A patient with diabetic ketoacidosis (DKA) presents with lethargy, confusion, low blood pressure, and elevated heart rate. Laboratory results indicate a serum potassium level of 2.8 mEq/L and severe metabolic acidosis. What should be the nurse's priority intervention?

C) Administer potassium supplements to correct hypokalemia.

A) Administer sodium bicarbonate to correct the metabolic acidosis.

B) Initiate aggressive fluid resuscitation with isotonic saline.

C) Administer potassium supplements to correct hypokalemia.

D) Increase the insulin infusion rate to rapidly reduce blood glucose levels.

A patient with diabetic ketoacidosis is showing signs of hypovolemic shock and hypokalemia. Which of the following interventions should the nurse prioritize to address the patient's current condition?

A) Administer an intravenous bolus of normal saline to improve blood pressure and perfusion.

B) Increase the rate of insulin infusion to rapidly correct blood glucose levels.

C) Administer oral potassium supplements to correct hypokalemia.

D) Initiate sodium bicarbonate infusion to correct metabolic acidosis.

A patient with hypovolemic shock and metabolic acidosis is being transferred to the ICU. The nursing care plan should prioritize which of the following interventions to ensure patient safety and promote stability?

B) Monitor central venous pressure for fluid management

A) Administer diuretics to prevent fluid overload

B) Monitor central venous pressure for fluid management

C) Initiate a high-protein diet to support metabolic needs

D) Encourage early ambulation to improve circulation

A patient in hypovolemic shock is being transferred to the intensive care unit for more intensive management, including the initiation of a central line. Given the patient's current condition, which of the following nursing interventions is the highest priority to ensure optimal patient outcomes?

D) Initiate continuous hemodynamic monitoring to guide fluid resuscitation efforts.

A) Administer additional potassium supplements to address hypokalemia.

B) Monitor urine output closely to assess for signs of worsening renal perfusion.

C) Prepare the patient for advanced imaging studies to evaluate for cerebral edema.

D) Initiate continuous hemodynamic monitoring to guide fluid resuscitation efforts.

A patient in the intensive care unit presents with signs of shock, mild cerebral edema, acute kidney injury, and hypokalemia. Which of the following nursing interventions is the highest priority for improving the patient's condition?

B) Increasing intravenous fluid administration to improve perfusion

A) Administering intravenous potassium supplements to correct hypokalemia

B) Increasing intravenous fluid administration to improve perfusion

C) Initiating measures to reduce intracranial pressure

D) Starting diuretics to manage fluid overload

A patient in the intensive care unit is experiencing signs of shock, cerebral edema, and acute kidney injury. Given her critically low potassium level of 2.9 mEq/L, which nursing intervention is the most appropriate to prioritize at this time?

C) Initiate continuous cardiac monitoring to detect potential arrhythmias.

A) Administer a potassium bolus to rapidly correct the hypokalemia.

B) Increase the rate of diuretics to promote renal function and fluid balance.

C) Initiate continuous cardiac monitoring to detect potential arrhythmias.

D) Withhold potassium supplementation to prevent hyperkalemia.

A patient in the critical care unit is showing signs of developing pneumonia with bilateral infiltrates on chest X-ray, diminished breath sounds, and elevated respiratory rate. Despite supplemental oxygen, the patient's oxygen saturation is only 93%. Which nursing intervention is most appropriate to address the patient's respiratory needs?

B) Encourage frequent use of incentive spirometry and deep breathing exercises

A) Increase the flow rate of supplemental oxygen to maintain saturation above 95%

B) Encourage frequent use of incentive spirometry and deep breathing exercises

C) Position the patient in a semi-Fowler's position to facilitate lung expansion

D) Administer a bronchodilator to open the airways and improve ventilation

A patient in the critical care unit shows stabilizing blood pressure and heart rate but continues to experience elevated respiratory rate and diminished breath sounds at the lung bases. A chest X-ray shows bilateral infiltrates, and empirical antibiotic therapy is initiated. Despite these measures, the patient's oxygen saturation remains low without supplemental oxygen. What is the most appropriate nursing intervention to prioritize in this situation?

B) Encourage frequent use of incentive spirometry to enhance lung expansion

A) Increase the rate of intravenous fluids to improve circulation

B) Encourage frequent use of incentive spirometry to enhance lung expansion

C) Adjust the patient's position to semi-Fowler’s to facilitate breathing

D) Initiate diuretic therapy to reduce potential fluid overload

A patient in the critical care unit is experiencing acute respiratory acidosis with a pH of 7.28, PaCO2 of 55 mmHg, and PaO2 of 60 mmHg, despite supplemental oxygen. The decision is made to initiate non-invasive positive pressure ventilation (NIPPV). Which nursing intervention is the most critical to perform immediately following the initiation of NIPPV?

