A patient with diabetic ketoacidosis (DKA) is receiving treatment for hypokalemia and metabolic acidosis. The nurse observes that the patient's serum potassium level is 3.0 mEq/L, and the heart rate is 110 bpm with a blood pressure of 94/58 mmHg. Which nursing intervention is the priority to prevent complications in this patient?

C) Initiate continuous cardiac monitoring to detect potential arrhythmias.

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

B) Administer sodium bicarbonate to correct metabolic acidosis quickly.

C) Initiate continuous cardiac monitoring to detect potential arrhythmias.

D) Administer a diuretic to manage potential fluid overload.

A patient with diabetic ketoacidosis exhibits a serum potassium level of 3.0 mEq/L and is receiving insulin therapy. Which nursing intervention is the most critical to prioritize in this situation?

C) Initiate continuous cardiac monitoring to watch for arrhythmias.

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

B) Administer sodium bicarbonate to correct metabolic acidosis immediately.

C) Initiate continuous cardiac monitoring to watch for arrhythmias.

D) Restrict fluid intake to prevent further electrolyte imbalances.

A patient is being monitored for acute kidney injury and persistent hypotension despite fluid resuscitation. The nursing team notes minimal urine output and a serum potassium level of 3.5 mEq/L. The bicarbonate level is 14 mEq/L, and arterial pH is 7.32. Which nursing intervention is most appropriate to address the patient's hemodynamic instability?

C) Monitor cardiac function and consider inotropic support.

A) Increase fluid resuscitation to raise blood pressure.

B) Administer sodium bicarbonate to correct metabolic acidosis.

C) Monitor cardiac function and consider inotropic support.

D) Increase potassium supplementation to address electrolyte imbalance.

A patient is being monitored for hypotension and low urine output despite aggressive fluid resuscitation. The clinical team is considering potential causes such as sepsis, ongoing fluid losses, and cardiac dysfunction. Which nursing intervention is most appropriate at this time to address the patient's hemodynamic instability?

B) Initiate a continuous infusion of vasopressor medication to stabilize blood pressure.

A) Administer an additional bolus of intravenous fluids to increase blood pressure.

B) Initiate a continuous infusion of vasopressor medication to stabilize blood pressure.

C) Monitor urine output hourly and report any changes immediately to the healthcare provider.

D) Prepare the patient for an echocardiogram to assess cardiac function.

A patient with mild left ventricular dysfunction and elevated BNP level is being treated with low-dose inotropic agents and a targeted fluid resuscitation approach. Which clinical finding would most likely indicate that the patient is developing fluid overload?

B) Elevated central venous pressure

A patient with mild left ventricular dysfunction and suspected cardiogenic shock is being treated with a low-dose inotropic agent and targeted fluid resuscitation. Which nursing intervention is most appropriate to monitor for potential complications associated with this treatment plan?

B) Monitor jugular venous distention and lung sounds for signs of fluid overload.

A) Measure blood pressure every 4 hours to assess for hypertension.

B) Monitor jugular venous distention and lung sounds for signs of fluid overload.

C) Encourage the patient to ambulate frequently to prevent deep vein thrombosis.

D) Administer diuretics regularly to ensure fluid removal and prevent overload.

A patient with suspected fluid overload exhibits increased work of breathing and fine crackles at the lung bases. An arterial blood gas analysis shows a pH of 7.48 and PaCO2 of 32 mmHg. Which nursing intervention is most appropriate to address the respiratory status of this patient?

C) Reduce the fluid infusion rate and consider low-dose diuretics.

A) Increase the rate of fluid infusion to support cardiac output.

B) Administer supplemental oxygen to improve oxygen saturation.

C) Reduce the fluid infusion rate and consider low-dose diuretics.

D) Encourage deep breathing exercises to reduce respiratory rate.

A patient in the ICU is showing signs of increased work of breathing and fine crackles at the lung bases after receiving fluid resuscitation and inotropic support. Which of the following actions should the nurse prioritize to address the suspected fluid overload while ensuring optimal oxygenation?

B) Administer a low-dose diuretic as ordered to reduce pulmonary congestion.

A) Increase the fluid infusion rate to maintain blood pressure.

B) Administer a low-dose diuretic as ordered to reduce pulmonary congestion.

C) Decrease oxygen saturation monitoring frequency as the patient is maintaining 96% on room air.

D) Encourage the patient to perform incentive spirometry hourly to improve lung expansion.

A patient receiving diuretic therapy for pulmonary congestion shows improvement in respiratory status but develops mild confusion and restlessness. Lab results indicate mild hyponatremia and slightly elevated BUN and creatinine. Which nursing intervention is most appropriate to address the patient's current condition?

C) Administer isotonic saline and reassess fluid balance.

A) Increase the rate of the diuretic infusion to enhance fluid removal.

