DKA Case Study

©2016 Keith Rischer/www.KeithRN.com

Diabetic Ketoacidosis (DKA)

Diana Humphries, 45 years old

Primary Concept

Fluid and Electrolyte Balance

Interrelated Concepts (In order of emphasis)
1. Acid-Base Balance
2. Glucose Regulation
3. Infection
4. Pain
5. Clinical Judgment

© 2016 Keith Rischer/www.KeithRN.com

FUNDAMENTAL Reasoning: STUDENT

Diabetic Ketoacidosis (DKA)
History of Present Problem:
Diana Humphries is a 45-year-old woman with chronic kidney disease stage III and diabetes mellitus type1 who checks

her blood sugar daily, or whenever she feels like it. She has been feeling increasingly nauseated the past 12 hours. She has

had a harsh, productive cough of yellow sputum the past three days. She checked her blood glucose before going to bed

last night and it was 382, but then she fell asleep early and missed her bedtime dose of glargine (Lantus) insulin. When

she awoke this morning, she had generalized abdominal pain and continued to feel nauseated and had a large emesis. Her

glucometer was unable to read her blood glucose because it was too high. She took 10 units of lispro (Humalog) insulin

this morning. Her nausea has increased all morning and she has been unable to eat or keep anything down despite having

an increased thirst and appetite. She also has had increased frequency of urination. When her lunchtime glucometer gave

no reading because it was too high and out of range, she called 9-1-1 to be evaluated in the emergency department (ED)

.

Personal/Social History:
Diana has been inconsistently compliant with her medical/diabetic regimen due to her struggles with anxiety and

depression that have worsened since her mother died three months ago. She considers 200 a good blood sugar reading.

She is divorced with no children and has been homeless and has lived in a shelter off and on the past month. She is on

Social Security disability because of complications related to diabetes. At one point during the intake interview, she

expressed to the nurse, “I’m going to die anyway, why does all this matter?”

What data from the histories are RELEVANT and have clinical significance to the nurse?

RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

Developing Nurse Thinking by Identifying Significance of Clinical Data
Patient Care Begins:

Current VS:

P-Q-R-S-T Pain Assessment (5th VS):
T: 101.6 F/38.7 C (oral) Provoking/Palliative: Coughing and deep breathing/Not coughing

P: 114 (regular)

Quality:

Sharp

R: 24 (regular/deep) Region/Radiation: Right chest

BP: 102/66

Severity:

5/10

O2 sat: 90% Room air

Timing:

Intermittent

© 2016 Keith Rischer/www.KeithRN.com

What VS data are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT VS Data: Clinical Significance:

What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Assessment Data: Clinical Significance:

Developing Nurse Thinking through APPLICATION of the Sciences
Fluid & Electrolytes/Lab/diagnostic Results:

Radiology Reports: Chest x-ray
What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Results: Clinical Significance:
Right lower lobe

infiltrate.

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

Current Assessment:

GENERAL

APPEARANCE:

Appears anxious and uncomfortable, body tense, occasional grimacing

RESP:

Breath sounds clear with coarse crackles in RLL, non-labored respiratory effort, harsh

productive cough with thick yellow phlegm visualized

CARDIAC:

Pink, warm & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation

at radial/pedal/post-tibial landmarks

NEURO:

Alert & oriented to person, place, time, and situation (x4)

GI:

Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants, nausea is

persistent

GU:

Frequency of urination, urine clear in color, denies pain or burning when voids

SKIN:

Skin integrity intact, lips dry, oral mucosa dry–tacky

Complete Blood Count (CBC):

Current:

High/Low/WNL?

Prior:

WBC (4.5–11.0 mm 3) 15.2 9.8

Hgb (12–16 g/dL) 11.8 11.2

Platelets (150–450x 103/µl) 155 162

Neutrophil % (42–72) 92 70

Band forms (3–5%) 3 1

© 2016 Keith Rischer/www.KeithRN.com

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

.

Basic Metabolic Panel (BMP): Current: High/Low/WNL? Prior:

Sodium (135–145 mEq/L) 122 138

Potassium (3.5–5.0 mEq/L) 6.4 4.2

CO2 (Bicarb) (21–31 mmol/L) 11 25

Glucose (70–110 mg/dL) 729 168

BUN (7–25 mg/dl) 56 42

Creatinine (0.6–1.2 mg/dL) 2.4 1.9

GFR (>60 mL/min) 20 38

Misc. Labs:

Lactate (0.5–2.2 mmol/L) 2.8 n/a

Urine Analysis (UA): Current: WNL/Abnormal?

