Analysis of the Diabetic Ketoacidosis Case Study Essay
Analysis of the Diabetic Ketoacidosis Case Study Essay
The rate of diabetes ketoacidosis complication is on the rise in line with the rate of population increase as well as urbanization all around the globe. Learning how to handle this complication and maintaining the blood glucose within the suitable levels is becoming a big challenge for those with diabetes, outlining the need of educating the patients as a modality for self-empowerment, treatment which is necessary for betterment of the quality of the lives of the patients. This paper seeks to analyze a patient’s condition and describe various factors that led to associated symptoms and the effects of those symptoms. The role of the nurses in trying to deal with this complication was also highlighted.Analysis of the Diabetic Ketoacidosis Case Study Essay
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Fever and cough started 2 days ago and the patient could not eat or drink water. He has been treated with an intensive insulin regimen (insulin glargine 24 IU at bedtime and a rapid-acting insulin analog before each meal). On examination he was tachypneic, his temperature was 39° C (102.2° F), pulse rate 104 beats per minute, respiratory rate 24 breaths per minute, supine blood pressure 100/70 mmHg; he also had dry mucous membranes, poor skin turgor, and rales in the right lower chest. He was slightly confused. Rapid hematology and biochemical tests showed hematocrit 48%, hemoglobin 14.3 g/dl (143 g/L), white blood cell count 18,000/ μ l, glucose 450 mg/dl (25.0 mmol/L), urea 60 mg/dl (10.2 mmol/L), creatinine 1.4 mg/dl (123.7 μ mol/L), Na+ 152 mEq/L, K+ 5.3 mEq/L, PO4 3−2.3 mEq/L (0.74 mmol/L), and Cl− 110 mmol/L. Arterial pH was 6.9, PO 2 95 mmHg, PCO 2 28 mmHg, HCO 3−9 mEq/L, and O 2 sat 98%. The result of the strip for ketone bodies in urine was strongly positive and the concentration of β-OHB in serum was 3.5 mmol/L. Urinalysis showed glucose 800 mg/dl and specific gravity 1030.Analysis of the Diabetic Ketoacidosis Case Study Essay
What is your diagnosis?
The patient has hyperglycemia, ketosis, and metabolic acidosis. Therefore, he has DKA. In addition, because of the pre-existing fever, cough, localized rales on auscultation and high white blood cell count, a respiratory tract infection should be considered. The patient is also dehydrated and has impaired renal function.
Do you need more tests to confirm the diagnosis?
Determination of the effective serum osmolality and anion gap should be performed in all patients presenting with potential DKA. Serum osmolality can be measured directly in the laboratory or be calculated. Calculated effective serum osmolality in this case was 329 mOsm/kg and the anion gap is 33 mEq/L. Typically DKA is a high anion gap metabolic acidosis while serum osmolality may vary from normal to high. In addition a chest X-ray should be performed and blood cultures be obtained to check for lower respiratory tract infection and isolate the pathogenic bacteria.Analysis of the Diabetic Ketoacidosis Case Study Essay
How will you manage this patient?
Immediate infusion of normal saline and intravenous insulin should be initiated as described in the text. Because his serum potassium level is in the normal range, 10 mEq of potassium should be added to each liter of normal saline infused. Serum potassium levels should be checked at 2, 6, 10, and 24 hours and appropriate adjustment to the dose must be made. In addition, 100 ml of bicarbonate plus 10 mEq of potassium in 200 ml of water can be administered in 1 hour because pH is 6.9 and plasma bicarbonate levels are low. Arterial pH and bicarbonate should be re-checked in 30 minutes and, if uncorrected, infusion of a similar or lower amount of bicarbonate should be repeated as discussed in the text. If infection is confirmed, intravenous administration of antibiotics should begin while waiting for the results of blood cultures. The patient was treated with fluids and electrolyte replacement and intravenous insulin for 48 hours. Afterwards, his blood glucose was 150 mg/dl (8.3 mmol/L), fever, nausea, vomiting and abdominal pain resolved, and he was able to eat and to drink water.Analysis of the Diabetic Ketoacidosis Case Study Essay
What is your next step?