B) Initiate a sodium-restricted diet to manage hyponatremia.

C) Administer isotonic saline and reassess fluid balance.

D) Encourage increased oral fluid intake to dilute serum sodium levels.

A patient receiving diuretic therapy for pulmonary congestion is now showing signs of mild confusion and restlessness, with a Glasgow Coma Scale (GCS) score dropping from 15 to 13. Laboratory results indicate mild hyponatremia and a slight increase in BUN and creatinine levels. What should be the primary nursing intervention to address the patient's altered mental status?

C) Initiate a slow infusion of isotonic saline and monitor neurologic status

A) Administer a hypertonic saline solution to rapidly correct sodium levels

B) Implement fluid restriction to manage potential fluid overload

C) Initiate a slow infusion of isotonic saline and monitor neurologic status

D) Increase diuretic dosage to further reduce pulmonary congestion

Dka - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency leads to increased lipolysis, releasing free fatty acids that are converted into ketones in the liver, causing metabolic acidosis.

• Secondary mechanism: Hyperglycemia results from uninhibited gluconeogenesis and glycogenolysis, leading to osmotic diuresis, dehydration, and electrolyte imbalances.

• Key complication: Severe dehydration and acidosis can cause electrolyte disturbances, particularly hypokalemia, which may lead to cardiac arrhythmias and impaired muscle function.

Patient Profile

Demographics:

45-year-old female, office manager

History:

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

• Current medications: Insulin glargine, lisinopril, metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Nausea and abdominal pain

• Key symptoms: Vomiting, polyuria, fatigue, shortness of breath

• Vital signs: Temperature 99.5°F, heart rate 115 bpm, respiratory rate 28 breaths/min, blood pressure 98/60 mmHg, blood glucose 450 mg/dL

Section 1

As the medical team continues to manage the patient's diabetic ketoacidosis (DKA), new diagnostic results reveal significant electrolyte imbalances. The latest laboratory findings indicate a serum potassium level of 3.0 mEq/L, confirming hypokalemia, and a bicarbonate level of 12 mEq/L, suggesting ongoing metabolic acidosis. The patient's arterial blood gas (ABG) analysis shows a pH of 7.28, further highlighting the severity of her acidosis. Concurrently, the patient's blood urea nitrogen (BUN) and creatinine levels are elevated, indicating possible acute kidney injury due to severe dehydration and osmotic diuresis.

In response to these findings, the clinical team prioritizes the correction of electrolyte imbalances and continues aggressive fluid resuscitation with isotonic saline to address the patient's dehydration. Intravenous potassium replacement is initiated cautiously, considering the risk of cardiac arrhythmias associated with hypokalemia. The insulin infusion is adjusted to gradually lower blood glucose while monitoring for potential shifts in potassium levels, as insulin therapy can drive potassium into cells, exacerbating hypokalemia.

As the patient receives treatment, the clinical team monitors her cardiac rhythm closely for any signs of arrhythmias due to the electrolyte disturbances. The patient's respiratory rate remains elevated at 30 breaths per minute, and her heart rate is slightly reduced to 110 bpm, indicating a partial response to fluid therapy. However, her blood pressure remains low at 94/58 mmHg, suggesting that additional interventions may be necessary to stabilize her hemodynamics. The medical team remains vigilant for any new complications, such as worsening acidosis or cardiac issues, as they continue to reassess her clinical status and adjust the treatment plan accordingly.

Section 2

As the clinical team continues to monitor the patient's response to treatment, a change in her status becomes evident. While her respiratory rate remains elevated at 30 breaths per minute, her heart rate shows a further decrease to 100 bpm, indicating ongoing improvement in response to fluid resuscitation. However, her blood pressure remains a concern, now measured at 92/55 mmHg, prompting the team to consider additional interventions to support her hemodynamics. Despite aggressive fluid replacement, her urine output is minimal, suggesting persistent renal impairment. This could be a sign that the acute kidney injury is still unresolved, likely due to ongoing dehydration and metabolic stress.

New diagnostic results reveal a serum potassium level of 3.5 mEq/L, showing a slight improvement but still on the lower end of normal, necessitating continued potassium supplementation. The bicarbonate level remains low at 14 mEq/L, and the arterial pH is now 7.32, indicating a slow but positive trend in resolving the metabolic acidosis. The patient's blood glucose levels have decreased steadily, now at 250 mg/dL, reflecting the effectiveness of the adjusted insulin therapy. However, the potential for hypoglycemia and further electrolyte shifts remains a concern, requiring careful monitoring.

