Question

The Case:

Ali is a 26-year-old type 1 diabetic. He was originally diagnosed at the age of 14, and currently manages his disease with an intensive regimen of insulin injections. Ali is employed as a schoolteacher and soccer coach. He presents today with a 2-day history of vomiting and diarrhea. He has been closely monitoring his blood glucoses and is using regular insulin for high blood glucose levels. He has only been able to tolerate liquids such as Gatorade, but today he is unable to even tolerate that, and comes to the clinic for evaluation of possible diabetic ketoacidosis (DKA).

Questions: 1. Describe the pathophysiology of DKA and why it occurs in patients with type 1 diabetes.

2. Based on the diagnosis of DKA, what assessment findings does the nurse correlate to this disorder?

3. The physician orders a complete metabolic panel, and Ali’s blood glucose is 425. Other lab values include a serum sodium of 152, serum potassium of 3.0, and BUN of 64. What is your assessment of these results?

4. Explain why it is important for Ali to continue to take his insulin even though his oral intake is decreased.

Answer 1

1.Unlike hypoglycemia, where the insulin level is in excess and the blood glucose level is extremely low, DKA is associated with a relative or absolute insulin deficiency and a severely elevated blood glucose level, typically greater than 300 mg/dL. Due to the lack of insulin, tissue such as muscle, fat and the liver are unable to take up glucose. Even though the blood has an extremely elevated amount of circulating glucose, the cells are basically starving. Because the blood brain barrier does not require insulin for glucose to diffuse across, the brain cells are receiving more than an adequate amount of glucose. Basically, the general body tissue is starving while the brain has more than an adequate supply of glucose. Thus, the patient does not experience the sudden onset of signs and symptoms associated with hypoglycemia.

There are three major pathophysiologic syndromes associated with an excessively elevated blood glucose level in DKA:

1. Metabolic acidosis
2. Osmotic diuresis
3. Electrolyte disturbance

2. A diagnosis of diabetic ketoacidosis requires the patient's plasma glucose concentration to be above 250 mg per dL (although it usually is much higher), the pH level to be less than 7.30, and the bicarbonate level to be 18 mEq per L or less.

For Ali high blood glucose levels, vomiting , diarrhoea and intolerance to fluid are relative findings favours DKA.

3. Ali has a major risk of Kidney disease.

4. Ali still on high blood sugar.