The patient can start to eat and drink water. Intravenous insulin can safely be discontinued and subcutaneous insulin begun. A bolus of rapid-acting insulin should be administered subcutaneously based on the results of the fingerstick test 1-2 hours before discontinuation of intravenous insulin, and 24 IU of basal insulin should be started. A careful history should be obtained to determine the cause of DKA and to avoid recurrence. This patient was not aware of the sick-day rules and had never been instructed to check often or how to correct high blood glucose values. Because he was not able to eat and drink water he reduced both the basal and the preprandial insulin to avoid hypoglycemia. The patient was educated about sick-day rules and to check urine and blood for ketones if blood glucose is above 300 mg/dl (16.7 mmol/L).Analysis of the Diabetic Ketoacidosis Case Study Essay
Case study 2
An 18-year-old female was taken to the emergency room in coma. Her parents noticed that she had polydipsia, polyuria, and rapid weight loss which started approximately 1 month ago and had worsened in the last week. She had not been taking any medications and the clinical history was otherwise unremarkable. On examination, breathing was deep and rapid (Kussmaul respiration), pulse rate was 100 beats per minute, and blood pressure 110/70 mmHg; she also had signs of dehydration. She was drowsy and confused. Rapid hematology and biochemical tests showed hematocrit 44%, hemoglobin 13 g/dl (140 g/L), white blood cell count 12,000/ μl, glucose 520 mg/dl (28.9 mmol/L), urea 50 mg/dl (8.5 mmol/L), creatinine 0.8 mg/dl (70.7 μmol/L), Na+ 148 mEq/L, K+ 4.6 mEq/L, PO4 3-2.0 mEq/L (0.64 mmol/L), and Cl− 112 mmol/L. Arterial pH was 7.0, PO 2 98 mmHg, PCO 2 25 mmHg, HCO 3−12 mEq/L, and O 2 sat 98%.Analysis of the Diabetic Ketoacidosis Case Study Essay
What is your diagnosis?
The patient has marked hyperglycemia and metabolic acidosis. The diagnosis of newly diagnosed type 1 diabetes presenting with DKA should be considered.
Which additional biochemical tests are required to confirm the diagnosis?
Determination of ketone bodies in blood or urine is necessary to confirm ketosis. In this case the strip for ketones in the urine was strongly positive and determination of β-OHB in serum was 4.0 mmol/L. Thus, the patient has the triad of hyperglycemia, ketosis, and acidosis and the diagnosis of DKA is confirmed.Analysis of the Diabetic Ketoacidosis Case Study Essay
How will you manage the patient?
Urgent administration of intravenous fluid and insulin should begin together with careful monitoring, replacement of electrolytes, and correction of acidosis. After resolution of DKA and as long as the patient is conscious, feeding can start. Transition from intravenous to subcutaneous insulin administration should begin. A bolus of rapid-acting insulin should be administered subcutaneously based on the results of the fingerstick test 1-2 hours before discontinuation of intravenous insulin. A total daily dose of insulin of 0.5-0.8 IU/kg is required, divided as 30-50% basal insulin and the remainder as rapid-acting insulin before each meal.
Fever and cough started 2 days ago and the patient could not eat or drink water. He has been treated with an intensive insulin regimen (insulin glargine 24 IU at bedtime and a rapid-acting insulin analog before each meal). On examination he was tachypneic, his temperature was 39° C (102.2° F), pulse rate 104 beats per minute, respiratory rate 24 breaths per minute, supine blood pressure 100/70 mmHg; he also had dry mucous membranes, poor skin turgor, and rales in the right lower chest. He was slightly confused. Rapid hematology and biochemical tests showed hematocrit 48%, hemoglobin 14.3 g/dl (143 g/L), white blood cell count 18,000/ μ l, glucose 450 mg/dl (25.0 mmol/L), urea 60 mg/dl (10.2 mmol/L), creatinine 1.4 mg/dl (123.7 μ mol/L), Na+ 152 mEq/L, K+ 5.3 mEq/L, PO4 3−2.3 mEq/L (0.74 mmol/L), and Cl− 110 mmol/L. Arterial pH was 6.9, PO 2 95 mmHg, PCO 2 28 mmHg, HCO 3−9 mEq/L, and O 2 sat 98%. The result of the strip for ketone bodies in urine was strongly positive and the concentration of β-OHB in serum was 3.5 mmol/L. Urinalysis showed glucose 800 mg/dl and specific gravity 1030.Analysis of the Diabetic Ketoacidosis Case Study Essay
What is your diagnosis?
The patient has hyperglycemia, ketosis, and metabolic acidosis. Therefore, he has DKA. In addition, because of the pre-existing fever, cough, localized rales on auscultation and high white blood cell count, a respiratory tract infection should be considered. The patient is also dehydrated and has impaired renal function.
Do you need more tests to confirm the diagnosis?
Determination of the effective serum osmolality and anion gap should be performed in all patients presenting with potential DKA. Serum osmolality can be measured directly in the laboratory or be calculated. Calculated effective serum osmolality in this case was 329 mOsm/kg and the anion gap is 33 mEq/L. Typically DKA is a high anion gap metabolic acidosis while serum osmolality may vary from normal to high. In addition a chest X-ray should be performed and blood cultures be obtained to check for lower respiratory tract infection and isolate the pathogenic bacteria.Analysis of the Diabetic Ketoacidosis Case Study Essay
How will you manage this patient?
