A patient with diabetic ketoacidosis (DKA) is showing signs of deterioration, including an increased respiratory rate, severe abdominal pain, and fluctuating consciousness. The nurse also notes hypotension and a further decline in potassium levels. What is the priority nursing intervention at this time?

B) Increase the rate of intravenous fluids to address hypovolemia.

A) Administer sodium bicarbonate to correct metabolic acidosis.

B) Increase the rate of intravenous fluids to address hypovolemia.

C) Initiate continuous cardiac monitoring to detect arrhythmias.

D) Titrate intravenous insulin infusion to control blood glucose levels.

A patient with diabetic ketoacidosis (DKA) is experiencing worsening symptoms despite treatment. Which nursing intervention should be prioritized to address the critical electrolyte imbalance identified in this patient?

C) Initiate potassium replacement therapy to correct hypokalemia

A) Administer sodium bicarbonate to correct the metabolic acidosis

B) Increase the rate of isotonic saline infusion to manage hypovolemia

C) Initiate potassium replacement therapy to correct hypokalemia

D) Adjust insulin infusion rate to more aggressively manage hyperglycemia

A patient with diabetic ketoacidosis (DKA) is experiencing persistent metabolic acidosis, as evidenced by an elevated anion gap and low pH. Despite insulin therapy and fluid resuscitation, her blood glucose remains elevated and her potassium level is low. What is the most appropriate immediate nursing intervention to address the electrolyte imbalance and prevent complications?

C) Administer additional potassium chloride to correct hypokalemia

A) Administer sodium bicarbonate to correct the acidosis

B) Increase the rate of insulin infusion to lower blood glucose more rapidly

C) Administer additional potassium chloride to correct hypokalemia

D) Initiate continuous renal replacement therapy (CRRT) to manage acute kidney injury

A nurse is caring for a patient with diabetic ketoacidosis (DKA) who presents with Kussmaul respirations, an elevated anion gap, and a serum potassium level of 3.2 mEq/L. Despite insulin therapy, the patient's blood glucose level remains high. What is the nurse's priority intervention to address the patient's current condition?

C) Increase the rate of intravenous fluids to improve perfusion and rehydrate the patient.

A) Increase the rate of intravenous insulin infusion to lower blood glucose levels.

B) Administer sodium bicarbonate to correct the metabolic acidosis.

C) Increase the rate of intravenous fluids to improve perfusion and rehydrate the patient.

D) Administer additional potassium supplements to correct hypokalemia.

A patient with diabetic ketoacidosis (DKA) is showing signs of acute kidney injury and worsening metabolic acidosis despite ongoing treatment. Which of the following interventions should the nurse prioritize to address the patient's current condition effectively?

B) Initiate continuous renal replacement therapy (CRRT) to manage electrolyte imbalances and support kidney function.

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

B) Initiate continuous renal replacement therapy (CRRT) to manage electrolyte imbalances and support kidney function.

C) Administer an additional bolus of intravenous fluids to improve perfusion and correct hypotension.

D) Increase the dosage of potassium supplementation to prevent cardiac arrhythmias.

A patient with diabetic ketoacidosis (DKA) and acute kidney injury (AKI) is admitted to the critical care unit. Despite aggressive fluid resuscitation, the patient remains hypotensive with a blood pressure of 90/60 mmHg and exhibits Kussmaul respirations. Her serum potassium is 3.4 mEq/L despite supplementation. Which of the following interventions should the nurse prioritize to address the patient's current status?

B) Initiate continuous renal replacement therapy (CRRT) to manage acute kidney injury and electrolyte imbalances.

A) Administer an additional bolus of normal saline to improve blood pressure.

B) Initiate continuous renal replacement therapy (CRRT) to manage acute kidney injury and electrolyte imbalances.

C) Increase the insulin infusion rate to lower blood glucose levels more rapidly.

D) Start vasopressor therapy to stabilize blood pressure.

A patient with diabetic ketoacidosis (DKA) and acute kidney injury (AKI) is being managed with CRRT and fluid resuscitation. The patient shows a decrease in heart rate and blood glucose but maintains an elevated anion gap and rising BUN and creatinine levels. Given these findings, which nursing intervention is most appropriate to prioritize at this time?

