Question

Terri is a 28-year-old 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 Glasgow 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

PaCO2 - 40 mmHg

HCO3 - 13 mmol/L

PaO2 - 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

Directions: Answer the following questions and cite references. Create a Nursing Care plan based on the case presented.

1. What condition explains the patient’s hypotension and diuresis? Discuss your answer.

2. What intravenous fluid/s is appropriate to treat this patient’s dehydration? Justify.

3. Discuss what has activated the renin– angiotensin– aldosterone mechanism?

4. Explain the physiology that triggered the patient to exhibit tachypnea.

5. Kindly interpret the patient’s ABG results. Explain your answers using up and down arrows, followed by a short narrative.

6. Justify the cause of the patient’s dysrhythmia.

7. Explain what should be monitored all throughout the patient’s stay.

8. Why is it important to maintain an accurate fluid balance record for this patient?

9. Please prepare a nursing care plan for Terri’s condition.

Answer 1

1. The patient condition is type 1 DM but now it enters the next level that is diabetic ketoacidosis. Hyperglycemic state patient of DM type 1 can lead to osmotic diuresis,tachycardia etc. Then hypotension is mainly caused due to volume depletion with peripheral vasodilation. This is confirmed by her respiratory status , breath odour and pH variations. The patient is hypotensive and diuretic because of that. Mainly polyuria is a symptom of type 1 diabetes . So now it is in a worse state of DKA. The patient had acetone or fruity breath, respiration rate concludes she is having kussmauls respiration .and pH she is having is metabolic acidosis.

2.Usually in hyperglycemic state the patient will be having nausea, vomiting , and excessive urination which results in dehydration. The patient should be provided with normal saline solution first to compensate this situation of increased glucose level.then hartmann's solution is otherwise called as ringer lactate commonly given to replace the low blood volume and low BP.

3. The main reason why the renin angiotensin mechanism is activated due to decreased BP in DKA. The glomerulus will decrease renin when there is hypotension which activates angiotensin that is causing vasoconstriction. This leads to increase in BP. The kidney will be acting as a compensatory mechanism .

4. The main reason for Terri to get tachypnea is due to DKA secondary to metabolic acidosis.In this pH variation the client will be having rapid and shallow respiration due to hyperventilation.Kussmaul respiration is mainly due to this . It can even lead the patient to go to diabetic coma and even death.

5.Diabetic patient usually having metabolic acidosis which can be denoted by

pH ⬇️ HCO3 ⬇️PCO2 ⬇️.

The meaning of this pH is reduced in acidosis and bicarbonate level will be decreased due to dehydration and as a compensatory mechanism the lung will cause respiratory alkalosis.

6.The main reason for the patient to have dyrhythima is mainly due to alternation in the level of potassium. High peaked T wave is due to incrssed K levels. After administration of 2L normal saline there will be intracellular fluid shift which results in this and due to metabolic acidosis.

7. The patient was having daily

Vital sign monitoring

Accurate input output chart

Continuous ECG monitoring

ABG analysis

Electorate level (K) monitoring

Based on the patient condition this should be monitored daily and accurately, if any abnormality immediately intimate the physician.

8.Because patient with diabetes will be having symptoms of microalbunemia. So that indicates patient is having diabetic nephropathy . This can leads to kidney failure .

9. Assessment:

Subjective data: Teri's partner Greg reports that she has been unwell with a flu-like illness for the past week with nausea and vomiting over the past 2 days.

Objective data: Teri seem to be lethargic and unable to make any sense.

Nursing diagnosis

1. Risk for fluid volume deficit related to nausea and vomiting secondary to osmotic diuresis.

Desired Outcomes or Nursing goal

• Client will remain normovolemic as evidenced by urinary output greater than 30 ml/hr, normal skin turgor, good capillary refill, normal blood pressure, palpable peripheral pulses, and blood glucose levels between 70-200 mg/dL.

