Question

Terri is old a 28-year-woman with a history of type 1 diabetes mellitus (TIDM), diagnosed when she was 5 years old. She has been brought into the emergency department this morning by her partner, Greg, as she is lethargic and unable to make any sense. Greg reports she has been unwell with a flu-like illness for the past week with nausea and vomiting over the past 2 days. Terri had decided not to take her usual insulin dose last night as she hadn't been eating and her blood sugar was only 8.1 mmol/L.

                On examination you find Terri has a Glaslow Coma Scale score (GCS) of 10 (eye opeming:3; verbal response :3; motor response:4); she has deep, rapid respirations, acetone smell on her breath and her skin is flushed ad dry. Greg reports she had gone to the toilet several times during the night and, when she woke up this morning, she had wet the bed. Her blood glucose level (BGL) is 42.1 mmol/L and her ketone levels are 7.1 mmol/L. Urinalysis shows large amounts of glucose and ketones with a low specific gravity. Her vital signs are:

• BP 102/54 mmHg
• Hr112 beats/minute
• Rr 36 breaths/minute, rapid and shallow
• T: 36.2 degree Celsius
• Spo2 96% with no supplemental oxygen

Medical staff suspect Terri has diabetic ketoacidosis (DKA) and order two large bore intravenous (IV) cannulae inserted for fluid resuscitation and IV insulin administration.

Phase 1

Terri has been in the emergency department for half an hour. An indwelling catheter is placed to closely monitor Terri's fluid balance while the diuresis continues. Terri is initially commenced on a rapid infusion of normal saline to replace fluid lost through the osmotic, diuresis and improve her BP. Medical staff have ordered the commencement of an IV insulin infusion to slowly decrease Terri's BGL and you access the hospital's protocol for this and prepare the infusion. Blood tests are taken to determine urea and electrolyte status as well as arterial blood gas analysis to assess the presence and extent of acidosis.

Although Terri's initial oxygen saturation levels were good, you apply a simple face mask with 6 L O2, supplemental oxygen as she is tachypnoeic and you want to optimise her FiO2. After receiving 2 L of normal saline, Terri's BP begins to improve. Her current vital signs are:

BP - 110/62 mmHg

HR - 102 beats/minute

RR - 34 breaths/minute, still rapid and shallow

T-37.2°C

Spo2 -97% with 6 LO via simple face mask

Phase 2                                                                                                                                                              

The results of the blood tests, received 30 minutes later, show Terri's potassium levels are 6.2 mmol/L. Her other electrolytes were within normal ranges. You immediately place her on a continuous electrocardiogram (ECG) monitor and take a 12-lead ECG, which shows high peaked T waves. Her ABG results are:

pH - 7.18

Paco, - 40 mmHg

HCO, - 13 mmol/L

PaO, - 125 mmHg

Base excess (BE) - 4 mEq/L

Sao2 - 95%

Twenty minutes after you take your initial ECG, Terri loses consciousness and her continuous ECG monitor shows a 6-second episode of ventricular tachycardia (VT), after which Terri regains consciousness, back to the original GCS 10 assessed on arrival. You notify medical staff and take another 12-lead ECG, which still shows peaked T waves, but no other abnormality. You monitor Terri closely for any further VT episodes. Her vital signs are:

BP - 106/62 mmHg

HR - 121 beats/minute

RR - 30 breaths/minute, still rapid and shallow

T -37.0°C

Spo2 -97% with 6 L 02 via simple face mask

Phase 3:

Terri has been treated for a total of 24 hours now. She has received IV fluid, which was switched to normal saline to Hartmann’s solution, after receiving 2 litres of normal saline, to ensure electrolytes were maintained; her IV insulin infusion continues. After 24 hours of treatment, Terri’s BGL is 31.3 mmol/L, ketones are 4.5 mmol/L and her potassium levels are now 3.2 mmol/L.

                ABG tests weretaken every hour for the first 6 hours, until her pH began to normalise, then every 2 hours. Her ABG is showing significant improvement and is currently:

-pH-7.34

-PaCO2-36 mmHg

-HCO2 -15 mmol/L

-PaO2- 105 mmHg

-BE- 3mEq/L

-SaO2-98%

A strict fluid balance chart was recorded and the indwelling catheter remained in place, for accurate urine output measurements, for 3 days until her condition stabilised. Her vital signs at present are:

-BP- 112/62 mmHg

-HR- 87 beats/min

-RR-22 breaths/min

-T- 37.1 °C

-SpO2-97% with 6 L O2 via simple face mask

1. CREATE A NURSING CARE PLAN FOR THE CASE PRESENTED.

Notes:

-Assessment: (Should have objective and subjective data)

-Diagnosis

-Planning: (Long-term and short-term goal)

-Intervention: (Should be classified if dependent, independent or collaborative intervention. Should be at least 10 interventions)

-Rationale- (rationale for each intervention)

-Evaluation

Answer 1