The clinical team remains vigilant for any emerging complications, such as worsening renal function or electrolyte imbalances. They decide to assess for potential underlying causes of the patient's persistent hypotension and low urine output, considering factors such as sepsis, ongoing fluid losses, or cardiac dysfunction. A focused cardiac assessment is ordered, including an echocardiogram, to evaluate cardiac function and rule out any underlying cardiac complications that might be contributing to her hemodynamic instability. As they await results, the team continues to adjust the treatment plan in response to the available data, ensuring the patient's condition is managed safely and effectively.

Section 3

As the clinical team continues to monitor the patient's progress, they receive the results of the focused cardiac assessment. The echocardiogram reveals mild left ventricular dysfunction, suggesting that cardiac output is compromised, potentially contributing to the patient's persistent hypotension. This finding prompts the team to consider the possibility of cardiogenic shock as a complicating factor in the patient's condition. Additionally, laboratory tests indicate an elevated B-type natriuretic peptide (BNP) level, further supporting the suspicion of cardiac involvement. These results necessitate a reevaluation of the patient's fluid management strategy, balancing the need for volume expansion with the risk of exacerbating cardiac strain.

In response to these findings, the medical team decides to cautiously introduce a low-dose inotropic agent to enhance myocardial contractility and support cardiac output. Simultaneously, they initiate a more targeted fluid resuscitation approach, closely monitoring for signs of fluid overload while ensuring adequate perfusion to vital organs. The decision to adjust treatment reflects a nuanced understanding of the interconnectedness of the patient's cardiac, renal, and metabolic challenges.

As these interventions are implemented, the patient's response is closely observed. Within a few hours, her blood pressure shows a slight improvement, now at 98/60 mmHg, and urine output begins to increase modestly, indicating a positive trend in renal function. Despite these encouraging signs, the team remains vigilant for any signs of fluid overload or worsening cardiac function, aware that the patient's journey is still unfolding. The next steps will involve ongoing assessment and adjustment of therapies to navigate the complexities of her multiple system challenges effectively.

Section 4

As the team continues to monitor the patient's progress, they notice a subtle change in her respiratory status. The patient begins to exhibit increased work of breathing, with a respiratory rate climbing to 28 breaths per minute. Auscultation of the lungs reveals fine crackles at the bases, prompting concern for pulmonary congestion. Despite the earlier improvement in blood pressure and urine output, these findings raise the suspicion of fluid overload, a potential complication from the careful balance of fluid resuscitation and inotropic support.

In response to these new developments, the team orders a chest X-ray to assess for pulmonary edema and re-evaluates the patient's current fluid management plan. The X-ray confirms mild bilateral pulmonary edema, correlating with the clinical findings. Concurrently, arterial blood gas analysis shows a slight respiratory alkalosis, with a pH of 7.48 and a PaCO2 of 32 mmHg, likely a compensatory response to her increased respiratory effort. These results highlight the delicate interplay between the patient's cardiac, respiratory, and metabolic states, requiring an adjustment in her therapeutic regimen.

To address this evolving complication, the healthcare team decides to slightly reduce the fluid infusion rate and introduce a low-dose diuretic to alleviate the pulmonary congestion while continuing to monitor cardiac output and renal function closely. The patient's oxygen saturation is maintained at 96% on room air, but supplemental oxygen is readily available if needed. This strategic adjustment aims to optimally balance the competing demands on the patient's compromised systems, demonstrating the team's commitment to dynamic and thoughtful clinical reasoning as they guide her through this complex phase of care.

Section 5

As the team continues to closely monitor the patient's response to the adjusted treatment plan, they observe a gradual improvement in her respiratory status. Over the next few hours, her respiratory rate decreases to 22 breaths per minute, and her work of breathing appears to lessen. The fine crackles initially noted at the lung bases begin to diminish, suggesting that the pulmonary congestion is responding positively to the diuretic therapy. The patient's oxygen saturation remains stable at 96% on room air, indicating adequate gas exchange.

Despite these encouraging signs, a new development warrants attention. The patient begins to exhibit signs of mild confusion and restlessness, with a Glasgow Coma Scale (GCS) score dropping from 15 to 13. Concerned about the potential causes of her altered mental status, the team orders a repeat set of laboratory tests, including comprehensive metabolic panel, serum electrolyte levels, and a neurologic evaluation. The results reveal a mild hyponatremia, with a sodium level of 132 mEq/L, and a slight increase in blood urea nitrogen (BUN) and creatinine, indicating a potential pre-renal state due to the diuretic therapy.

Recognizing the complexity of the patient's condition, the healthcare team decides to adjust her electrolyte and fluid management. They initiate a cautious supplementation of sodium and reassess her fluid balance to prevent further dehydration while continuing to monitor her renal function closely. The patient's neurologic status is evaluated continuously to detect any further changes. This nuanced approach underscores the importance of integrating clinical data into the decision-making process, as the team remains vigilant in navigating the multifaceted challenges presented by her evolving clinical picture.