Immediate infusion of normal saline and intravenous insulin should be initiated as described in the text. Because his serum potassium level is in the normal range, 10 mEq of potassium should be added to each liter of normal saline infused. Serum potassium levels should be checked at 2, 6, 10, and 24 hours and appropriate adjustment to the dose must be made. In addition, 100 ml of bicarbonate plus 10 mEq of potassium in 200 ml of water can be administered in 1 hour because pH is 6.9 and plasma bicarbonate levels are low. Arterial pH and bicarbonate should be re-checked in 30 minutes and, if uncorrected, infusion of a similar or lower amount of bicarbonate should be repeated as discussed in the text. If infection is confirmed, intravenous administration of antibiotics should begin while waiting for the results of blood cultures. The patient was treated with fluids and electrolyte replacement and intravenous insulin for 48 hours. Afterwards, his blood glucose was 150 mg/dl (8.3 mmol/L), fever, nausea, vomiting and abdominal pain resolved, and he was able to eat and to drink water.Analysis of the Diabetic Ketoacidosis Case Study Essay
What is your next step?
The patient can start to eat and drink water. Intravenous insulin can safely be discontinued and subcutaneous insulin begun. A bolus of rapid-acting insulin should be administered subcutaneously based on the results of the fingerstick test 1-2 hours before discontinuation of intravenous insulin, and 24 IU of basal insulin should be started. A careful history should be obtained to determine the cause of DKA and to avoid recurrence. This patient was not aware of the sick-day rules and had never been instructed to check often or how to correct high blood glucose values. Because he was not able to eat and drink water he reduced both the basal and the preprandial insulin to avoid hypoglycemia. The patient was educated about sick-day rules and to check urine and blood for ketones if blood glucose is above 300 mg/dl (16.7 mmol/L).Analysis of the Diabetic Ketoacidosis Case Study Essay
Case study 2
An 18-year-old female was taken to the emergency room in coma. Her parents noticed that she had polydipsia, polyuria, and rapid weight loss which started approximately 1 month ago and had worsened in the last week. She had not been taking any medications and the clinical history was otherwise unremarkable. On examination, breathing was deep and rapid (Kussmaul respiration), pulse rate was 100 beats per minute, and blood pressure 110/70 mmHg; she also had signs of dehydration. She was drowsy and confused. Rapid hematology and biochemical tests showed hematocrit 44%, hemoglobin 13 g/dl (140 g/L), white blood cell count 12,000/ μl, glucose 520 mg/dl (28.9 mmol/L), urea 50 mg/dl (8.5 mmol/L), creatinine 0.8 mg/dl (70.7 μmol/L), Na+ 148 mEq/L, K+ 4.6 mEq/L, PO4 3-2.0 mEq/L (0.64 mmol/L), and Cl− 112 mmol/L. Arterial pH was 7.0, PO 2 98 mmHg, PCO 2 25 mmHg, HCO 3−12 mEq/L, and O 2 sat 98%.
What is your diagnosis?
The patient has marked hyperglycemia and metabolic acidosis. The diagnosis of newly diagnosed type 1 diabetes presenting with DKA should be considered.
Which additional biochemical tests are required to confirm the diagnosis?Analysis of the Diabetic Ketoacidosis Case Study Essay
Determination of ketone bodies in blood or urine is necessary to confirm ketosis. In this case the strip for ketones in the urine was strongly positive and determination of β-OHB in serum was 4.0 mmol/L. Thus, the patient has the triad of hyperglycemia, ketosis, and acidosis and the diagnosis of DKA is confirmed.
How will you manage the patient?
Urgent administration of intravenous fluid and insulin should begin together with careful monitoring, replacement of electrolytes, and correction of acidosis. After resolution of DKA and as long as the patient is conscious, feeding can start. Transition from intravenous to subcutaneous insulin administration should begin. A bolus of rapid-acting insulin should be administered subcutaneously based on the results of the fingerstick test 1-2 hours before discontinuation of intravenous insulin. A total daily dose of insulin of 0.5-0.8 IU/kg is required, divided as 30-50% basal insulin and the remainder as rapid-acting insulin before each meal.
Blood gas analysis involves determination of three parameters (pH, bicarbonate and partial pressure of carbon dioxide, pCO2) necessary for assessment of patient acid-base status and identification of those whose acid-base is disturbed. There are four classes of acid-base disturbance: metabolic acidosis, metabolic alkalosis, respiratory acidosis and respiratory alkalosis.Analysis of the Diabetic Ketoacidosis Case Study Essay
Of these, metabolic acidosis, characterized by initial reduction in bicarbonate and pH along with compensatory decrease in pCO2, is the most common. Abnormal accumulation of keto acids is one of many causes of metabolic acidosis. This condition, called ketoacidosis, is the focus of two recently published case study reports.
