UNIVERSITY OF SANTO TOMAS

COLLEGE OF NURSING
NCM 103
MS CASE # 2
(Endocrine, Urinary)

FOCUS OF STUDY:
A. ENDOCRINE DISORDERS: THYROID & DM
B. URINARY: RENAL FAILURE

CASE SCENARIO:
PART I

S.B. is a 72-year-old married woman with a past medical history of seizure disorder controlled
with Tegretol (last seizure was 5 years ago), underwent Total Thyroidectomy for Toxic Nodular Goiter
three years ago and presently receiving Synthyroid. She has a history of HTN for the past 10 years and is
receiving Enalapril for it. She has been diagnosed with DM Type 2 since age 40 years old and being
managed with Oral antidiabetic agents. She is obese and the family admits to her being non-compliant
to her diabetic control regimen. She sought consult at the doctor’s clinic last September 2012 for her
non-healing 2-cm wound with sero-purulent drainage at her right foot. She reports that her latest blood
tests two months ago reveal an elevated glycosylated hemoglobin, BUN & creatinine levels. The
daughter states that the patient has been advised to undergo further tests for her kidneys to determine
the extent of her Diabetic Nephropathy. After the consult visit, the doctor advised admission for
treatment of the foot ulcer and further evaluation of her diabetic condition.
1. What relevant assessment data will you need related each of your patient’s medical
condition? Give the rationale for each assessment data.
2. Identify predisposing factors to each of her medical problems that you need to check out with
S.B.
3. Illustrate using a flow chart the pathophysiology of each of the medical problems of S.B. and
their possible complications .
4. Using another flow chart, indicate the pathophysiologic relationship of the medical problems
of S.B. How do these conditions relate to each other, if they do?
5. Prior to the thyroid surgery of your patient,
5.1. What manifestations would you have seen for a toxic nodular goiter ?
These may include weakness and fatigue, palpitations and chest pain or
pressure, and changes in memory and mood. Toxic nodular goiter does not
cause the bulging eyes that can occur with Graves disease.

5.2. What medications were ordered to SB to help manage her condition? Give their
rationale?
6. Following total thyroidectomy,
6.1 What complications can possibly occur and why? Give their nursing and collaborative
preventive interventions.
6.2. Why is the patient being given Synthyroid? What specifIc health teachings need to be
given regarding this drug.
It replaces or provides more thyroid hormone, which is normally produced by the
thyroid gland. Low thyroid hormone levels can occur naturally or when the thyroid gland
is injured by radiation/medications or removed by surgery. The drug should not be used
 to treat obesity or weight problems, the dose needs may be different during pregnancy.

7. What criteria is used for the establishment of a definite diagnosis of DM?

A hemoglobin A1c (HbA1c) level of 6.5% or higher. A fasting plasma glucose (FPG) level of
126mg/dL or higher. A 2 hour plasma glucose level of 200 mg/dL and random plasma glucose
of 200 g/dL or higher in a patient with classic symptoms of hyperglycemia.

8. What health teachings can be given to the family members of S.B. to keep them from
developing DM?
Take medications as prescribed by the doctor, monitor blood sugar, follow a sensible diet, do
not skip meals, exercise regularly and see a doctor regularly to monitor for complications.

9. What 2 acute complications of DM2 should be watched out for in S.B.? Give their
manifestations, preventive and therapeutic interventions.
Hyperosmolar hyperglycemic nonketotic syndrome, and hypoglycemia. Possible signs
and symptoms of Hyperosmolar hyperglycemic nonketotic syndrome include: Blood
sugar level of 600 milligrams per deciliter (mg/dL) or 33.3 millimoles per liter (mmol/L)
or higher, excessive thirst and dry mouth. To prevent HHNS, know the symptoms of
high blood sugar, monitor blood sugar level, increase fluid intake, follow diabetes
management plan and stay current on vaccinations. Treatment typically includes:
Intravenous fluids to counter dehydration, intravenous insulin to lower your blood
sugar levels, intravenous potassium, and occasionally sodium phosphate replacement
to help your cells function correctly. The manifestations of hypoglycemia are
shakiness, dizziness, sweating, hunger, irritability or moodiness, anxiety or
nervousness and headache. To prevent hypoglycemia, monitor blood sugar, don’t
skip or delay meals or snack, measure medication carefully and take it on time and
eat additional snack. The treatments are insulin glargine, diabetes management,
sulfonylurea and diazoxide