B) Monitor for signs of fluid overload, such as pulmonary edema.

A) Increase the rate of insulin infusion to further reduce blood glucose levels.

B) Monitor for signs of fluid overload, such as pulmonary edema.

C) Discontinue CRRT to prevent worsening of acute kidney injury.

D) Administer additional potassium supplements to prevent hypokalemia.

A patient with diabetic ketoacidosis (DKA) and acute kidney injury (AKI) is being treated in the ICU. The critical care team is monitoring her closely, noting a decrease in heart rate and respiratory rate, but continued Kussmaul respirations and an elevated anion gap. Given the current findings, which nursing intervention would be most appropriate to prioritize at this time?

B) Monitor for signs of fluid overload and adjust the CRRT settings as needed.

A) Increase the rate of fluid resuscitation to further improve blood pressure.

B) Monitor for signs of fluid overload and adjust the CRRT settings as needed.

C) Administer sodium bicarbonate to correct the metabolic acidosis quickly.

D) Initiate broad-spectrum antibiotics immediately to address the suspicion of infection.

A patient with diabetic ketoacidosis (DKA) and acute kidney injury is now exhibiting signs of pulmonary edema following aggressive fluid resuscitation. The healthcare team has decided to adjust the fluid management strategy and introduce diuretic therapy. Which of the following nursing actions is most appropriate to prioritize in this situation?

B) Monitor the patient's potassium levels closely to prevent hypokalemia.

A) Administer supplemental oxygen to maintain oxygen saturation above 95%.

B) Monitor the patient's potassium levels closely to prevent hypokalemia.

C) Increase the rate of continuous renal replacement therapy (CRRT) to remove excess fluid quickly.

D) Encourage the patient to increase oral fluid intake to support kidney function.

A patient with diabetic ketoacidosis (DKA) and acute kidney injury (AKI) is experiencing respiratory distress with a sudden drop in oxygen saturation and crackles at the lung bases. The healthcare team has transitioned to conservative fluid management and initiated diuretic therapy. Which nursing action is most critical in this scenario?

B) Monitor electrolyte levels, especially potassium, due to diuretic therapy

A) Increase the oxygen flow to maintain saturation above 90%

B) Monitor electrolyte levels, especially potassium, due to diuretic therapy

C) Prepare the patient for immediate intubation

D) Discontinue CRRT to prevent further fluid overload

dka - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency leads to decreased glucose uptake by cells, causing hyperglycemia. This results in osmotic diuresis and dehydration as excess glucose is excreted in urine.

• Secondary mechanism: The lack of insulin triggers lipolysis, breaking down fats into free fatty acids, which are converted to ketone bodies in the liver. The accumulation of ketones leads to metabolic acidosis.

• Key complication: Metabolic acidosis, coupled with electrolyte imbalances (such as low potassium), can lead to altered mental status, cardiac arrhythmias, and potentially life-threatening conditions if untreated.

Patient Profile

Demographics:

45-year-old female, high school teacher

History:

• Key past medical history: Type 1 diabetes mellitus diagnosed 15 years ago, hypertension

• Current medications: Insulin glargine 20 units at bedtime, lisinopril 10 mg daily, metoprolol 50 mg twice daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Nausea and vomiting for the past 24 hours

• Key symptoms: Abdominal pain, fruity-smelling breath, increased thirst, frequent urination, fatigue

• Vital signs: Temperature 99.5°F (37.5°C), heart rate 120 bpm, respiratory rate 26 breaths per minute, blood pressure 105/65 mmHg, oxygen saturation 96% on room air

Section 1

Change in Patient Status:

As the healthcare team initiates treatment for diabetic ketoacidosis (DKA), they closely monitor the patient for changes in her condition. Despite initial fluid resuscitation with isotonic saline and the administration of regular insulin, the patient's clinical status begins to deteriorate. Her respiratory rate increases to 32 breaths per minute, indicating possible compensation for worsening metabolic acidosis. She reports severe abdominal pain that is now radiating to her back, and her level of consciousness begins to fluctuate, with episodes of confusion and disorientation.