Nursing Interventions	Rationale
Assess precipitating factors such as other illnesses, new-onset diabetes, or poor compliance with treatment regimen.	These will provide baseline data for education once with resolved hyperglycemia. Urinary tract infection and pneumonia are the most common infections causing DKA and HHNS among older clients.
Assess skin turgor, mucous membranes, and thirst.	To provide baseline data for further comparison. Skin turgor will decrease and tenting may occur. The oral mucous membranes will become dry, and the client may experience extreme thirst.
Monitor hourly intake and output.	Oliguria or anuria results from reduced glomerular filtration and renal blood flow.
Monitor vital signs:
Monitor BP especially for orthostatic hypotension.	Decreased blood volume may be manifested by a drop in systolic blood pressure and orthostatic hypotension.
Monitor respirations, e.g., acetone breath, Kussmaul’s respirations.	Acetone breath is due to the breakdown of acetoacetic acid. Kussmaul’s respiration (rapid and shallow breathing) represent a compensatory mechanism by the respiratory buffering system to raise arterial pH by exhaling more carbon dioxide.
Monitor temperature.	Fever with flushed, dry skin may indicate dehydration.
Monitor heart rate.	Compensatory mechanism results in peripheral vasoconstriction with a weak, thready pulse that is easily obliterated.
Assess neurological status every two (2) hours.	Decreased level of consciousness results from blood volume depletion, elevated or decreased glucose level, hypoxia or electrolyte imbalances.
Weigh client daily.	Provides baseline data of current fluid status and adequacy of fluid replacement. A weight loss of 2.2 lbs over 24 hours indicates a 1 liter of fluid loss.
Monitor laboratory studies:

Implementation :

• Provided 2 ltr of normal saline
• Monitored accurate intake and output chart
• Chartedvital signs periodically
• GCSwas assessed
• Urinalysis was done

2. Assessment: Subjective data: Patient seems unconscious and ECG variation noticed.( Peaked T waves)

Nursing diagnosis: Decreased cardiac output related to dysrhythmia secondary to variation in potassium levels

Desired Outcomes/Nursing goal

• Maintain/achieve adequate cardiac output as evidenced by BP/pulse within normal range, adequate urinary output, palpable pulses of equal quality, usual level of mentation.
• Display reduced frequency/absence of dysrhythmia(s).
• Participate in activities that reduce myocardial workload.

Nursing Interventions	Rationale
Palpate pulses (radial, carotid, femoral, dorsalis pedis), noting rate, regularity, amplitude (full or thready), and symmetry. Document presence of pulsus alternans, bigeminal pulse, or pulse deficit.	Differences in equality, rate, and regularity of pulses are indicative of the effect of altered cardiac output on systemic or peripheral circulation.
Auscultate heart sounds, noting rate, rhythm, presence of extra heartbeats, dropped beats.	Specific dysrhythmias are more clearly detected audibly than by palpation. Hearing extra heartbeats or dropped beats helps identify dysrhythmias in the unmonitored patient.
Monitor vital signs. Assess adequacy of cardiac output and tissue perfusion, noting significant variations in BP/pulse rate equality, respirations, changes in skin color, temperature, level of consciousness, sensorium, and urine output during episodes of dysrhythmias.	Although not all dysrhythmias are life-threatening, immediate treatment may be required to terminate dysrhythmia in the presence of alterations in cardiac output and tissue perfusion.

Implementation:

• Assessed the patient condition
• Checked the vital signs
• Checked the lab values of K
• ECG monitored.
• Monitored the patient on cardiac monitoring device.
• Checked the oxygen saturation
• Checked the GCS

3. Assessment : Objective data: Patient vitals are increased

High risk for infection related to hyperglycemia secondary to indwelling catheter

Desired Outcomes

• Nurse will identify interventions to prevent reduce risk of infection.
• Patient remains free of infection, as evidenced by normal vital signs and absence of signs and symptoms of infection.
• Early recognition of infection to allow for prompt treatment.