The first describes two cases of diabetic ketoacidosis (DKA), the most common presentation of ketoacidosis. This is an acute and potentially life-threatening complication of diabetes (principally type 1 diabetes but also, less commonly, type 2 diabetes) that results from absolute or relative deficiency of insulin. Intercurrent illness (e.g. infection) can precipitate DKA and it can obviously also occur if prescribed exogenous insulin is not administered.
Biochemically, DKA is characterized by three findings: high anion gap metabolic acidosis (due to accumulation of keto acids that overwhelm normal blood buffering mechanisms); increased ketones (acetoacetate, β-hydroxybutyrate and acetone) in blood and urine; and increase, typically severe increase, in blood glucose concentration (hyperglycemia).Analysis of the Diabetic Ketoacidosis Case Study Essay
These two cases of DKA are notable because in both cases blood glucose at presentation was within normal limits; the patients were not hyperglycemic as is almost invariably the case in DKA, but euglycemic.
The first case concerns a 21-year-old female who had been diagnosed with type 1 diabetes 5 years previously. Her regular insulin treatment was administered by an insulin pump. Two days after failure of her insulin pump this young lady presented to hospital complaining of weakness and inability to eat. She was ”moderately” dehydrated but showed no signs or symptoms suggestive of infection.
Admission blood gas analysis revealed partially compensated metabolic acidosis (reduced pH: 7.1, reduced bicarbonate: 6 mmol/L, reduced pCO2: 14 mmHg (1.9 kPa). Electrolyte results (Na+, K+, Cl– and HCO3–) indicated a raised anion gap (22 mmol/L, reference range 1-10 mmol/L). She also had increased ketones in blood and urine. All these results were strongly suggestive of DKA.Analysis of the Diabetic Ketoacidosis Case Study Essay
However, her blood glucose was unexpectedly well within normal limits (74 mg/dL or 4.1 mmol/L). Despite intensive investigation no evidence was found to suggest that this lady was suffering from any non-diabetic condition that can give rise to metabolic (keto) acidosis, and a diagnosis of euglycemic diabetic ketoacidosis (EDKA) was therefore eventually made.
The second case reported in this paper concerns a 25-year-old female who had been diagnosed with type 1 diabetes at the age of 15 years. Her regular treatment involved daily insulin injections before meals and bedtime. This current admission to hospital was occasioned by recent onset of signs and symptoms of urinary tract infection (burning pain during urination, along with high-grade fever). She also reported nausea and consequent reduction in food intake. Physical examination revealed signs of dehydration. Urine testing confirmed urine tract infection. Arterial blood gas analysis revealed marked reductions in pH (7.03), bicarbonate (6.7 mmol/L) and pCO2 (13 mmHg, 1.7 kPa).Analysis of the Diabetic Ketoacidosis Case Study Essay
These results along with the found high anion gap (26 mmol/L) confirmed high anion gap metabolic acidosis. This finding along with abnormally high concentration of ketones in blood and urine and history of type 1 diabetes suggested DKA. However, blood glucose was unexpectedly normal (97 mg/dL, 5.4 mmol/L). Non-diabetic causes of metabolic (keto) acidosis were excluded and a diagnosis of euglycemic diabetic ketoacidosis (EDKA) was eventually made.
In discussion of these two case stories the authors describe how insulin deficiency can lead to accumulation of keto acids and consequent high anion gap metabolic (keto) acidosis. They explain the distinction between DKA and EDKA. They also discuss how a diagnosis of EDKA can be only made by exclusion of non-diabetic conditions that can also give rise to ketoacidosis in association with normal blood glucose. Analysis of the Diabetic Ketoacidosis Case Study Essay
A separate case study report focuses on ketoacidosis occurring in the non-diabetic patient. This case concerns a 27-year-old lady who 8 weeks after giving birth to a healthy infant presented with a 4-day history of nausea and vomiting and other non-specific symptoms (general malaise, body aching and fatigue). Her poorly condition, assumed to be due to gastroenteritis, had left her unable to tolerate food and she had not eaten for 4 days. Pregnancy and birth had been uneventful and the patient had been exclusively breastfeeding her baby since birth.
