Nick 18 has just begun his first semester in his first year of an engineering degree at
University of Sydney.

Nick 18 has just begun his first semester in his first year of an engineering degree at
University of Sydney. He was diagnosed with type 1 diabetes mellitus at age six and prior
to his first semester at uni Nicks parents had helped Nick maintain strict control over his
blood glucose levels insulin administration diet exercise and overall health. He is
currently prescribed Humulin R Twice a day. When Nick was in high school several
teachers on staff were very supportive of his condition and encouraged Nick to maintain
regular eating schedules and inject insulin at regular intervals. For years his diabetes
was managed well.
He is living away from his parents and siblings for the first time and lives in on-campus
dormitory university accommodation. Over the past several months Nick has been
introduced to many stressors that he is challenged by. He is away from the support of his
family he is responsible for his own meals and insulin management he is involved in a
whole new social group and he is struggling to keep up with the workload of his course.
In addition Nick is on the universitys rugby team and feels peer pressure from his
teammates to engage in activities such as chasing girls binge-drinking late night fastfood runs skipping class pulling all-nighters before exams and extreme training
Presentation to Emergency
After a night of hard-core partying friends found Nick looking unwell in the dorms
common room and brought him to the hospitals Emergency Department. Nicks friends
reported that they found him shaking and sweating uncontrollably and floating between
being unconscious and irritable and uncooperative. They put him in their car and brought
him straight to the Emergency Department.
Observations on arrival
Upon arrival Nicks observations were:

Blood pressure 140/94
Pulse rate 116bpm
Respiratory rate 26 breaths/min shallow
Temperature 37.5oC
O2 Sat 93%.

Skin diaphoretic warm and pale
Blood glucose level 2.5mmol/L
Medical diagnosis and treatment plan
The doctor diagnoses Nick as having a hypoglycaemic episode. Nicks immediate
treatment includes the administration of SC 1mg glucagon and 50mL of 50% Glucose IV
over 2 hours.
Nick in the medical ward
On the ward
It is now three days later and Nicks condition is stable. You are the nurse assigned to
Nick for the duration of your shift on the medical ward. Nicks current vital signs are as
Temp O2 sats
128/78 60 beats/min 16 breaths/min 37.5oC 97%
He is alert and oriented to person place and time with no subjective complaints of pain.
He is neurologically intact. His blood glucose level has stabilized to his pre-university
state of 7.8 mmol/L (non-fasting state). He is eating regularly and his fluid intake is equal
to his fluid output.
Where to from here?
Nick does not want his parents to discover that he is in the hospital for the second time in
seven months and has asked the team not to inform his parents. After his last admission
in his first semester his parents were threatening to pull him out of university and have
him attend a local university so that he can return home.
Nick is readmitted to hospital and transferred to the
medical ward
Nick becomes unwell again
It is now at the end of the university year and Nick has represented to the local hospital.
He presented to the Emergency Department late the previous evening very unwell
complaining of vomiting for the past two days and admitted to skipping several doses of
insulin recently. He mentioned that he was feeling feverish at home and reported an
occasional cough. He was transferred to the medical ward this evening from the
Emergency Department and is assigned to your care.
Whilst reading through Nicks notes from his assessment in the Emergency Department
you find the following: pain throughout all abdominal quadrants with cramping reported
in all four abdominal quadrants. He was extremely lethargic and difficult to rouse at times.
He complained of severe thirst. His skin was extremely dry. Electrocardiogram (ECG)
showed a sinus tachycardia at 120 bpm. Lungs were clear bilaterally but respirations
were deep and rapid. There was an acetone smell to Nicks breath. He denied alcohol
and illicit drug use and could recall no drug or food allergies. He did report that one of his
aunts has type 1 diabetes mellitus.
You are aware of Nicks social history as a university student. You notice Nicks last
hospital admission was for hypoglycaemia resulting from his university life style.
However since Nick has presented with a different health issue related to his Type 1
Diabetes you ask him about his current situation. Nick states I often struggle with the
costs of university and rugby and sometimes my medication runs out or I forget to get my
scripts filled.
During the past year Nick has been admitted to the hospital with the diagnosis of
hypoglycaemia once and diabetic ketoacidosis (DKA) once. In addition he had failed to
attend two of his follow up appointments because he couldnt take time off university to
attend appointments.
On arrival at the ED
On arrival at emergency Nicks observations were:

BP 124/80
HR 122 bpm
Respirations 32/min
Temperature 35.8o C
His initial urinalysis revealed:

Specific gravity: 1.015
Ketones: 4+
Leukocytes: few
Glucose: 4+
Nitrates: 0
RBCs: many
His initial blood studies revealed:

Hgb: 14.5 g/dl
Hct: 58%
Ca+: 8.8 mmol/L
Phosphate: 6.8 mg/dl
Na+: 126 mmol/L
K+: 5.3 mmol/L
Cl-: 95 mmol/L
Creatinine: 0.9 mg/dl
BUN: 52 mg/dl
Glucose: 254 mg/dl
Ketones positive
Arterial blood gases

pH: 7.19
PO2: 100 mm Hg
HCO3: 10 mEq/l
PCO2: 20 mm Hg
SAO2: 98% (room air)
Nicks daily insulin doses are as follows:

mane 16U 30/70 Humulin
nocte 12U 30/70 Humulin
Whilst in Emergency the priority of care for Nick was the correction of the following: fluid
loss with intravenous fluids hyperglycaemia with insulin electrolyte disturbance
particularly potassium loss and his acid-base balance. Fortunately he responded well to
his treatment and once his blood studies began to improve and he was able to tolerate
oral fluids and food he was transferred to the medical ward for ongoing assessment over
the next three to five days.
Treatment on the ward
Nick arrives on the ward with the following orders:

IV 0/9% normal saline q6h
Strict fluid balance chart
Diabetic diet as tolerated
Hourly blood glucose test
q6h blood tests (including full blood count serum electrolytes and chemistry venous
blood gas glucose urea)
Test all urine
Continue with his insulin regime