Nursing Interventions	Rationale
Assess for signs of infection and inflammation.	Infection is a common cause of DKA. Signs of infection includes fever, chills, dysuria, and increased WBC count.
Observe client’s feet for ulcers, infected toenails, or other medical problems.	Due to impaired circulation in diabetes, foot injuries are predisposed to poor wound healing.
Observe aseptic technique during IV insertion and medication administration.	Elevated blood sugar weakens the immune system thus clients are more prone to infection.
Provide skin care.	An intact skin protects against infection.
Encourage proper handwashing technique.	To avoid the risk of cross-contamination.
Encourage adequate oral fluid intake (2-3 liters a day unless contraindicated).	Reduces susceptibility to infection.
Encourage deep breathing exercise; Maintain client in semi-Fowler’s position.	Helps in mobilizing secretions. And expanding the lung.
Obtain sample for culture and sensitivity as indicated.	Identifies the bacteria/fungus that causes an infection and the appropriate drug for it.
Administer antibiotics as indicated.	Early initiation of antibiotic may help to prevent sepsis.

Implementation:

Assessed the patient condition

Provided neutropenic precautions

Checked the vital signs

Assessed any area for redness or inflammation

Administered drugs as per physicians order.

4. Assessment : Subjective data: Teri's partner says that she is having flue like symptoms for the past 2 weeks

Objective data: symptoms of hyperglycemia and other related symtoms seriousness is not known for the partner Greg.

Nursing diagnosis : Deficient knowledge related to lack of exposure to this condition by her partner

Desired Outcomes

• Client will verbalize understanding of the disease condition and potential complication.
• Client will correctly perform necessary procedures and explain rationale on each action.
• Client will demonstrate lifestyle changes and participate in treatment regimen.

Nursing Interventions	Rationale
Establish rapport and trust.	Create an environment where trust and good rapport facilitates good relationship in the learning process.
Explain the signs and symptoms of diabetic ketoacidosis.	Symptoms of hyperglycemia include polyuria, polydipsia, polyphagia, flushed skin, and body malaise.
Discuss the following with the client: Normal blood glucose level. Risk factors. Client’s type of diabetes. The relationship between elevated glucose level and insulin deficiency.	Baseline knowledge enables the client to make informed lifestyle choices.
Demonstrate proper blood glucose testing using the glucometer. Instruct client to check the urine for ketones once blood glucose reaches 250 mg/dL or higher.	Monitoring blood glucose 3-4 times a day is an essential part of managing diabetes to avoid further complications. Blood glucose >250mg/dl and high urine ketones should be reported to the physician immediately.
Teach signs of hypoglycemia: Dizziness. Sweating. Hunger. Pallor. Diaphoresis. Nervousness. Tremors.	These are signs of excessive insulin dosage, resulting in hypoglycemia. Early recognition of these symptoms promotes immediate intervention.
Teach client that polyuria, polydipsia, and polyphagia are signs of hyperglycemia which requires increased dosage of insulin.	These are signs of insufficient insulin dosage and hyperglycemia which may lead to coma and death if untreated.
Explain the importance of having a dietary plan: Limit intake of simple sugar, fat, salt and alcohol. Increase intake of whole grains, fruits, and vegetables.	Medical nutrition therapy is important in managing diabetes and preventing the rate of development of diabetes complications. A high-fiber diet can slow the absorption of glucose, decreased excess insulin levels and lowered lipid concentrations in clients with type 2 diabetes.
Teach client to monitor blood glucose during periods of exercise and adjust insulin dose.	The insulin dose should be adjusted after increased or decreased food intake and before any exercise. Exercise may increase usage of glucose.
Advise the client the importance of daily examination of the feet and foot care.	Decreased peripheral circulation place the client at risk for an undetected foot injury.
Advise the client the importance of routine eye examination.	Clients with a poorly controlled diabetes may experience changes in vision that may lead to blindness.
Review of medication regimen, including, onset, peak, and duration of prescribed insulin, as applicable with the client.	A good way to properly use insulin is to learn these aspects of drug usage. This will help in the adjustment of the doses or the food intake to stop unwanted ups and downs in the glucose level.
Review self-administration of insulin and care of equipment. Have client demonstrate procedure (e.g., drawing up and injecting insulin, insulin pen technique, or pump therapy).	Evaluate understanding of the procedure. Recognizes potential problems such as short-term memory so that alternative solutions can be made for the administration of the insulin.
Discuss timing of insulin injection and mealtime.	Regular insulin works best if administering it 30 minutes before eating. While a product called insulin lispro (Humalog) works best when taking within 15 minutes of eating. With the onset twice as fast as regular insulin and a duration nearly half as long. Hypoglycemia may result more rapidly. If a blood glucose reading is >80 mg/dL, the insulin should be injected after eating rather than before the meal.
Discuss the use of a medical alert bracelet.	This enables the client to have a quick entry into the health system, and appropriate care will be given immediately.
Stress the importance of strict follow-up care.	To prevent or delay the development of complications from diabetes.