Admission venous blood gases revealed a high anion gap metabolic acidosis (pH 7.02, bicarbonate 5 mmol/L, and anion gap 37 mmol/L). The high anion gap was found on testing to be due to increased ketones in blood and urine, confirming the diagnosis of ketoacidosis. Absence of a history of diabetes and finding of normal blood glucose (3.6 mmol/L) excluded a diagnosis of diabetic ketoacidosis. The cause of ketoacidosis in this case was attributed to the combined effect of lactation, gastroenteritis and reduced food (carbohydrate) intake. Analysis of the Diabetic Ketoacidosis Case Study Essay
In discussion of this case history, the authors reflect that ketoacidosis in lactating women is a rare but recognized occurrence; they cite nine previous reports. In most cases, including the one reported here, inadequate carbohydrate diet (starvation) is thought to be a significant factor in lactation-induced ketoacidosis. The report includes extended discussion of why lactating women may be at greater than normal risk of ketoacidosis, and the ketogenic effect of a low carbohydrate diet
Diabetic ketoacidosis (DKA) is a potentially life-threatening metabolic emergency that occurs as a complication of uncontrolled diabetes. Low serum insulin levels in DKA prevent glucose from entering the cells to perform normal metabolic functions, causing the cells to respond as if in a starvation state. The production of counter-regulatory hormones (e.g., catecholamines, cortisol, glucagon, growth hormone) in response to the low insulin levels exacerbates the perceived state of starvation. To compensate, the liver begins to break down stored glycogen and fat to produce glucose, which produces ketone acid byproducts that lead to metabolic acidosis and hyperlipidemia. Hyperventilation with deep, gasping breaths (i.e., Kussmaul respirations) can ensue as a compensatory mechanism to counteract the acidosis. The kidneys initiate osmotic diuresis to excrete the excess glucose that is entering the bloodstream. Unless impaired, the kidneys also excrete water and electrolytes, leading to dehydration and electrolyte imbalances. Blood becomes concentrated due to dehydration. Although electrolyte levels can be elevated according to the laboratory test results, the total body electrolyte stores in the tissues can be low. Electrolyte imbalances and hyperosmolarity (i.e., increased solution concentration expressed as osmoles of solute/kg of serum water) can result in cardiac arrhythmias and even coma. DKA in pregnancy can cause fetal distress, fetal malformation, fetal demise, and maternal mortality.Analysis of the Diabetic Ketoacidosis Case Study Essay
DKA occurs mainly in patients with diabetes mellitus, type 1 (DM1), but it can affect patients with diabetes mellitus, type 2 (DM2) or, rarely, patients with gestational diabetes (i.e., pregnancy-induced diabetes). Regardless of whether affected by DM1 or DM2, the patient can have impaired beta-cell (i.e., the pancreatic cells that produce insulin) function. Pregnant women have a reduced buffering capacity (i.e., the ability to compensate for pH imbalances), which makes them more susceptible to acidosis; they can be unable to produce enough insulin to meet fetal demands despite normal beta-cell function. The most common precipitating factors for DKA regardless of the type of diabetes are insulin administration errors, infection, and new-onsetdiabetes. Other known precipitating factors include medications (e.g., corticosteroids, thiazides, salicylates, atypical antipsychotics), recreational drug use, alcohol abuse, severe medical illness, starvation, surgery, trauma, pregnancy, and emotional stress. The severity of DKA does not correspond to the blood glucose level; pregnant women with DKA can even have normal blood glucose levels. Most patients with DKA are seen in the emergency department and require admission to the ICU for close monitoring and management. The differential diagnosis includes hyperglycemic hyperosmolar syndrome (i.e., a life-threatening diabetic emergency with similar symptoms but without ketoacidosis) and other types of acidosis. Treatment includes insulin and glucose administration, fluid/Analysis of the Diabetic Ketoacidosis Case Study Essay
electrolyte restoration, and resolution of the underlying cause. DKA is best prevented via patient education.
Facts and Figures
The reported incidence of DKA in adults with DM1 is 0–56 per 1,000 persons per year (Farsani et al., 2017). DKA incidence is 50% or 2 of every 100 persons with DM1. Approximately 20% of patients with DM1/DM2 initially present with DKA. DKA can occur at any age; 36% of cases occur in patients aged < 30 years, 27% occur in those aged 30–60 years, 23% occur in those aged 51–70 years, and 14% occur in those aged > 70 years (for information on DKA in children, see Quick Lesson About … Diabetic Ketoacidosis in Children ). DKA is the most common cause of death in patients with DM1 who are under the age of 40. The reported mortality rate for DKA is as high as 10%. There are more than 100,000 annual hospital admissions for DKA in the United States, and DKA accounts for 8–29% of all hospital admissions in patients with diabetes mellitus (DM).
Risk Factors
Two primary risk factors for DKA include insulin dependence and age < 25 years. Other significant risk factors include Black race, chronic alcohol abuse, recreational drug use, and mental illness, all of which often result in noncompliance with drug regimens and/or drug-induced hyperglycemia. Additional specific medical risk factors include new-onset DM, infection, gastroparesis, pancreatitis, stroke, myocardial infarction, abdominal crisis, and trauma, but any severe medical illness can trigger DKA.Analysis of the Diabetic Ketoacidosis Case Study Essay
Signs and Symptoms/Clinical Presentation
Common signs and symptoms of DKA include polyuria (i.e., excessive urination), polydipsia (i.e., excessive thirst), nausea, emesis, abdominal pain, change in appetite, weakness, malaise, sudden weight loss, blurred vision, headache, drowsiness, fruity breath odor, dry mucous membranes, tachycardia, hypotension, and hypothermia. As DKA progresses, Kussmaul respirations and coma can develop. Fever can be present in patients with a coexisting infection.
