in glomerular filtration it promotes osmotic diuresis and glucosuria.
 Impaired kidney function
Impaired kidney function is defined as the malfunction of the kidney when the removal of the
fluids, chemicals and the wastes from the blood are not effectively done. This causes
impaired hydrogen ion secretion from the body. Kidney exhibits inability to secrete
potassium in the urine which leads to life threatening symptom of arrhythmias. Symptoms
may also exhibit hyperphosphatemia (Palmer and Clegg, 2016). Literature studies exhibit that
10% to 15% of the adult population are affected in the western countries with impaired
kidney function. It is a major risk factor for elevated cardiovascular disease and the mortality
rate. It is indeed a health priority in the developed as well as the developing countries. The
level of impairment of the kidney function is measured by GFR, glomerular filtrate rate. The
rate of the renal blood flow of approximately 400ml/100g of the tissue per minute is much
higher that the blood flow observed in the other well perfused vascular beds present in the
liver, heart and the brain (Toth-Manikowski and Atta, 2015). Therefore, this is evident that
the renal tissues will be exposed to the potentially harmful agents circulating in the blood.

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The glomerular filtration retains the anionic macromolecules due to the negative charge of
the membrane. The major contributor to the malfunctioning of the kidney is glomerular
hypertension and hyperfiltration.
Answer 3:
Nursing intervention in hyperosmolar hyperglycaemic syndrome, hyperglycaemia and
impaired kidney function:
The patient should be continuously monitored on the cardiac system of the patient. The
possible invasive haemodynamic monitoring should also be done (Noll et al., 2019).
Fluid therapy should be exploited in aid of the patient. The patients tend to have a deficit
of 8 to 10 litres of fluid. The main aim of this therapy ensures improvement of the renal
perfusion and to bolster intravascular, interstitial and intercellular fluid. Isotonic fluid should
be administered to the patient and up to 1.5 litres of the solution should be infused unless the
patient has cardiac complications (Broadley, Clark and Ritchie, 2019). Depending on the
electrolyte levels normal to hypotonic solution should be infused. The blood glucose level of
the patient may be reduced so the patient should be administered 5% dextrose to ensure that
the blood glucose level does not fall below the desired level. The serum osmolality should be
strictly monitored to prevent iatrogenic fluid overload (Hamelin, Yan and Stiell, 2018).
Infusion of low dose of insulin is required to aid to the hyperglycaemic emergencies.
However, fast acting insulin analogs like insulin lispro and insulin aspart. The blood glucose
level should be monitored every hour. It should be checked that there is no rapid reduction of
blood glucose as it may lead to complications like cerebral edema (Broadley, Clark and
Ritchie, 2019).
Electrolyte shifts are a common complication in the kidney impairment. The electrolyte
level in the individuals should be monitored every 2 to 4 hours. The serum sodium and

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potassium levels should be closely monitored. the hypotonic and isotonic solutions should be
exploited to adjust the sodium levels in the patient’s blood. It should be noted that during
fluid and insulin therapy the level of potassium may drop drastically. Replacement therapy
should be started if the potassium level drops below the normal range. Potassium infusions
should be administered to the patients to avoid such emergencies. The magnesium level
should also be monitored and if required infusions should be administered (Munshi et al.,
2016).

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References:
Broadley, L., Clark, K. and Ritchie, G., 2019. Prevention and management of
hyperglycaemic crisis. Nursing Standard, 34(7).
Dhatariya, K.K. and Vellanki, P., 2017. Treatment of diabetic ketoacidosis
(DKA)/hyperglycemic hyperosmolar state (HHS): novel advances in the management of
hyperglycemic crises (UK versus USA). Current diabetes reports, 17(5), p.33.
Fayfman, M., Pasquel, F.J. and Umpierrez, G.E., 2017. Management of hyperglycemic crises:
diabetic ketoacidosis and hyperglycemic hyperosmolar state. Medical Clinics, 101(3),
pp.587-606.
Hamelin, A.L., Yan, J.W. and Stiell, I.G., 2018. Emergency department management of
diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: national survey of
attitudes and practice. Canadian journal of diabetes, 42(3), pp.229-236.
Hirsch, I. and Emmett, M., 2018. Diabetic ketoacidosis and hyperosmolar hyperglycemic
state in adults: Clinical features, evaluation, and diagnosis. UpToDate. Retrieved January, 1,
p.2019.
Munshi, M.N., Florez, H., Huang, E.S., Kalyani, R.R., Mupanomunda, M., Pandya, N., Swift,
C.S., Taveira, T.H. and Haas, L.B., 2016. Management of diabetes in long-term care and
skilled nursing facilities: a position statement of the American Diabetes
Association. Diabetes care, 39(2), pp.308-318.
Noll, K.M., Franck, A.J., Hendrickson, A.L., Telford, E.D. and Dietrich, N.M., 2019.
Integration of Around-the-Clock Clinical Pharmacy Specialists Into the Critical Care Team
Can Increase Safety of Hyperglycemic Crisis Management. Clinical Diabetes, 37(1), pp.86-
89.

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Palmer, B.F. and Clegg, D.J., 2016. Physiology and pathophysiology of potassium
homeostasis. Advances in physiology education, 40(4), pp.480-490.
Skyler, J.S., Bakris, G.L., Bonifacio, E., Darsow, T., Eckel, R.H., Groop, L., Groop, P.H.,
Handelsman, Y., Insel, R.A., Mathieu, C. and McElvaine, A.T., 2017. Differentiation of
diabetes by pathophysiology, natural history, and prognosis. Diabetes, 66(2), pp.241-255.
Toth-Manikowski, S. and Atta, M.G., 2015. Diabetic kidney disease: pathophysiology and
therapeutic targets. Journal of diabetes research, 2015.
Umpierrez, G. and Korytkowski, M., 2016. Diabetic emergencies—ketoacidosis,
hyperglycaemic hyperosmolar state and hypoglycaemia. Nature Reviews
Endocrinology, 12(4), p.222.