A patient with diabetic ketoacidosis (DKA) is receiving insulin therapy and fluid resuscitation. Her blood glucose level has decreased, but her serum potassium has dropped to 3.2 mEq/L. The patient exhibits irregularities on the cardiac monitor. What is the most appropriate nursing intervention at this time?

B) Administer intravenous potassium chloride while monitoring cardiac rhythm

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

B) Administer intravenous potassium chloride while monitoring cardiac rhythm

C) Restrict fluid intake to prevent further shifts in electrolytes

D) Administer a diuretic to manage potential fluid overload

A patient with diabetic ketoacidosis (DKA) who has been receiving fluid resuscitation and insulin therapy now exhibits hypokalemia with a potassium level of 3.2 mEq/L. Which nursing intervention is most appropriate to prioritize at this time?

B) Administer potassium chloride intravenously while monitoring cardiac rhythm.

A) Increase the rate of insulin infusion to expedite glucose control.

B) Administer potassium chloride intravenously while monitoring cardiac rhythm.

C) Discontinue fluid resuscitation to prevent further dilution of electrolytes.

D) Encourage oral intake of potassium-rich foods to correct hypokalemia.

A patient with diabetic ketoacidosis has been receiving treatment, including intravenous potassium chloride and insulin. The patient's serum potassium level is now 3.8 mEq/L, and her blood pressure has decreased to 98/62 mmHg. Which nursing intervention is most appropriate to address her current hemodynamic status while continuing to manage her condition?

B) Administer a bolus of normal saline to address potential dehydration.

A) Increase the rate of insulin infusion to improve potassium levels.

B) Administer a bolus of normal saline to address potential dehydration.

C) Increase the rate of potassium chloride infusion to stabilize blood pressure.

D) Initiate a vasopressor to quickly elevate blood pressure.

A patient with diabetic ketoacidosis (DKA) is receiving treatment. Her serum potassium level has risen to 3.8 mEq/L, and her mental status is improving. However, her blood pressure is now 98/62 mmHg, and her skin remains dry. Which nursing intervention should be prioritized to address the patient's current condition?

B) Administer a bolus of normal saline to improve blood pressure and hydration status.

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

B) Administer a bolus of normal saline to improve blood pressure and hydration status.

C) Reduce fluid administration to prevent fluid overload and potential electrolyte imbalance.

D) Discontinue potassium chloride infusion to prevent hyperkalemia.

A patient with diabetic ketoacidosis (DKA) is showing signs of hypotension and tachycardia despite fluid therapy adjustments. Which of the following nursing interventions is the most appropriate to address the patient's current hemodynamic status?

C) Administer additional isotonic saline boluses while monitoring for signs of fluid overload.

A) Increase the rate of intravenous insulin infusion to rapidly resolve ketoacidosis.

B) Initiate a vasopressor to immediately raise blood pressure and improve perfusion.

C) Administer additional isotonic saline boluses while monitoring for signs of fluid overload.

D) Restrict fluid intake to prevent fluid overload and potential pulmonary edema.

A patient with diabetic ketoacidosis is showing signs of hypotension and tachycardia. Her blood pressure is 90/58 mmHg, heart rate is 102 beats per minute, and she has cool extremities with delayed capillary refill. What is the priority nursing intervention at this time?

A) Administer a bolus of isotonic saline to increase intravascular volume.

B) Initiate vasopressor therapy to improve blood pressure.

C) Increase the rate of insulin infusion to address the elevated anion gap.

D) Restrict fluids to prevent potential fluid overload.

A patient with decreased ejection fraction and hypokalemia is being managed for hypotension and possible acute kidney injury. Which nursing intervention is most appropriate to prioritize at this time?