Assessment
Patient History
Patient might report abdominal pain that resolves with treatment
Patient might report changes in mental status
Laboratory Tests That Can Be Ordered
Serum glucose is usually > 250 mg/dL, although in pregnant women with DKA glucose levels can be within normal limits
Elevated serum β-hydroxybutyrate (β-OHB) and/or serum ketones
Complete metabolic panel shows HCO3 ≤ 15 mEq/L and anion gap > 10 in DKA
Arterial or venous blood gases can show a pH < 7.3
Urinalysis can reveal ketones and glucose Analysis of the Diabetic Ketoacidosis Case Study Essay
Blood cultures can be ordered if sepsis is suspected as a precipitating factor
Toxicology panel can be ordered if salicylate poisoning or drug use is suspected
Other Diagnostic Tests/Studies
EKG usually shows sinus tachycardia in DKA, but can also show arrhythmias
Chest X-ray can be ordered if respiratory infection is a suspected cause of DKA
Treatment Goals
Administer Medications as Prescribed and Monitor for Complications
Administer prescribed insulin (for precautions, see Red Flags , below)
Insulin molecules adhere to IV tubing. When hanging an insulin drip, flush the IV tubing with 50 mL of the insulin solution before connecting the tubing to the patient to promote administration of an adequate concentration of insulin
Administer IV fluids at the prescribed rate and adjust per order as laboratory values change (e.g., protocols usually start with 0.9% normal saline [NS] and progress to 0.45% NS and dextrose 5% in water [D5W] per lab values)
In rare cases, bicarbonate can be ordered. Bicarbonate should never be given in 0.9% NS because it creates a hypertonic solution and increases osmolality
Administer prescribed potassium, which is usually ordered as soon as potassium levels are normal because potassium levels can drop quickly as fluids and insulin take effect; phosphate, magnesium, and calcium replacement can also be ordered
Monitor the timely completion of lab draws and frequently check test results; report decompensation or lack of improvement. Initially, glucose is usually monitored hourly. Metabolic panels are usually drawn every 2–4 hours
Monitor every 2–4 hours including heart rhythm for the development of arrhythmias, neurologic status for signs of cerebral edema, and intake and output; frequently assess for signs of fluid overload Analysis of the Diabetic Ketoacidosis Case Study Essay
Monitor for deep vein thrombosis (DVT) and other thrombotic conditions
Provide Emotional Support and Patient Education
Assess anxiety level and coping ability; promote emotional well-being and educate (for patient education, see below for What Do I Need to Tell the Patient/Patient’s Family?)
Request referral, as appropriate, to a social worker for identification of local resources for educational programs, in-homecare, and support groups
Food for Thought
It is difficult to predict which patients are at increased risk for experiencing recurrent episodes of DKA. In one clinical study, investigators found that few clinical differences existed between patients who experience one episode of DKA and those who experience multiple episodes (Cooper et al., 2016)
Red Flags
Serum potassium must be at least 3.3 mEq/L before initiating insulin administration, because insulin can cause a swift drop in potassium levels
Carefully monitor insulin drips because medication errors can be fatal (e.g., have a second nurse check the label on the bag and the infusion pump rate; prime the tubing and waste the first 50 mL of medication; administer subcutaneous insulin when the insulin drip is discontinued, as ordered)
Patients with coexisting renal insufficiency or heart failure can have an atypical presentation and are particularly vulnerable to fluid overload during fluid resuscitation
Complications of DKA include electrolyte imbalances, cerebral edema, thrombotic events (e.g., pulmonary embolism, stroke, DVT), and acute kidney injury
What Do I Need to Tell the Patient/Patient’s Family?Analysis of the Diabetic Ketoacidosis Case Study Essay
Educate about the prescribed treatment regimen, proper medication administration, glucometer and ketone strip use, and the signs and symptoms of DKA
Follow the “Sick Day Rules” for self-managing diabetes during periods of illness
Continue prescribed diabetic medications as usual
Test blood glucose and urine ketones every 3–4 hours
Report a glucose reading > 300 mg/dL or urine ketones to the treating clinician
If nauseous, eat frequent (e.g., 6–8 times a day), small meals of soft foods such as gelatin, soup, custard, or crackers
If vomiting, diarrhea, or fever persists, continue calorie intake through liquids (e.g., orange juice, broth, or sports drinks) very 30–60 minutes
Report nausea, emesis, or diarrhea promptly to the treating clinician
If unable to keep liquids down, hospitalization can be necessary to prevent DKA
Introduction
Briefly explain the pathophysiology of the development of DKA. Why was it triggered in this patient?