10. Can the patient develop a DKA? Support your answer.

Diabetic ketoacidosis can happen in type 2 diabetes but it is very rare since there’s somewhat a
sufficient level of insulin that may prevent the occurrence of DKA by suppressing lipolysis. If
there is a lack of insulin in a type 2 diabetic patients then the process of lipolysis can occur and
undergo DKA. Such causes of DKA can stem from the decreased or missed doses of insulin,
illness, or infection and undiagnosed and untreated diabetes.

11. How do you recognize the difference between a Somogyi effect & the Dawn phenomenon?
The somogyi effect is a rebound effect in which an overdose of insulin induces hypoglycemia.
Usually occurring during hours of sleep, the somogyi effect effect produces a decline in blood
glucose level, in response to too much insulin. Counter regulatory hormones are released,
stimulating lipolysis, gluconeogenesis and glycogenolysis, which in turn produce rebound
hyperglycemia and ketosis. The danger of this effect is that when blood glucose is measure in
the morning, hyperglycemia is apparent and the patient may increase the insulin dose. The
effect is associated with the occurrence of undetected hypoglycemia during sleep, though it can
happen anytime. The dawn phenomenon sometimes called the dawn effect is an early morning
increase in blood sugar which occurs to some extent in all humans, more relevant to people with
 diabetes. Dawn phenomenon is not associated with nocturnal hypoglycemia.

12. Discuss briefly the management strategies for DM and their rationale.
Management Rationale

13. Make a nutritional health teaching plan for S.B.

14. What are the different types of oral antihyperglycemic agents that can be given? Make a
table to include: Type of drug; examples; therapeutic action; onset, peak & duration of action;
side effects
Drug Example Therapeutic Onset Peak Duration of Side
action action effects
Sulfonylureas

S.B’s non-healing wound is debrided and treated further with oral antibiotics.
15. The patient asks, “When will this wound heal? Why is it taking so long? What other bad
thing can I have because of this?” What would be your response to these queries?
16. What relevant teaching can you provide at this time?
17. Should the patient’s foot condition further deteriorate, when would amputation be
indicated? What major concerns related to care would you have?

The doctor evaluates for other possible effects of her poorly managed DM.
18. What tests would you expect to be ordered? What would their findings be to indicate the
presence of complications?3

The lab test results return confirming previous results with elevated BUN & creatinine.
S.B. appears worried & states, “My mother had DM and had dialysis for several years before she died
because of chonic Renal failure. I don’t want to have the same thing happen to me.”
19. How will you address this concern?
20. When does the nephrologist generally decide to perform dialysis on a patient? What is the
purpose of this procedure?
21. Do you believe the patient would be a good candidate for renal transplant? Defend your
answer.

S.B. is eventually sent home after a week’s stay in the hospital with take home regimen for her medical
problems.
Outline your comprehensive discharge teaching plan for your patient.

STUDENTS, PLS NOTE:

1. The following RLE groups will make a pathophysiologic flowchart of the ff:
RLE 1 – HYPERTHYROIDISM AND COMPLICATIONS
RLE 2 – DM
RLE 3 - DM COMPLICATIONS
RLE 4 - Renal Failure
Focus only on the critical points.
2. Each student is to read and answer each question of the case.
3. The facilitated discussion will dwell on the questions stated. Students who give
answers to the questions will be given the participation grade.
Class secretaries, kindly provide the facilitator the CLASS LIST for grading purposes

NCM 103/MN/2018