C) Assess the patient's respiratory effort and comfort with the NIPPV mask.

A) Encourage the patient to use an incentive spirometer every hour.

B) Monitor the patient's blood pressure every 15 minutes.

C) Assess the patient's respiratory effort and comfort with the NIPPV mask.

D) Increase the oxygen flow rate to enhance oxygen delivery.

DKA - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency leads to the inability of cells to uptake glucose, resulting in hyperglycemia. This forces the body to rely on fat for energy, causing increased lipolysis and subsequent production of ketone bodies, leading to metabolic acidosis.

• Secondary mechanism: The accumulation of ketone bodies in the blood decreases blood pH, resulting in ketoacidosis. This metabolic acidosis is compounded by dehydration from osmotic diuresis, as excess glucose is excreted in urine, pulling water and electrolytes with it.

• Key complication: The combination of severe dehydration, electrolyte imbalance, and acidosis can lead to life-threatening complications such as shock, cardiac arrhythmias, and cerebral edema if not promptly treated.

Patient Profile

Demographics:

45-year-old female, accountant

History:

• Key past medical history: Type 1 Diabetes Mellitus diagnosed 15 years ago, hypertension

• Current medications: Insulin glargine, insulin lispro, lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Nausea and abdominal pain

• Key symptoms: Polyuria, polydipsia, fatigue, fruity-smelling breath

• Vital signs: Temperature 99.5°F, heart rate 110 bpm, respiratory rate 28 breaths per minute, blood pressure 95/60 mmHg, blood glucose 450 mg/dL

Section 1

As the care team continues to monitor the patient, a new complication arises. The patient suddenly becomes more lethargic and confused, indicating a potential change in neurological status. Upon reassessment, her vital signs reveal a further drop in blood pressure to 85/55 mmHg, and her heart rate has increased to 120 bpm. Despite initial fluid resuscitation efforts, her signs of dehydration and poor perfusion persist, suggesting a progression towards hypovolemic shock.

Laboratory results return, showing a significant electrolyte imbalance. Her serum potassium level is now dangerously low at 2.8 mEq/L, likely due to insulin administration driving potassium back into cells while the kidneys continue to excrete it during osmotic diuresis. Additionally, her arterial blood gas analysis indicates a severe metabolic acidosis with a pH of 7.15 and a bicarbonate level of 8 mEq/L. This data confirms the worsening of her diabetic ketoacidosis and highlights the urgent need for correction of her electrolyte disturbances and acidosis.

The care team begins to consider the potential need for intensive care management, including continuous cardiac monitoring due to the risk of arrhythmias from hypokalemia. They also evaluate the need for further aggressive fluid replacement and the cautious administration of potassium supplements. Meanwhile, insulin therapy is carefully titrated to reduce blood glucose levels slowly, avoiding rapid shifts that could exacerbate cerebral edema. This unfolding scenario necessitates a reevaluation of the treatment strategy, emphasizing the importance of vigilant monitoring and prompt intervention to stabilize the patient's condition.

Section 2

As the medical team intensifies their efforts, they closely monitor the patient's response to interventions. Despite aggressive fluid resuscitation and the careful administration of potassium supplements, the patient's blood pressure remains precariously low, indicating persistent hypovolemic shock. Her blood pressure stabilizes slightly at 90/60 mmHg, but she remains tachycardic with a heart rate of 115 bpm. The patient's mental status shows minimal improvement, as she remains lethargic and intermittently confused, raising concerns about adequate cerebral perfusion and potential cerebral edema.

New laboratory results reveal a marginal improvement in the metabolic acidosis, with the arterial blood gas now showing a pH of 7.20 and bicarbonate levels at 10 mEq/L. However, her potassium levels have only slightly increased to 3.0 mEq/L, necessitating continued supplementation and monitoring for cardiac arrhythmias. The patient's blood glucose has gradually decreased to 250 mg/dL, reflecting careful titration of insulin therapy. Despite these efforts, the patient's urine output has diminished, suggesting worsening renal perfusion, which could further complicate electrolyte management.

Recognizing the need for more intensive management, the care team decides to transfer the patient to the intensive care unit for continuous hemodynamic monitoring and more tailored interventions. They initiate a central line to facilitate more precise fluid and electrolyte replacement. The team also discusses the potential need for advanced imaging studies to rule out cerebral edema. The patient’s evolving condition underscores the importance of diligent reassessment and adaptability in the management strategy, as each intervention influences her physiological stability and guides the next steps in her critical care journey.