Diabetic ketoacidosis is really a serious diabetic complication that occurs when one’s body produces high levels of ketones which are blood acids. It develops when your body is not able to produce insulin in enough quantities. Insulin usually plays a major role in helping glucose (a key energy source for the muscles and other tissues) enter the cells. Lack of sufficient insulin makes the body start breaking down fat for alternate fuel. This process leads to a buildup of toxic acids known as ketones in ones bloodstream, eventually leading to diabetic ketoacidosis if not treated early enough. (Mayo clinic, 2012).Analysis of the Diabetic Ketoacidosis Case Study Essay
Why it was triggered in the patient is because
The main reason why Diabetic ketoacidosis (DKA) was triggered in this patient was simply because of shortage of insulin. Another factor that could have contributed to the shortage was simply because of the episodes of vomiting and anorexia which made him to stop taken insulin. This shortage automatically results to the burning of fatty acids to produce highly acidic ketone bodies which research shows is the cause for most of the complications and symptoms. Patients with undiagnosed diabetes may suffer diabetes ketoacidosis as the first symptoms. However patients known to suffer from diabetes resulting from various causes such as inter-current disease or relatively bad compliance with insulin therapy can also fall victim to this complication under certain circumstances. It is definitely one of the most serious complications for those people with diabetes mellitus.Analysis of the Diabetic Ketoacidosis Case Study Essay
What clinical signs/symptoms of DKA does Jeff exhibit? What are the pathophysiological causes of each one?
‘DKA’ causes acid ailment from the blood vessels to be a link between ketone currently being produced. Nevertheless physicians are usually not proficient at diagnosing ‘DKA’ on many instances. For that reason, one has to be aware of the signs and symptoms of the illness. Recalling these indicators could even save one, their own or even another person’s life. Some of the signs and symptoms exhibited by Jeff are;
– Nausea and vomiting
– Anorexia
– Bad breath
– Fast and strained breathing
– Lethargic
– Confusion
Nausea and vomiting
Experiencing nausea and vomiting may also be a sign of DBK. It is usually caused by the ailment from the blood vessels. Failure of proper food movement in the intestines may lead to such nausea and vomiting.
Bad breath
One can find that they are experiencing bad breath from their mouth. Usually it smells like a fruit due to acetone.Analysis of the Diabetic Ketoacidosis Case Study Essay
Anorexia
Anorexia occurring in DKA is due to fuel fat catabolism which in turn exacerbates the symptom.
Fast and strained breathing
Rapid breathing and strained breathing may be a symptom of DBK. This happens because our bodies are trying to hit off a number of acids over the lungs (C.Kruger, & Mineapolis, 2008).
Lethargy and confusion
These symptoms are caused by the effects of the excess ketones and sodium in the blood. These are the electrolytes that lead to neurologic symptoms once they are in excess values.
Discuss Jeff’s laboratory studies and the physiological basis for all the abnormals.
Blood glucose= 730mg/dl
Serum K (potassium) =5.2mEq/L
Hgb A1c=8.5%
ABG: pH=7.26
pCO2=13mmHg
HCO3=5mEq/L
The serum biochemistry profile of Jeff clearly indicates what is going on within his system. In this system, we can clearly see that the blood glucose is exceedingly high with the 730mg/dl figure. This shows that there has been deficiency in the work of insulin over a period of time. The degree of this hyperglycemia is also influenced by the severity of the diabetic ketoacidosis, the renal profile of the patients and presence of dehydration.
The blood pH is still within the normal range because of it is usually expected to fall below 7 when there is diabetic ketoacidosis to cause a state of acidosis. The implication of that state of pH will be fatal when compared to this present pH.Analysis of the Diabetic Ketoacidosis Case Study Essay
The value of potassium is slightly on the normal side. The basic factor for this stable value is that which relates to what DKA usually causes in terms of DKA causes more of hypokalemia hence the value of potassium should be expected to go down. However there are situations where acidosis and the insulin deficiency will contribute to the rise of potassium making it to go up. In such situations when fluid is administered, the value will then fall.
The pCO2 and HCO3 are of both values that are lower than the normal values. The physiological basis for these values might be as a result of the deep and fast respiration which characterized the DKA. Since pCO2 is meant to be excreted during respiration, deeper respiration will thus result in excretion of more of the carbon dioxide.
Analyze the ABG results. Is there compensation?
ABG: pH=7.26
pCO2=13mmHg
HCO3=5mEq/L
Analyzing the ABG status, we can see that the pH is below the normal hence indicating a state of acidosis. As we know in terms of the value of the respiratory involvement in the cause of acidosis, to determine that, we have to evaluate the PaCO2 values to know where the problem is actually from. The PaCO2 which is 13mmHg is a value that is extremely below the normal range. The implication of this is that the source of the acidosis must have been metabolic source and not respiratory. This is because according to the Herdenson-Hasselbalch equation, when there is high PaCO2, definitely that will result in low pH (acidosis). Taking a thorough look at the value of the HCO3 which is very low than the average, we can deduce clearly that the origin of the acidosis being experienced by the patient is clearly metabolic and not of respiratory origin.