Color (yellow) Clear

Clarity (clear) Cloudy

Specific Gravity (1.015–1.030) 1.005

Protein (neg) Positive

Glucose (neg) >1000

Ketones (neg) Large

Bilirubin (neg) Negative

Blood (neg) Negative

Nitrite (neg) Negative

LET (Leukocyte Esterase) (neg) Negative

MICRO

RBCs (<5) 1

WBCs (<5) 2

Bacteria (neg) Negative

Epithelial (neg) Negative

© 2016 Keith Rischer/www.KeithRN.com

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance:

Lab Planning: Creating a Plan of Care with a PRIORITY

Lab:

Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions

Required:

Creatinine

Value:

2.4

Critical

Value:

Lab: Normal

Value:

Clinical Significance: Nursing Assessments/Interventions

Required:

Potassium

Value:

6.4

Critical
Value:

Pharmacology:

Home Med:

Classification: Mechanism of Action: Nursing Considerations:

Labetolol

Simvastatin

Gabapentin

© 2016 Keith Rischer/www.KeithRN.com

Pathophysiology:
1. What is the primary problem that your patient is most likely presenting?

2. What is the underlying cause/pathophysiology of this primary problem?

Developing Nurse Thinking by Identifying Clinical RELATIONSHIPS
1. What is the RELATIONSHIP of the past medical history and current medications?

(Which medication treats which condition? Draw lines to connect)

Past Medical History (PMH):

Home Meds:

 Chronic Kidney disease stage III (diabetic
nephropathy)

 Anemia

 Diabetes mellitus type 1 since age 12

 Diabetic retinopathy

 Neuropathy in lower legs

 Hyperlipidemia

 Hypertension

 Coronary artery disease

 Gastroesophageal reflux disease (GERD)

 Anxiety

 Depression

1. Aspirin 81mg PO daily

2. Lisinopril 10 mg PO daily

3. Lorazepam 1mg PO bid prn

4. Citalopram 40 PO mg daily

5. Zolpidem 10 mg PO at HS prn

6. Gabapentin 300 mg PO bid

7. Labetalol 200 mg PO bid

8. Omeprazole 20 mg PO daily

9. Simvastatin 40 mg PO HS

10. Glargine insulin 50 units SQ at HS

11. Lispro insulin SQ sliding scale AC and HS

2. Is there a RELATIONSHIP between any disease in PMH that may have contributed to the development of the
current problem? (Which disease likely developed FIRST then began a “domino effect”?)

PMH:

What Came FIRST:

 Chronic Kidney disease stage III
(diabetic nephropathy)

 Anemia
 Diabetes mellitus type 1 since age 12
 Diabetic retinopathy
 Neuropathy in lower legs
 Hyperlipidemia
 Hypertension
 Coronary artery disease

 Gastroesophageal reflux disease
(GERD)

 Anxiety
 Depression

What Then Followed:

© 2016 Keith Rischer/www.KeithRN.com

3. What is the RELATIONSHIP between the primary care provider’s orders and primary problem?

Care Provider Orders:

How it Will Resolve Primary Problem/

Nursing Priority:

Blood glucose stat

12 lead EKG

Place on cardiac monitor

Establish IV and initiate NS 0.9% bolus

of 1000 mL

Ondansetron 4 mg IV push every 4 hours

for nausea

Hydromorphone 0.5 mg every 4 hours

for pain

Developing Nurse Thinking by Identifying Clinical PRIORITIES
1. Which Orders Do You Implement First and Why?

Care Provider Orders: Order of Priority: Rationale:

1. Blood glucose stat
2. 12-lead EKG
3. Place on cardiac monitor
4. Establish IV and initiate

NS 0.9 percent bolus of

1000 mL

5. Ondansetron 4 mg IV push
6. Hydromorphone 0.5 prn

every 4 hours for pain

2. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)

3. What interventions will you initiate based on this priority?

Nursing Priority:

Nursing Interventions: Rationale: Expected

Outcome:

© 2016 Keith Rischer/www.KeithRN.com

4. What are the PRIORITY psychosocial needs that this patient and/or family likely have that will need to be
addressed?

5. How can the nurse address these psychosocial needs?

6. What educational/discharge PRIORITIES will be needed to develop a teaching plan for this patient and/or family?

Caring & the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?

2. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person?

Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention

in the moment as the events are unfolding to make a correct clinical judgment.

