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D6 Leonard Mays, a 58 y.o., Caucasian, homeless man with long-standing insulin-treated type 2 diabetes has been diagnosed with right lower extremity cellu

D6 Leonard Mays, a 58 y.o., Caucasian, homeless man with long-standing insulin-treated type 2 diabetes has been diagnosed with right lower extremity cellu

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D6 Leonard Mays, a 58 y.o., Caucasian, homeless man with long-standing insulin-treated type 2 diabetes has been diagnosed with right lower extremity cellulitis. He has taken a prescribed oral antibiotic for the past week but has not noticed much improvement. For the last 2 days, he has complained of intermittent fevers and chills, nausea with poor oral intake, and proximally spreading erythema over his right leg. On the evening of admission, a worker at the homeless shelter notices that he is markedly confused and calls 911. In the emergency room, he is oriented only to his name. The patient is tachypneic, breathing deeply at a rate of 24/min. He is febrile at 38.8°C. He is normotensive, but his heart rate is elevated at 112 bpm. On examination, this patient is a delirious, unkempt man with a fruity breath odor. His right lower extremity is markedly erythematous and exquisitely tender to palpation. Serum chemistries reveal glucose of 488 mg/dL, potassium of 3.7 mg/dL, and sodium of 132 m/dL. Urine dip-stick is grossly positive for ketones.

In this discussion:

1. Describe and discuss with your colleagues the pathophysiology of ketoacidosis in this diabetic patient. What is causing his altered mental status?

2. Describe the pathogenetic mechanism of his respiratory pattern.

3. Describe and discuss a plan of care for this patient during his first few days in the hospital.

4. Describe a plan of care for him at discharge (he will likely be admitted to the “medical floor” of the homeless shelter, which has the services of an Nurse Practitioner three times per week and a registered nurse four times per week).  Include plans for at least one population-focused intervention.

Include citations from the text or the external literature in your discussions.

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