Implementation:

Given teaching to the partner about the disease condition and the treatment modalities

Taught the patient partner to use SMBG in home itself.

Taught the important of lab investigation periodically

Importance of followup is mentioned.

5. Assessment :Assessment : Patient partner says that she is having nausea and vomiting for the past week.

Objective : patient seen to be fatigue and lethargic

Imbalanced nutrition less than body requirement related to hypermetabolic state.

Desired Outcomes

• Client will display normal energy level.
• Client will take appropriate amounts of calories/nutrients.
• Client will demonstrate stabilized weight or gain toward desired range with normal laboratory values.

Nursing Interventions	Rationale
Determine client’s dietary program and usual pattern.	Recognizes deficits and deviations from therapeutic needs.
Monitor weight daily or as indicated.	Assessing sufficiency of food intake, including absorption and utilization.
Auscultation bowel sounds, note the presence of abdominal pain/abdominal bloating, nausea or vomiting. Maintain on NPO status, as indicated.	Imbalances in the fluid and electrolytes and hyperglycemia reduces gastric motility resulting in delayed gastric emptying that will influence the selected intervention.
Involve patients in planning family as indicated.	Provide information on the family to understand the nutritional needs of the patient.
Recognize signs of hypoglycemia.	Hypoglycemia can occur because of a reduced carbohydrate metabolism while still given insulin, it can potentially be life threatening and should be recognized.
Monitor laboratory studies (Serum glucose, pH, HCO3, acetone).	With a controlled fluid replacement and insulin therapy, blood glucose will gradually decrease. With the optimal insulin dosages administration, glucose can then enter the cells and will act as energy. As a result, acetone levels decrease and acidosis is corrected.
Perform fingerstick glucose testing.	Monitoring of blood glucose such as using finger-stick blood samples has helped in diabetes management for effective glycemic control.
Administer glucose solution, e.g., dextrose and half normal saline.	Solutions containing glucose are added after insulin and fluids have brought the blood glucose to approximately 400 mg/dL. When the metabolism of carbohydrate reaches normal, caution must be taken to prevent hypoglycemia.
Administer regular insulin by intermittent or continuous IV method.	Intravenous (IV) infusion is the choice route of insulin delivery because the rapid onset and short duration of action associated with IV infusion allow for matching insulin requirements to rapidly changing blood glucose levels.
Collaborate with a dietician for initiation of resumption of oral intake.	Helps in calculating and adjusting diet to meet nutritional needs of the client; Dietician assists the client and the family on producing meal plans.
Provide a diet consisting of 60% Carbohydrates, 20% fats, 20% proteins in designated number of meals.	Complex carbohydrates (peas, beans, whole grains, and vegetables) decreases glucose and cholesterol levels. Food intake is scheduled according to specific insulin characteristics and individual client’s response.
Administer medication as prescribed.	Beneficial in treating symptoms related to affecting GI tract such as diabetic gastroparesis, to improve oral intake and nutrient absorption.
Prochlorperazine (Compro); diphenhydramine (benadryl).	Medications to control nausea and vomiting.
Metoclopramide (Reglan); erythromycin (Eryc).	Medications to stimulate the stomach muscles.

Implementation :

Patient is on IV fluids ( NS and RL)

Accurately monitoring the input output chart

Patient will be out on TPN as per the glucose level and physicians order.