1. What did I learn from this scenario?

2. How can I use what has been learned from this scenario to improve patient care in the future?

1. RELEVANT Data from Present ProblemRow
2. 1:
3. Clinical SignificanceRow1:
4. RELEVANT Data from Social HistoryRow1:
5. Clinical SignificanceRow1_2:

Current VS:

6. PQRST Pain Assessment 5th VS:
7. P 114 regular:

Quality:

8. Sharp:
9. R 24 regulardeep:
10. Right chest:
11. BP 10266:

Severity:

12. 510:

Timing:

13. Intermittent:
14. RELEVANT VS DataRow1:
15. Clinical SignificanceRow1_3:

Current Assessment:

16. GENERAL APPEARANCE:
17. Appears anxious and uncomfortable body tense occasional grimacing:

RESP:
CARDIAC:
NEURO:

18. Alert oriented to person place time and situation x4:

GI:
GU:
SKIN:

19. Skin integrity intact lips dry oral mucosa drytacky:
20. RELEVANT Assessment DataRow1:
21. Clinical SignificanceRow1_4:
22. Clinical SignificanceRight lower lobe infiltrate:

Current:
Prior:

23. WBC 45110 mm 3:
24. HighLowWNL152:
25. 98:
26. Hgb 1216 gdL:
27. HighLowWNL118:
28. 112:
29. HighLowWNL155:
30. 162:
31. Neutrophil 4272:
32. HighLowWNL92:
33. 70:
34. Band forms 35:
35. HighLowWNL3:

1:

36. RELEVANT LabsRow1:
37. Clinical SignificanceRow1_5:
38. TREND ImproveWorseningStableRow1:
39. Current_2:
40. Prior_2:
41. HighLowWNL122:
42. 138:
43. HighLowWNL64:
44. 42:
45. HighLowWNL11:
46. 25:
47. HighLowWNL729:
48. 168:
49. BUN 725 mgdl:
50. HighLowWNL56:
51. 42_2:
52. HighLowWNL24:
53. 19:
54. GFR 60 mLmin:
55. HighLowWNL20:
56. 20Misc Labs:
57. HighLowWNLMisc Labs:
58. 38Misc Labs:
59. HighLowWNL28:
60. na:
61. RELEVANT LabsRow1_2:
62. Clinical SignificanceRow1_6:
63. TREND ImproveWorseningStableRow1_2:
64. Urine Analysis UA:
65. Current_3:
66. Color yellow:
67. WNLAbnormalClear:
68. Clarity clear:
69. WNLAbnormalCloudy:
70. WNLAbnormal1005:
71. Protein neg:
72. WNLAbnormalPositive:
73. Glucose neg:
74. WNLAbnormal1000:
75. Ketones neg:
76. WNLAbnormalLarge:
77. Bilirubin neg:
78. WNLAbnormalNegative:
79. Blood neg:
80. WNLAbnormalNegative_2:
81. Nitrite neg:
82. WNLAbnormalNegative_3:
83. WNLAbnormalNegative_4:
84. NegativeMICRO:
85. WNLAbnormalMICRO:
86. RBCs 5:
87. WNLAbnormal1:
88. WBCs 5:
89. WNLAbnormal2:
90. Bacteria neg:
91. WNLAbnormalNegative_5:
92. Epithelial neg:
93. WNLAbnormalNegative_6:
94. RELEVANT LabsRow1_3:
95. Clinical SignificanceRow1_7:
96. Clinical SignificanceCritical Value:
97. Nursing AssessmentsInterventions RequiredCritical Value:

Lab:

98. Potassium Value 64:
99. Clinical SignificanceCritical Value_2:
100. Nursing AssessmentsInterventions RequiredCritical Value_2:

Home Med:

101. ClassificationLabetolol:
102. Mechanism of ActionLabetolol:
103. Nursing ConsiderationsLabetolol:
104. ClassificationSimvastatin:
105. Mechanism of ActionSimvastatin:
106. Nursing ConsiderationsSimvastatin:
107. ClassificationGabapentin:
108. Mechanism of ActionGabapentin:
109. Nursing ConsiderationsGabapentin:
110. Past Medical History PMH:

Home Meds:
PMH:
What Came FIRST:
What Then Followed:
Care Provider Orders:

111. How it Will Resolve Primary ProblemNursing PriorityBlood glucose stat 12 lead EKG Place on cardiac monitor Establish IV and initiate NS 09 bolus of 1000 mL Ondansetron 4 mg IV push every 4 hours for nausea Hydromorphone 05 mg every 4 hours for pain:
112. Order of Priority1Blood glucose stat 212lead EKG 3Place on cardiac monitor 4Establish IV and initiate NS 09 percent bolus of 1000 mL 5Ondansetron 4 mg IV push 6Hydromorphone 05 prn every 4 hours for pain:
113. Rationale1Blood glucose stat 212lead EKG 3Place on cardiac monitor 4Establish IV and initiate NS 09 percent bolus of 1000 mL 5Ondansetron 4 mg IV push 6Hydromorphone 05 prn every 4 hours for pain:
114. Nursing PriorityRow1:
115. Nursing InterventionsRow1:
116. RationaleRow1:
117. Expected OutcomeRow1:
118. Text8:
119. Text9:
120. Text10:
121. Text11:
122. Text12:
123. Text13:
124. Text14:
125. Text15:
126. Text16:
127. Text17: