Patient Case Study: Diabetic Ketoacidosis

Health History

●       Patient: J.D.

●       Age: 30 years old

●       Gender: Female

●       Ethnicity: Hispanic

●       Chief complaint: cold sweats, nausea, vomiting, and disorientation.

●       The patient’s history of present illness on admission includes type I diabetes and missing insulin administration, which led to diabetic ketoacidosis (Bedaso, Oltaye, Geja, & Ayalew, 2019).

●       Past and current medical history: Type I diabetes since she was 9 years old, hypothyroidism, hypertension, and asthma.

 Laboratory/ Diagnostic Testing

Diabetic ketoacidosis can be detected by the signs and symptoms the patient presents; however, to confirm the diagnosis laboratory test can be performed (American Diabetic Association, 2019). A patient with diabetic ketoacidosis will display results of metabolic acidosis in the arterial blood gases that contain low bicarbonate and low pH.

○       Ph: 7.20

○       PCO2:50

○       HCO3: 12

○       PO2: 96%

Diabetic ketoacidosis is characterized by the blood sugar above 250 mg/dl (American Diabetic Association, 2019), so the complete blood test is done to see the blood sugar level for this patient.

○       Glucose: 70-110 mg/L (600)

○       BUN: 10-20 mg/dl (13)

○       Na: 135-145 mEq/L (134)

○       K: 3.5-5 mEq/L (5.2)

○       Cl: 96-106 mEq/L (111)

○       Creat: 0.6-1.2 mg/L (1.3)

○       Ca: 9-10.5 mg/L (8.2)

○       Phos: 2.5-4.5 mg/L (2.1)

○       Mag: 1.5-2.5 mg/L (1.6)

○       WBC: 5,000-10,000 (16,500)

○       RBC: 3.8-5.1 (3.58)

○       Hgb: 12-16 g/dl (10.9)

○       Hct: 37%-47% (31.9%)

○       Plt: 150,00- 400,000 (233,000)

●       Urine analysis is required for DKA patients to assess kidney function and the presence of ketones, which can  help diagnose diabetic ketoacidosis (American Diabetic Association, 2019).

○       Urine PH: 7.0 neutral (4.0)

○       Protein = 6.0 – 8.3 g/dL (10.0 g/dL)

○       Ketones = 0.6 – 1.5 mmol/L (2.5 mmol/L)

Collaborative Management

Here is a list of medications that the patient is currently on:

●       Lispro (sliding scale) for hyperglycemia

●       Lantus (long-term 15 units) for hyperglycemia

●       Lisinopril for hypertension

●       Gabapentin for diabetic neuropathic pain

●       Montelukast for asthma

●       Levothyroxine for hypothyroidism

Here are some possible treatments for DKA:

●       Administer prescribed D5W to replenish fluids and electrolytes and adjust the rate as lab values change (Smith & Schub, 2018).

●       Glucagon PRN per protocol if less than 40 and symptomatic

●       Glucometer check every 1 to 2 hours

According to the American Diabetes Association, there are certain dietary measures that a patient with diabetes should be complying with and that includes a carbohydrate diet to maintain blood glucose in their normal range, an increase of water intake to flush out excess glucose through the urine and increase their physical activity levels as tolerated to also help maintain glucose levels (2019).

Collaborative care involves various members of the healthcare team and has them work together to have a common goal, which is to promote the patient’s highest quality of life by implementing and reinforcing the goals of each member. As stated in the American Diabetes Association, “it is important to choose diabetes care team members who can provide the level of support you want and provide help when you need it” (2019). The healthcare team members and their goal for this patient includes:

●       Primary Physician – gives an order for routine check including physical exams, lab tests, and medication prescriptions. To ensure the goals are met.

●       Registered Nurse – to ensure the patient is stable and is compliant with her care and is knowledgeable about her condition.

●       Nutrition dietician -to educate the patient on what diet is best for her diabetes, which will help her maintain proper glucose levels.

●       Physical Therapy – to improve the patient’s physical strength and educate them on ways to stay active around the house when discharged.

●       Family Support – families, relatives, and friends play a big role in inpatient care. They promote rapid healing and support any patient education on how to maintain a healthy condition and knowing when to go to the healthcare provider or in an emergency situation.

Nursing Diagnoses

The priority physiological nursing diagnosis for this client would be fluid and electrolyte imbalance related to type I diabetes as evidenced by cold sweats, nausea, vomiting, and disorientation. According to Karlya, fluid and electrolytes are the most important thing we need to monitor closely with DKA patients otherwise the patient might suffer from dysrhythmia (Karlya, 2015).  Short term goal for this patient is to maintain glucose level within their baseline by giving the correct dose of insulin which will minimize the risk of hyperglycemia and electrolyte imbalance. One long term goal for this patient is to identify the early signs and symptoms of hyperglycemia and hypoglycemia before discharge to prevent electrolyte imbalance. The following are the interventions, rationale, and evaluation for this patient:

1. Monitor cardiac rhythm and LOC changes
   1. Rationale: To identify dysrhythmias and LOC changes due to hypokalemia.
   2. Evaluation: Patient is alert and oriented to person, place, time, and situation and cardiac rhythm is within normal range.
2. Assess patient compliance with treatment (Ackley, Ladwig, & Makic, 2017).
   1. Rationale: To find out what is leading the patient to hyperglycemia.
   2. Evaluation: Patient had a lack of funds to buy needed medications, so compliance was not consistent and missed a few doses of insulin.
3. Monitor blood glucose every 1-2 hours.
   1. Rationale- To maintain glucose within normal limits by giving appropriate units of insulin.
   2. Evaluation: Blood glucose is in the desired range.
4. Monitor fluids (intake and output) and electrolyte lab values.
   1. Rationale: To prevent dehydration or overhydration and electrolyte imbalance.
   2. Evaluation:  Patient is adequately hydrated and there is no sign of fluid overload, i.e no edema and no crackles in the lungs.
5. Assess vitals (signs and symptoms of infection), listen to the heart, lungs, and bowel-sounds.
   1. Rationale: If temperature, blood pressure, heart rate, and respiratory rate is elevated, that might be the signs of infection which can trigger DKA. Heart and lung sounds are to see if the patient is fluid overloaded.
   2. Evaluation: There is no sign of infection, lung sound is clear and there is no heart murmur.

●       A minimum of 3 potential patient education needs for consideration include:

○       Educate patients about the importance of maintaining blood glucose levels within normal ranges to prevent electrolyte imbalance and dehydration.

○       Educate patient about the importance of maintaining proper diet and exercise.

○       Educate patient about the importance of monitoring blood glucose more than once a day when they are experiencing stress, infection, trauma or if they are feeling sick because those things can fluctuate  the blood glucose level and may cause DKA.

The priority psychosocial nursing diagnosis for this patient is ineffective health maintenance related to insufficient resources as evidenced by the patient’s verbalization of the lack of financial resources. A short term goal for this patient is that the patient will discuss the fear of blocks to implementing a health regimen (Ackley, Ladwig, & Makic, 2017). A long term goal for this patient is that the patient will be following mutually agreed on health care maintenance plan by next scheduled appointment in 2 weeks.

There are five key nursing interventions with rationales and evaluations that we laid out for this patient:

1. Assess for family patterns, economic issues, spiritual, and cultural patterns that influence compliance with a given medical regimen (Ackley, Ladwig, & Makic, 2017).
   1. Rationale: If the patient does not have adequate support from their family or financially, it will be hard to comply with the given medical regimen,
   2. Evaluation: Husband is the sole provider at the moment, so they do not have adequate insurance to cover medical bills for medications.
2. Provide culturally appropriate education and health services (Ackley, Ladwig, & Makic, 2017).
   1. Rationale: Each culture has a different way of expressing themselves about their health and how they cope with it. Hispanics do not normally talk about their health issues, so they are reluctant to comply with treatments.
   2. Evaluation: By discharge, the patient will verbalize the kinds of cultural foods that will need to be limited to control glucose levels.
3. Help patient choose a healthy regimen (diet and exercise) to implement after discharge.
   1. Rationale: a healthy regimen will help the patient prevent complications from any of her medical diagnoses.
   2. Evaluation: By discharge, the patient will verbalize a healthy regimen.
4. Reinforce education of risk factors related to noncompliance with a treatment regimen.
   1. Rationale: Patient needs to understand why it is important to continue treatment plan to reduce worsening symptoms or prevent complications.
   2. Evaluation: By discharge, the patient will verbalize risk factors related to noncompliance with the treatment regimen.
5. Use technology to remind patients to refill and pick up prescriptions.
   1. Rationale: By using this technology, the patient can identify how much money is needed to obtain the necessary medication.
   2. Evaluation: By discharge, the patient will demonstrate the use of technology. reminder.

There are three potential patient education needs for consideration which includes:

1. Provide the family with credible sources where information can be obtained from social media (where most libraries have internet access with printing capabilities) (Ackley, Ladwig, & Makic, 2017).
2. Increase blood glucose monitoring during times of illness or infection.
3. Develop collaborative multidisciplinary partnerships (Ackley, Ladwig, & Makic, 2017).

References

• Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing diagnosis handbook: an evidence-based guide to planning care. St. Louis: Elsevier.
• Bedaso, A., Oltaye, Z., Geja, E., & Ayalew, M. (2019). Diabetic ketoacidosis among adult patients with diabetes mellitus admitted to emergency unit of Hawassa university  comprehensive specialized hospital. BMC Research Notes, 12(1), 137. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1186/s13104-019-4186-3
• Karlya, T. (2015). Parents, professionals need better awareness of DKA and diabetes symptoms. Endocrine Today, 13(11), 16. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search-proquest-com.chamberlainuniversity.idm.oclc.org/docview/1738799289?accountid=147674
• Smith, N. R. M. C., & Schub, T. B. (2018). Diabetic Ketoacidosis in Adults. CINAHL Nursing Guide. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=nup&AN=T704387&site=eds-live&scope=site
• Umpierrez, G. E., Murphy, M. B., & Kitabchi, A. E. (2019, January 1). Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome. Retrieved from https://spectrum.diabetesjournals.org/content/15/1/29
• Your Health Care Team. (n.d.). Retrieved from https://www.diabetes.org/diabetes/medication-management/your-health-care-team