D) Monitor cardiac rhythm closely while gradually correcting electrolyte imbalances

A) Administer a rapid bolus of intravenous fluids to increase blood volume

B) Initiate low-dose vasopressor therapy to support blood pressure

C) Provide high-dose potassium supplementation to correct hypokalemia quickly

D) Monitor cardiac rhythm closely while gradually correcting electrolyte imbalances

A patient with hypotension, decreased urine output, and hypokalemia is being assessed in a critical care setting. An echocardiogram indicates reduced ejection fraction. Which of the following nursing interventions is most appropriate to prioritize in managing this patient's condition?

B) Initiate low-dose vasopressor therapy to stabilize hemodynamics.

A) Administer a rapid bolus of normal saline to increase blood pressure.

B) Initiate low-dose vasopressor therapy to stabilize hemodynamics.

C) Increase oral potassium supplementation to address hypokalemia.

D) Place the patient in a Trendelenburg position to improve perfusion.

diabetic ketoacidosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency leads to decreased glucose uptake by cells, causing hyperglycemia. As a result, the body perceives an energy deficit and initiates lipolysis, breaking down fat stores into free fatty acids.

• Secondary mechanism: The liver converts these free fatty acids into ketone bodies for energy, leading to an accumulation of ketones in the blood, which causes metabolic acidosis. This process is unregulated due to the lack of insulin, exacerbating acid-base imbalance.

• Key complication: The combination of severe hyperglycemia, ketosis, and acidosis results in dehydration and electrolyte imbalances, notably hyperkalemia, which can progress to life-threatening complications if untreated.

Patient Profile

Demographics:

45-year-old female, high school teacher

History:

• Key past medical history: Type 1 Diabetes diagnosed at age 18, hypertension

• Current medications: Insulin glargine, lisinopril, metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe abdominal pain and confusion

• Key symptoms: Nausea, vomiting, polyuria, dehydration, fruity-scented breath

• Vital signs: Temperature 101.3°F, Heart rate 120 bpm, Respiratory rate 28 breaths per minute, Blood pressure 90/60 mmHg

Section 1

As the healthcare team conducts the initial assessment, key findings highlight the severity of the patient's condition. On physical examination, the patient appears lethargic and disoriented, responding to questions with difficulty. Her skin is dry and tenting is observed, indicative of significant dehydration. Auscultation reveals tachycardia and tachypnea, consistent with Kussmaul respirations, as the body attempts to compensate for the metabolic acidosis by expelling more carbon dioxide. The fruity odor on her breath, a classic sign of ketone accumulation, is noted.

Laboratory results confirm the clinical picture: blood glucose is critically elevated at 550 mg/dL, and arterial blood gas analysis shows a decreased pH of 7.15, with a bicarbonate level of 12 mEq/L, confirming metabolic acidosis. Serum ketones are positive, and a comprehensive metabolic panel reveals hyperkalemia with a potassium level of 5.8 mEq/L. Despite the high serum potassium, the total body potassium is likely depleted due to osmotic diuresis and dehydration. The anion gap is elevated, further corroborating the diagnosis of diabetic ketoacidosis.

Given these findings, the immediate focus is on fluid resuscitation to address dehydration and electrolyte imbalances, with intravenous insulin administered to reduce hyperglycemia and halt ketogenesis. However, as treatment progresses, the healthcare team must remain vigilant for potential complications, such as hypoglycemia or hypokalemia, as insulin therapy can drive potassium back into the cells, causing a rapid drop in serum levels. Continuous monitoring of vital signs and laboratory parameters is crucial to guide ongoing therapeutic adjustments and prevent further deterioration of the patient's condition.

Section 2

As the healthcare team implements the initial interventions, the patient begins to show subtle changes in her status. After several hours of fluid resuscitation and insulin therapy, her blood glucose levels have gradually decreased to 250 mg/dL. However, the team notices a concerning trend in her laboratory results: her potassium level has dropped to 3.2 mEq/L, indicating the onset of hypokalemia. This rapid shift occurs as the insulin drives potassium back into the cells, underscoring the importance of vigilant electrolyte monitoring. The patient’s heart rate remains elevated at 110 beats per minute, but there are emerging irregularities on the cardiac monitor, suggestive of potential arrhythmias due to the low potassium level.