What distinguishes this case history from one of HHNK (hyperglycemic hyperosmolar nonketosis). How do the symptoms of DKA and HHNK differ from those of hypoglycemia?
The fact that distinguishes this case from hyperglycemic hyperosmolar nonketosis is fact that this case occurs in young adult unlike the HHNK that usually occur in the elderly. It is not exclusively encountered in people with type 1 diabetes mellitus and no associated increase in ketone level like what is obtained in diabetic ketoacidosis. The differences between the symptoms of these three conditions or complications are related to their underlying pathophysiology. The fact that hypoglycemia is related to lowered sugars makes the associated symptoms to be more of those that relates to reduced sugar such Confusion, Dizziness, Feeling shaky, Hunger, Headaches, and Irritability. Those symptoms of HHNK and DKA are related to more of acidosis symptoms which are; Nausea, vomiting, anorexia, bad breath, fast and strained breathing, and confusion.Analysis of the Diabetic Ketoacidosis Case Study Essay
What educational needs must be met before the patient’s discharge? How should he be instructed to handle further illnesses? Research and discuss current dietary recommendations for Diabetics. How can his wife contribute to the management of his diabetes?
The educational need Jeff is as regards to the management of his diabetes from the aspect of diet, check-ups and medication use. These are very important in preventing most of the complication that brought him to the hospital. In a bid to handle further illnesses, any time he feels some abnormal changes in the way he breathe or his body system is changing rapidly, he needs to consult the specialist on time.
Diabetics need to focus on timing when feeding. I.e. should have almost the same timing for all their meals. They should also focus on nutrition that helps to reduce weight. Consume few calories once in a while. Sugar reduction remains the key in the management of meal.
What other physiological disorders are commonly associated with diabetes mellitus? How can Jeff best attempt to limit these complication risks?
– Diabetic ketoacidosis,
– hyperglycemia hyperosmolar state,
– hypoglycemia,
– diabetic coma,
– respiratory infections and
– periodontal diseases Analysis of the Diabetic Ketoacidosis Case Study Essay
Jeff can prevented these complications by focusing on these preventive measures
As it is always said, prevention is better than cure. To avoid Diabetes Ketoacidosis and all other complication or physiological disorders associated with diabetes, Jeff must become rigorous with his diabetes management, monitoring his blood sugar levels, checking his ketone amount, as well as altering his insulin dose whenever desired. Issue on diabetes are usually very frightening thus the need for one to comply strictly with the physicians advice so as to manage the complication appropriately.
What are the roles of the nurses in the management of DBK?
Effectively take care for the patients.
Nursing has always reflected the technological advancement of its time and age. Therefore, nurses should effectively be able to interpret the most recent technological developments in healthcare to their patients. In this era, patients suffering from diabetes should be able to cope with insulin pumps, continuous monitoring of blood glucose, prosthetic devices used for amputations, and dialysis at homes. Nurses have the responsibility of guiding and ensuring patients are well conversant with the technological advancements around them. They should aim at using any available knowledge of technology they have at ensuring that diabetes patients smoothly transition to diabetes self-management. Caring and technology are intimately interwoven nurses can demonstrate high caring levels by applying the knowledge they have on technology to benefit their patients.Analysis of the Diabetic Ketoacidosis Case Study Essay
Enhancing their knowledge on diabetes
Nurses will many at times be needed to make an extra step in critically analyzing what’s affecting their patients. Cardiology, dermatology, neurology, gastroenterology, nephrology, psychiatry and ophthalmology will definitely become sub specialized zones of concern for nurses as they learn more on how to help and educate their patients. As their knowledge level increases, they will have some sense of pride in the amount of information they will be able to share with their patients.
Patient education
Nurses should be educators of the patients in matters concerning diabetes and DBK. They should be able to educate their patients on the dos and don’ts of diabetes. They should also aim at promoting behavior change of their patients through relevant education on that and also ensure that the patients are taught about the national standards for diabetes self-management Analysis of the Diabetic Ketoacidosis Case Study Essay
Increase psychological support to patients
Psychological support is very important in every nursing field especially when patients are suffering from chronic illnesses and their complications. Diabetic patient at times come across difficult news and usually have to make quit tough decisions. Some may be diagnosed with complications such as kidney failure and they may be asked to choose either go for a transplant or dialysis. At this point, they really need someone to encourage and give them hope. A caring and empathetic nurse should be present to encourage the patient and give them hope. Analysis of the Diabetic Ketoacidosis Case Study Essay
