Question

Diabetes question

You are a nurse working in the accident and emergency department and have been allocated to assess and care for Jack.

Jack is a 27 years old, single man of Asian heritage who is homeless. He was diagnosed with Type 1 diabetes 12 months ago. He has a history of bipolar disorder. He has presented to the emergency department feeling unwell

An assessment finding reveals the following on Jack

Visually, Jack looks unwell and complains of nausea, abdominal pain, blurred vision, headache, needing to drink a lot and an increasing need to urinate. Jack stated he has lost his supply of insulin, glucometer and finger pricker.

Vital signs and blood and urine test showed

Temp- 35.8, HR 110 bpm, RR 22 rpm, BP 90/50 mmhg, body weight 60kg

Blood test results reveal- BGL 22mmol/L, HbA1c 8%, Ketone 0.4mmol/L

He is considered at risk of DKA and is managed, in the first instance in the emergency department

QUESTION

1, Describe how each of these aspects of the information presented above has led to the diagnosis of pre-DKA state

2, Identify three priority nursing problems and provide rationale for making each of these priority

3, you are required to formulate a goal to address each priority nursing problem

Answer 1

A diagnosis of diabetic ketoacidosisrequires 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.
.Therapeutic goals appear to remain consistent within recent research literature for treatment of DKA. Replacing of fluid loss, decreasing serum blood glucose, reversing acidosis and ketosis, correcting electrolyte imbalances and identifying underlying causes are the main priorities of care.

.Treatment

Therapeutic goals appear to remain consistent within recent research literature for treatment of DKA. Replacing of fluid loss, decreasing serum blood glucose, reversing acidosis and ketosis, correcting electrolyte imbalances and identifying underlying causes are the main priorities of care.^10,11

Initial treatment should assess the patients airway, with intubation and ventilation a possible requirement for those severely comatosed.

A nasogastric tube may be required if the patient is vomiting to prevent aspiration.

Fluid replacement

The next priority should be fluid replacement. Hypotension requires rapid fluid resuscitation with 0.9% saline solution being the fluid of choice.¹² It is vital that a patient receives fluid and not insulin as first priority.

Fluid replacement alone reduces hyperglycaemia and acidosis and increases tissue perfusion whilst being necessary to correct the electrolyte imbalance that has occurred.

Studies have demonstrated that a high volume of fluid replacement in a short time initially will have a positive effect on treatment outcomes, though care must be taken to ensure adequate assessment of the patient for such treatment.¹³ It is vital that an accurate fluid balance chart is maintained at all times during care of the patient with DKA.

Insulin therapy

Once fluid replacement has been initiated an insulin infusion should be commenced. A continuous infusion of insulin that yields a ratio of 1:1 (ie. 50 units of rapid acting insulin to 50ml of 0.9% saline solution) has been accepted as method of choice.¹⁴

Continuous infusion negates the difficulty of erratic absorption which can result in volume depleted patients. A continuous low dose of insulin (ie. six units) has also been shown to be as effective as high or fluctuating insulin administration, thus an infusion set at a rate of six units an hour is considered gold standard.

It is vital that the nurse ensures an accurate record of blood glucose readings in case the infusion needs to be increased or decreased at any stage.

Once blood glucose has fallen to below 10mmol/l the infusion should be halved and 0.9% saline solution exchanged for dextrose saline as the patient now requires carbohydrate.¹⁰

The above recommendations may need to be adjusted with individual patients and nurses should observe the patient continuously for signs of hypoglycaemia.

Potassium replacement

Potassium replacement should only commence after a laboratory result has been established. It should be noted that the initial potassium result might be high offering a false reflection of the patients true condition. Indeed it has been suggested that hypokalaemia may be masked by the presence of acidosis itself.⁷ A low laboratory result indicates that potassium replacement should commence immediately as further hypokalaemia is likely with rehydration.

Additional potassium replacement should be based upon further laboratory analysis with two hourly urea and electrolyte samples recommended until the patient is haemodynamically stable.¹⁰

Use of bicarbonate

There has been much discussion about the use of bicarbonate in the treatment of DKA with significant disparity in opinion. The most recent studies suggest that bicarbonate therapy is unnecessary when the blood pH is above 7.1.¹⁵ Thus bicarbonate should only be considered for use in treatment of DKA when blood pH is less than 7.0.

Education

Given the nature of DKA it is imperative that each patients knowledge of diabetes and the complications of diabetes be revisited by both the patient and a healthcare professional.

In light of the inherent dangers associated with DKA, all patients with diabetes must be educated to recognise both signs and symptoms in order that prompt action may be taken.

With the introduction of modern technology it is now possible for patients to record blood ketones ([beta]-hydroxybutyrate), hence much earlier detection of impending DKA is possible. Involvement of the diabetes nurse specialist at the early stages of admission is also vital to ensure follow up care and support is provided.

Serious condition

DKA must be recognised and treated as the life threatening condition that it is. Staff should be regularly updated on treatment changes and patient presentation so that no patient is misdiagnosed. Treatment should commence immediately with fluid replacement taking precedence over insulin administration.

Patient education, reason for DKA development and prevention of further episodes are all areas which must be addressed by healthcare professionals involved in the care of the patient. Where possible all patients should be referred to the diabetes nurse specialist for education and follow up care.

1Criteria and classification of (DKA)

DKA	Mild	Moderate	Severe
Plasma glucose (mg/dl)	>250 mg/dl	>250mg/dl	250mg/dl
Arterial pH	7.25-7.30	7.00-7.24	<7.00
Serum bicarbonate (mEq/L)	15-18	10- 15	<10
Urine ketone*	+	+	+
Serum ketone*	+	+	+
Effective Serum Osmolality**	Variable	Variable	Variable
Anion Gap***	>10	>12	>12
Mental Status	Alert	Alert/drowsy	Stupor/coma