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Diabetes
Dave Perillo
Inpatient
Hyperglycemia
A lesson in selecting the correct protocol
By Heidi Rymaszewski, DNP, ANP-BC, BC-ADM, CDE
➼ William, a 49-year-old black
man, presented to the emergency department
with a 1-week history of polyuria,
polydipsia, blurred vision, dizziness and
a 1-day history of vomiting and diarrhea.
His serum blood glucose level at the time
of admission was 1,087 mg/dL. Arterial
pH was 7.34, serum bicarbonate was
25 mEq/L, serum osmolality was 425
mOsm/kg, serum ketones were positive,
and HbA 1c was 12.2%.
The patient had no personal or family
history of diabetes. He reported a past
medical history significant for cardiomyopathy,
heart failure (ejection fraction of
20%), pacemaker implant, hypertension,
obstructive sleep apnea and depression.
William was unemployed and receiving
disability payments. He was unmarried,
had no children and lived alone.
His oven did not work and he did not
have a microwave. Most of his meals
were convenience foods purchased at
the gas station and heated on a hot plate.
He quit smoking about 5 years ago. His
alcohol intake was approximately three
12-ounce beers per week, usually during
the weekend. He reported that he did not
use drugs. His exercise was limited due
to shortness of breath.
Physical and Systems Review
The review of systems was negative except
for constitutional symptoms. William said
he felt fatigued and that he had lost about
10 pounds over the past 2 to 3 months.
Heidi Rymaszewski is an adult nurse practitioner and certified diabetes educator who works
in the Diabetes and Nutrition Education Department at Aurora Medical Group in Milwaukee.
She has completed a disclosure statement and reports no relationships related to this article.
The patient also reported having blurred
vision for the past week; he had not seen
an eye doctor or dentist in years. William
reported one episode of diarrhea and vomiting
of undigested food in the last week.
He complained of poor appetite for the
past month. He usually ate two meals daily,
with multiple snacks of junk food. He did
not have a schedule for meals, and he often
ate late into the night. He frequently drank
juice and regular cola. He reported that
he had been urinating about five times
per night. He complained of cramping
in both feet, especially in the evening.
William’s physical examination was
normal except for a weight of 260 pounds
(BMI 36.2), blood pressure of 170/90
mm Hg, and a mildly elevated pulse at
92 beats per minute. His lips and buccal
mucosa were somewhat dry. Acanthosis
nigricans was present on his neck and
elbows, which is a symptom of insulin
resistance often seen in type 2 diabetes.
The patient was diagnosed with diabetes
(type undetermined at this point)
based on the random blood glucose level
greater than 200 mg/dL. He was placed
on the emergency department’s diabetic
ketoacidosis (DKA) protocol (Table 1)
based on his positive serum ketones. He
was admitted to a general medical unit.
Inpatient Course
William’s glucose level decreased to the
200 mg/dL to 300 mg/dL range after 4
hours of insulin infusion. Finger sticks
every 2 hours showed that it remained in
that range. Adjustment to the infusion
rate was based on the DKA protocol. He
was kept on the same regimen for the rest
of that day and half of the following day,
until he was feeling better and began to
experience hunger.
William ate the breakfast provided
to him by the hospital’s dietary department,
and his glucose level before lunch
increased into the high 300 mg/dL range.
Because his serum ketones were negative
at that point, the hospitalist physician
decided that he should be switched to
a subcutaneous insulin regimen. The
plan was to discharge him later that
day. Because William’s glucose level was
uncontrolled on the insulin infusion
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