Critical care case study - Diabetic ketoacidosis: Nursing

Nurse Jiyun works in the emergency department and is caring for Osborne a 47 year old patient with a history of type one diabetes mellitus who was diagnosed with diabetic ketoacidosis or DKA.

Nurse Ji Yun goes through the steps of the clinical judgment measurement model to make clinical decisions about Osborne's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action and evaluating outcomes.

First, nurse Jian recognizes important cubes including Osborne's vital signs which are temperature 99.4 °F or 37.5 °C. Heart rate 118 BPM respirations, 28 breaths per minute BP, 90/56 millimeters of mercury and oxygen saturation.

91% on 2 L of oxygen per nasal cannula upon assessment. Nurse Jian notes, Osborne's breathing is deep and labored and his breath has a sweet odor.

He's slightly lethargic and is oriented to person and place but not time. Nurse Jian notes that Osborne's current blood glucose level is 400 mg per deciliter or 22.2 millimoles per liter.

Next, nurse Jian analyzes these cues. He reviews the electronic health record or E Hr and sees that Osborne recently recovered from pneumonia and his urine is positive for ketones.

Also arterial blood gas results show a ph of 7.2 and a bicarbonate of 15 mill equivalents per liter. Indicating metabolic acidosis.

Nurse jian knows diabetic ketoacidosis is a life threatening complication of type one diabetes, mellitus caused by an insulin deficiency where glucose can't be taken up into cells and used for energy.

He also knows that infections like pneumonia can precipitate diabetic ketoacidosis by increasing stress hormones that contribute to elevated glucose and reduced insulin utilization.

As glucose levels rise, the kidneys reach the maximum amount of glucose they can reabsorb. So, extra glucose spills into the urine resulting in glycose urea.

Additionally, since glucose is osmotically active glyco urea is accompanied by a large amount of water in the urine resulting in polyurea.

Glucose also pulls water out of cells and into the bloodstream, expanding the blood volume and leaving the cells dehydrated.

As an alternative energy source fat is converted into glucose by metabolizing fatty acids resulting in ketones. This results in a build up of acidic ketones within the blood giving rise to metabolic acidosis to compensate the respiratory rate increases to blow off excess carbon dioxide and increase the Ph resulting in deep rapid breathing called Kozol respirations.

Additionally, as ketone byproducts are exhaled, they cause the breath to have a fruity smell. Eventually, diabetic ketoacidosis can severely alter level of consciousness, interfering with airway patency and ultimately resulting in cerebral edema and coma.

Nurse Jiyun recognizes that Osborne needs prompt management of diabetic ketoacidosis. Now using the information he's gathered.

Nurse Qi Yun chooses a priority hypothesis of impaired glucose regulation. Then he generates solutions to address Osborne's impaired glucose regulation, including pharmacologic and non pharmacologic interventions.

And he establishes the expected outcome that after intervening Osborne's blood glucose will improve within 15 minutes. Then nurse Jian takes action to implement these solutions first.

He speaks with the emergency provider to report his assessment findings and obtain orders. Nurse Jian notes orders for a bolus of isotonic fluids and subsequent maintenance IV fluids as well as a bolus of regular IV insulin followed by a continuous insulin infusion.

There are also orders to increase oxygen as needed to ensure oxygen saturation above 94%. After gathering the necessary supplies, nurse Jiyun Re enter Osborne's room.

Hi, Osborne, I just spoke with the emergency provider who put in some orders to help lower your blood sugar and make you more comfortable.

Uh Yeah, it's hard to breathe. I just feel awful.

I understand. I'm going to increase your oxygen a bit and put some fluids and insulin in your IV to bring your sugar down, which will also help your breathing.

After Osborne communicates understanding of the plan of care. Nurse Jian increases Osborne's oxygen from 2 to 4 L and ensures he's hooked to the cardiac and vital signs, monitor.

He then administers the medications following safe medication administration principles. He elevates the head of Osborne's bed to facilitate breathing and provides him with cool washcloths for comfort.

Before leaving the room, nurse, Jian ensures the vital sign monitor is programmed to measure BP every five minutes. Then he hands Osborne the call white and tells him he'll be monitoring the insulin drip and blood glucose levels.

15 minutes later, nurse Ji Yun reenters Osborne's room to reassess Osborne and evaluate the outcomes of his actions. He takes Osborne's vital signs which are BP.

100/64 millimeters of mercury, heart rate, 105 BPM, respirations, 22 breaths per minute and oxygen saturation. 97% on 4 L per nasal cannula.

His current blood glucose level is 384 mg per deciliter or 26.8 millimoles per liter. All right.

As a quick recap, nurse Jian recognized and analyzed cues related to Osborne's impaired blood glucose regulation due to diabetic ketoacidosis and prioritized hypotheses and generated solutions to address this problem.

Nurse Jian then implemented pharmacologic and nonpharmacologic measures to manage Osborne's diabetic ketoacidosis and evaluated the outcomes compared with the expected outcomes.

Since Osborne's blood glucose improved within 15 minutes. Nurse Jian determined the plan of care was successful