Diabetic Ketoacidosis (DKA)
Jenna Vest, Kaylee Locker, Aida Gutierrez
Diana Humphries, 45 years old
Primary Concept
Fluid and Electrolyte Balance
... [Show More]
Interrelated Concepts (In order 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:
Missed dialysis
Persistent nausea, large emesis
Cough, yellow sputum
Missed dose of Lantus
Glucometer unable to register
waste products will accumulate (including potassium) and fluid imbalance
Red flag for DKA in a diabetic patient on dialysis
Colored sputum is indicative of infection, in this case possible pneumonia. Pneumonia increases the likelihood of DKA in a diabetic patient
Lantus is a long acting insulin. The short acting insulin (Humalog) she took in the morning could not regain control of her blood sugar alone.
Most glucometers have an ability to read up to 500, an inability to register means an extremely high blood glucose.
RELEVANT Data from Social History: Clinical Significance:
Inconsistent with medical/diabetic
regimen
Anxiety/Depression
Denial of issue/knowledge deficit
Homeless/Shelter/disability Inability to maintain health status, inability to adhere to medication regimen
Lack of self-care, inability to learn
Inability to comprehend education, lack of knowledge on disease and appropriate treatment
Lack of resources, lack of stability
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
• Diabetes mellitus type 1 since age 12
• Diabetic retinopathy
• Neuropathy in lower legs
• Hyperlipidemia
• Hypertension
• Coronary artery disease
• Gastroesophageal reflux disease (GERD)
• Anxiety
• Depression 1. Aspirin 81mg PO daily
2 .Lisinopril 10 mg PO daily 3. Lorazepam 1mg PO bid prn
4. Citalopram 40 PO mg daily
5. Zolpidem 10 mg PO at HS prn
6. Gabapentin 300 mg PO bid
7. Labetalol 200 mg PO bid 8. Omeprazole 20 mg PO daily
9 .Simvastatin 40 mg PO HS
10. Glargine insulin 50 units
SQ at HS
11. Lispro insulin SQ sliding scale AC and HS 1. Salicylate
2.ACE inihibitor
3. Benzodiazepine
4. SSRI
5. Nonbenzodiazepine
6. Anticonvulsant, GABA analogue
7. Beta Blocker
8. Proton Pump Inhibitor
9. HMG-CoA reductase inhibitor, “statin”
10. Long acting Insulin
11. Short acting Insulin 1. Low dose aspirin helps prevent cardiac events
2.Reduce blood pressure, reduce CAD events
3. Sedate/reduce anxiety
4. Anti-depressant
5. Aid with sleep
6. Reduce nerve pain
7. Reduce Blood Pressure
8. Reduce symptoms of GERD
9. Reduction of cholesterol production
10. Glucose management
11. Glucose management
What medications treat which conditions?
Draw a line to identify what illness is being managed by what medication?
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 Type 1
• Underline what PMH problem(s) FOLLOWED as dominoes --- Everything else
Patient Care Begins
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 101.6 F/38.7 C (oral) Provoking/Palliative: Coughing and deep breathing/Not coughing
P: 114 (regular) Quality: Sharp
R: 24 (regular/deep) Region/Radiation: Right chest
BP: 102/66 Severity: 5/10
O2 sat: 90% Room air Timing: Intermittent
RELEVANT VS Data: Clinical Significance:
R: Temp 101.6
R: Elevated Pulse 114
R: Respiration 24
R: Low BP
R: O2 Sat 90%
Patient has an elevated temperature which is the classic inflammatory response to infection
Patient is likely dehydrated which can elevate the HR + coughing and difficulty breathing
Patient has a low O2 sat, breathing quicker with pain in the right chest, evidence of pleural pain (possible pneumonia)
The patient’s HR is high, trying to compensate and bring up the blood pressure.
The patient is not breathing enough oxygen on her own, 90% is too low. This may be additional evidence of pneumonia
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
Current Assessment:
GENERAL
APPEARANCE: Appears anxious and uncomfortable, body tense, occasional grimacing
RESP: Breath sounds clear with coarse crackles in RLL , nonlabored respiratory effort, harsh productive cough with thick yellow phlegm visualized
CARDIAC: Pink, warm & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants, nausea is persistent
GU: Frequency of urination, urine clear in color, denies painful or burning when voids
SKIN: Skin integrity intact, lips dry, oral mucosa dry–tacky
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? [Show Less]