Section 3

As the patient settles into the intensive care unit, the team conducts a comprehensive initial assessment to establish a new baseline. Her vital signs indicate continued instability, with a blood pressure of 88/58 mmHg and a heart rate of 120 bpm. Respiratory rate is elevated at 26 breaths per minute, and she remains febrile with a temperature of 101.3°F, suggesting a potential underlying infection. Auscultation reveals diminished breath sounds at the lung bases, and her skin appears cool and clammy, consistent with ongoing peripheral vasoconstriction due to shock. Neurologically, the patient is still lethargic, responding sluggishly to verbal stimuli, raising the urgency of evaluating cerebral perfusion.

The team receives the results from the advanced imaging studies, which reveal signs of mild cerebral edema, confirming their suspicion and prompting the initiation of measures to reduce intracranial pressure. Meanwhile, her renal function tests indicate worsening acute kidney injury, with her creatinine rising to 2.8 mg/dL and blood urea nitrogen at 45 mg/dL, likely due to persistent hypoperfusion. Her potassium remains critically low at 2.9 mEq/L despite supplementation, prioritizing the need for careful titration to mitigate the risk of arrhythmias.

Recognizing the complexity of her condition, the team makes strategic adjustments to her management plan. They increase the rate of intravenous fluids and adjust her insulin regimen to aid in reducing cerebral edema while maintaining glucose control. Diuretics are considered to manage fluid overload and support renal function, balanced cautiously against the risk of exacerbating electrolyte imbalances. The team continues to vigilantly monitor her hemodynamic status and neurological signs, understanding that meticulous attention to these parameters is crucial in guiding the next steps of her critical care journey. This dynamic situation requires constant reassessment and adaptation to ensure the best possible outcomes for the patient.

Section 4

As the critical care team continues to monitor the patient, they note a change in her status that highlights both progress and new challenges. After increasing the rate of intravenous fluids and adjusting her insulin regimen, her blood pressure begins to stabilize, now reading at 98/64 mmHg, and her heart rate decreases slightly to 110 bpm. However, despite these improvements, her respiratory rate remains elevated at 28 breaths per minute, and auscultation continues to reveal diminished breath sounds at the lung bases. A chest X-ray, conducted to rule out complications such as pulmonary edema or infection, reveals bilateral infiltrates, raising concerns for developing pneumonia due to her weakened immune state and prolonged immobility.

In response to these findings, the team initiates empirical antibiotic therapy to address the suspected pneumonia, understanding the critical need to tackle potential infections promptly. They also engage respiratory therapy to provide pulmonary support and begin incentive spirometry to encourage deep breathing, aiming to improve ventilation and oxygenation. Her oxygen saturation, which had dipped to 89% on room air, improves to 93% with supplemental oxygen via nasal cannula.

The patient’s renal function, however, shows no signs of immediate improvement. Her creatinine level remains elevated at 2.9 mg/dL, and urine output is minimal despite aggressive fluid resuscitation. Given these findings, the nephrology team is consulted to evaluate the potential need for renal replacement therapy should her kidney function continue to decline. The team remains vigilant for any further signs of fluid overload, given the risk of exacerbating her respiratory condition, and they continue to closely monitor her electrolyte levels, knowing that maintaining balance is critical to avoiding cardiac complications. This delicate interplay of systems underscores the complexity of managing her care as they strive to stabilize her condition and prevent further deterioration.

Section 5

As the critical care team continues to monitor the patient, a new complication arises that requires immediate attention. Despite the initial improvement in her oxygen saturation and blood pressure, her respiratory status deteriorates overnight. The patient's respiratory rate increases to 32 breaths per minute, and her oxygen saturation falls to 85% even with supplemental oxygen. On auscultation, there are now coarse crackles throughout the lung fields, suggesting worsening pulmonary status. Repeat arterial blood gas analysis reveals a pH of 7.28, PaCO2 of 55 mmHg, and PaO2 of 60 mmHg, indicating the development of acute respiratory acidosis, likely secondary to respiratory muscle fatigue and worsening pneumonia.

In light of these findings, the team reassesses the patient's ventilation strategy. The decision is made to escalate respiratory support by initiating non-invasive positive pressure ventilation (NIPPV) to help improve alveolar ventilation and reduce the work of breathing. The team is mindful of the need to avoid intubation if possible, given her compromised immune state and the associated risks. Simultaneously, they review her antibiotic regimen to ensure broad-spectrum coverage is adequate, considering the possibility of resistant organisms given her clinical course.

Throughout these interventions, the team closely monitors her renal function, which remains a concern. Her creatinine level has increased to 3.2 mg/dL, and urine output continues to be scant. The nephrology team recommends starting continuous renal replacement therapy (CRRT) to support her kidney function while avoiding fluid overload, which could further compromise her respiratory status. The integration of CRRT allows for precise fluid management and electrolyte correction, crucial for stabilizing her overall condition. These developments highlight the intricate balance required in managing a critically ill patient with multiple organ dysfunction, emphasizing the importance of timely interventions and interdisciplinary collaboration in her ongoing care.