The nursing staff conduct a thorough assessment and identify a concerning drop in blood pressure to 90/60 mmHg, suggesting a progression to hypovolemic shock. Capillary refill is delayed, and her skin appears cool and clammy, signs consistent with inadequate perfusion. The previously noted fruity breath odor is now more pronounced, and the patient is increasingly lethargic, requiring repeated stimulation to maintain alertness. A rapid bedside glucose test reveals a blood glucose level of 380 mg/dL, and a follow-up electrolyte panel shows a further decline in potassium, now at 2.8 mEq/L, indicating a critical need for electrolyte repletion.

These changes suggest that despite ongoing treatment, the patient is experiencing new complications related to her DKA. The nursing team must prioritize interventions to stabilize her hemodynamic status and prevent further deterioration. This includes careful titration of intravenous insulin to address persistent hyperglycemia, aggressive fluid management to combat hypovolemia, and immediate potassium replacement to correct the severe hypokalemia. These steps are crucial in preventing potential life-threatening complications, such as cardiac arrhythmias or further neurological compromise. The team must also be vigilant for signs of other possible complications, such as pancreatitis or infection, which could further complicate the patient's recovery.

Section 2

As the nursing team implements the necessary interventions to address the patient's deteriorating condition, they closely monitor her response to treatment. Within the next hour, the patient's hemodynamic status remains unstable despite aggressive fluid resuscitation and potassium supplementation. Her blood pressure shows minimal improvement, fluctuating around 92/62 mmHg, and her heart rate remains elevated at 122 beats per minute. These findings indicate persistent hypovolemia and possible ongoing metabolic derangement. The team notes that her respiratory rate has increased further to 36 breaths per minute, with deep, labored breathing patterns suggestive of Kussmaul respirations, as the body attempts to compensate for severe metabolic acidosis.

A new set of diagnostic results reveals a concerning increase in her anion gap, now elevated to 28 mEq/L, indicating worsening acidosis. Additionally, her blood urea nitrogen (BUN) and creatinine levels have risen, suggesting possible acute kidney injury secondary to dehydration and poor perfusion. The arterial blood gas (ABG) analysis shows a pH of 7.15, further confirming the severity of her acid-base imbalance. Despite insulin therapy, her blood glucose remains elevated at 360 mg/dL, and her serum potassium, though supplemented, is only slightly improved at 3.2 mEq/L. The team recognizes that these lab results highlight the need for continued intensive care.

In response to these findings, the healthcare team decides to escalate the patient's care by consulting the critical care unit for potential transfer. They increase the rate of intravenous fluids and adjust the insulin infusion to better target her persistent hyperglycemia. Simultaneously, they continue to monitor her potassium levels closely, increasing the frequency of electrolyte checks to prevent further complications such as cardiac arrhythmias. The team remains vigilant for any signs of additional complications, such as pancreatitis or infection, which could further impact her recovery. This coordinated approach aims to stabilize the patient's condition and mitigate the risk of further deterioration, underscoring the importance of dynamic clinical reasoning and timely interventions in managing complex cases like DKA.

Section 3

As the patient is transferred to the critical care unit, the nursing team conducts a thorough reassessment to evaluate her current status and identify any emerging complications. Upon arrival, her vital signs are rechecked, showing a heart rate now at 130 beats per minute, with persistent hypotension at 90/60 mmHg despite ongoing fluid resuscitation. Her respiratory rate remains elevated at 38 breaths per minute with pronounced Kussmaul respirations, indicating that her body continues to struggle with severe metabolic acidosis. The team notes that her skin is cool and clammy, and her capillary refill time is delayed, suggesting inadequate perfusion and possible progression towards shock.

A new set of laboratory results arrives, further complicating the clinical picture. Her blood glucose has decreased slightly but remains high at 320 mg/dL, while her anion gap has widened further to 30 mEq/L. This suggests that metabolic acidosis is not yet controlled, and the underlying ketoacidosis may be worsening. Her serum potassium, despite aggressive supplementation, has not improved significantly, stabilizing only at 3.4 mEq/L, raising concerns about potential cardiac instability. Additionally, her BUN and creatinine levels continue to rise, confirming the suspicion of acute kidney injury, likely exacerbated by ongoing hypoperfusion.

