Diabetic Ketoacidosis (DKA)
Diana Humphries, 45 years old
Primary Concept
Fluid and Electrolyte Balance
Interrelated Concepts (In order
... [Show More] of emphasis)
1. Acid-Base Balance
2. Glucose Regulation
3. Infection
4. Pain
5. Clinical Judgment
6. Patient Education
7. Communication
8. Collaboration
UNFOLDING Reasoning Case Study: STUDENT
Diabetic Ketoacidosis (DKA) History
of Present Problem:
Diana Humphries is a 45-year-old woman with chronic kidney disease stage III and diabetes mellitus type1 who checks her blood sugar daily, or whenever she feels like it. She has been feeling increasingly nauseated the past 12 hours. She has had a harsh, productive cough of yellow sputum the past three days. She checked her blood glucose before going to bed last night and it was 382, but then she fell asleep early and missed her bedtime dose of glargine (Lantus) insulin. When she awoke this morning, she had generalized abdominal pain and continued to feel nauseated and had a large emesis. Her glucometer was unable to read her blood glucose because it was too high. She took 10 units of lispro (Humalog) insulin this morning. Her nausea has increased all morning and she has been unable to eat or keep anything down despite having an increased thirst and appetite. She also has had increased frequency of urination. When her lunchtime glucometer gave no reading because it was too high and out of range, she called 9-1-1 to be evaluated in the emergency department (ED).
Personal/Social History:
Diana has been inconsistently compliant with her medical/diabetic regimen due to her struggles with anxiety and depression that have worsened since her mother died three months ago. She considers 200 a good blood sugar reading. She is divorced with no children and has been homeless and has lived in a shelter off and on the past month. She is on Social Security disability because of complications related to diabetes. At one point during the intake interview, she expressed to the nurse, “I’m going to die anyway, why does all this matter?”
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Chronic Kidney Disease
Type 1 Diabetes and checks blood sugar whenever she feels like it
Blood Sugar 383 before bed and didn’t take her bedtime Lantus
Generalized abdominal pain, nausea, emesis Increased thirst, appetite, urination
Lunchtime glucometer gave no reading because too high Decreased function of the kidneys and if patient is in DKA there is an increased load on kidneys due to polyuria
Puts her at risk for developing DKA especially since she doesn’t check her blood sugar regularly
Blood sugar already high before bed so we know it was high for a while before she called 911
Signs and symptoms of hyperglycemia Signs and symptoms of hyperglycemia Severe hyperglycemia
RELEVANT Data from Social History: Clinical Significance:
Inconsistently compliant with her medical/diabetic regimen
Anxiety and Depression from her mother’s death
Divorced with no children Homeless
Inability to comply with medications increases risk for complications.
Doesn’t have emotional support
Due to her current financial hardship, she is unable to comply with her medications and her diabetes regimen.
Receives social security disability benefits
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
• Chronic Kidney disease stage III (diabetic nephropathy)
• Anemia 1. Aspirin 81mg PO daily
2 .Lisinopril 10 mg PO daily
3. Lorazepam 1mg PO bid prn
Salicylates ACE inhibitors
Benzodiazepine SSRI
Sedative Analgesic adjunct Beta Blocker Antilipidemia Pancreatics Pancreatics
Aspirin will help with the pain caused by her neuropathy.
• Diabetes mellitus type 1 4. Citalopram 40 PO mg daily since age 12 5. Zolpidem 10 mg PO at HS
• Diabetic retinopathy prn
• Neuropathy in lower legs 6. Gabapentin 300 mg PO bid
• Hyperlipidemia 7. Labetalol 200 mg PO bid 8.
• Hypertension Omeprazole 20 mg PO daily
• Coronary artery disease 9 .Simvastatin 40 mg PO HS
• Gastroesophageal reflux 10. Glargine insulin 50 units disease (GERD) SQ at HS
• Anxiety 11. Lispro insulin SQ sliding Lisinopril will help manage her
hypertension and with her kidney disease.
Lorazepam will help calm down the patient and make her less anxiety.
Zolpidem will allow the patient to sleep better.
• Depression scale AC and HS Gabapentin will help with nerve pain caused by her neuropathy.
Labetalol will help with her hypertension and decrease her heart rate decreasing stress on the heart.
Omeprazole will decrease the stomach acid helping with her GERD.
Simvastatin will help her cholesterol and lipids which will help with hyperlipidemia and coronary artery disease.
Glargine is long acting insulin used to manage diabetes
Lispro is rapid acting insulin used to manage diabetes
What medications treat which conditions?
Draw a line to identify what illness is being managed by what medication?
Listed in the table
One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her life?
• Circle what PMH problem started FIRST Diabetes
• Underline what PMH problem(s) FOLLOWED as dominoes hypertension, kidney disease, heart disease, depression and anxiety.
Patient Care Begins
Current VS: P-Q-R-S-T Pain Assessment (5th VS): [Show Less]