In light of these developments, the healthcare team prioritizes the need for a more precise and aggressive management strategy. They decide to initiate continuous renal replacement therapy (CRRT) to address the acute kidney injury and assist in correcting the electrolyte imbalances. Concurrently, they adjust the insulin infusion to achieve tighter glycemic control and increase the fluid resuscitation rate, while carefully monitoring for any signs of fluid overload. The team also begins empirical antibiotic therapy, suspecting a possible underlying infection that could be contributing to the patient's deteriorating condition. This multidimensional approach reflects the necessity of integrating clinical reasoning with dynamic interventions to manage the complexities of DKA and its associated complications effectively.

Section 4

As the critical care team implements the updated management plan, they closely monitor the patient’s response to interventions. Over the next few hours, subtle changes in the patient’s condition are observed. Her heart rate begins to decrease slightly, now measuring at 120 beats per minute, suggesting a modest improvement in her hemodynamic stability. However, her blood pressure remains tenuous at 95/65 mmHg, indicating that while fluid resuscitation has had some effect, the patient is still at risk for cardiovascular compromise. Her respiratory rate shows a slight reduction to 34 breaths per minute, although Kussmaul respirations persist, highlighting ongoing metabolic acidosis.

New laboratory results reveal that the blood glucose has decreased further to 280 mg/dL, reflecting the effectiveness of the adjusted insulin therapy. Despite this, the anion gap remains elevated at 28 mEq/L, indicating that the resolution of ketoacidosis is still incomplete. Of particular concern is the serum potassium level, which has risen to 4.0 mEq/L following CRRT initiation, alleviating some concerns about cardiac instability. However, the patient’s renal function shows no significant improvement, with BUN and creatinine levels continuing to rise, underscoring the severity of the acute kidney injury.

In response to these findings, the healthcare team decides to maintain the current CRRT settings and fluid strategy while increasing vigilance for any signs of fluid overload, such as pulmonary edema. They also initiate a targeted diagnostic work-up to identify any source of infection, given the ongoing suspicion of sepsis as a contributing factor. This includes obtaining blood cultures and a chest X-ray to rule out pneumonia. The team’s approach exemplifies the need for ongoing clinical reasoning, as they balance the management of DKA with the emergent complications of acute kidney injury and potential infection, all while preparing for possible adjustments to the treatment plan in response to the patient’s evolving clinical status.

Section 5

As the healthcare team continues to monitor the patient, a new complication emerges that further complicates the clinical picture. Despite ongoing interventions and close surveillance, the patient begins to exhibit signs of respiratory distress. Her oxygen saturation, which had been stable around 95% on 4L of nasal cannula, suddenly drops to 88%. Auscultation of the lungs reveals crackles at the bases, suggesting the development of pulmonary edema, likely secondary to aggressive fluid resuscitation. The patient's heart rate climbs back up to 130 beats per minute, and her blood pressure remains low at 90/60 mmHg, raising concerns about worsening cardiovascular compromise.

In light of these developments, the team decides to adjust the fluid management strategy, shifting from aggressive resuscitation to a more conservative approach while enhancing diuretic therapy to address the fluid overload. A repeat chest X-ray confirms bilateral infiltrates consistent with pulmonary edema. This prompts the team to reassess the balance between treating DKA and managing the complications of acute kidney injury and fluid overload. They decide to continue CRRT at current settings to support renal function while optimizing the patient's fluid status.

Throughout this process, the team emphasizes the importance of ongoing clinical reasoning and vigilance. They reevaluate the patient's electrolyte balance, particularly focusing on potassium levels, which remain stable at 3.9 mEq/L, but require careful monitoring due to the risk of hypokalemia as diuretics are introduced. The team also remains attentive to potential infectious processes, keeping a close watch on the results of blood cultures. This integrated approach underscores the complexity of managing DKA with concurrent acute kidney injury and highlights the critical need for dynamic adjustments in the care plan as the patient's condition evolves.