Clinically, the patient remains lethargic, but there is a slight improvement in her orientation; she is now able to respond to simple commands, though still with some delay. Her respiratory rate has reduced slightly to 26 breaths per minute, yet Kussmaul respirations persist, indicating ongoing metabolic distress. Despite aggressive hydration efforts, her skin turgor has improved only marginally, and she continues to exhibit signs of dehydration. The healthcare team must now adjust their approach to address the hypokalemia promptly, balancing potassium supplementation cautiously to avoid overshooting and causing hyperkalemia again.

The patient's evolving condition compels the team to re-evaluate their treatment strategy, emphasizing the need for a delicate balance between correcting the acidosis and maintaining electrolyte stability. They prepare to administer potassium chloride intravenously, continuously monitoring her cardiac rhythm and serum electrolytes to ensure safe correction. The team also considers adjusting the insulin infusion rate, taking into account the patient's improved but still critical status. These interventions will be closely monitored to prevent further complications and guide the patient towards stabilization, highlighting the intricate interplay of clinical reasoning required in managing diabetic ketoacidosis with developing complications.

Section 3

As the healthcare team administers intravenous potassium chloride, they remain vigilant in monitoring the patient's response to this critical intervention. Over the next few hours, her serum potassium level gradually rises to 3.8 mEq/L, which is within the lower normal range, mitigating the immediate risk of arrhythmias. The cardiac monitor reflects this improvement, with her heart rate decreasing to 98 beats per minute and the irregularities becoming less frequent. However, the team notes that her blood pressure has started to edge downward, now reading 98/62 mmHg, raising concerns about her overall hemodynamic stability.

Simultaneously, the patient's mental status shows more notable improvement; she is now able to follow commands more promptly, though fatigue still clouds her cognition. Her respiratory status is also showing signs of improvement; her respiratory rate has decreased to 22 breaths per minute, and her Kussmaul respirations are less pronounced, suggesting partial resolution of metabolic acidosis. Despite these positive changes, her skin remains dry, and she reports feeling weak, underscoring the persistent dehydration that needs addressing. Her urine output has increased, reflecting improved renal perfusion, yet close attention is necessary to ensure that fluid shifts do not exacerbate her electrolyte imbalances.

The team must now decide on the next steps. They consider slightly reducing the insulin infusion rate to prevent further precipitous drops in potassium levels while continuing to monitor her glucose and electrolyte levels closely. They also plan to adjust her fluid administration, aiming to optimize hydration without overloading her cardiovascular system. These evolving clinical parameters require ongoing assessment and adjustments, highlighting the complexity of managing a patient with diabetic ketoacidosis and emphasizing the need for precise clinical reasoning and coordinated care to guide her towards recovery.

Section 4

As the day progresses, the healthcare team continues to closely monitor the patient's response to the treatment regimen. New diagnostic results reveal that her blood glucose has decreased to 180 mg/dL, a significant improvement from admission levels, yet still requiring careful management to avoid hypoglycemia. Her serum bicarbonate level has risen to 17 mEq/L, indicating a gradual resolution of the metabolic acidosis, although it is not yet within normal limits. Despite these positive trends, her anion gap remains elevated at 14 mEq/L, signaling that the ketoacidosis has not fully resolved.

The patient's hemodynamic status, however, starts to present a new challenge. Despite adjustments to her fluid therapy, her blood pressure has further decreased to 90/58 mmHg. This hypotension, coupled with her persistent tachycardia at 102 beats per minute, raises concerns about potential hypovolemia or an evolving cardiac complication. Her extremities remain cool to the touch, and capillary refill is slightly delayed, reinforcing the suspicion of inadequate perfusion.

Given these findings, the team deliberates over the next steps. They consider the potential need for vasopressor support if her blood pressure continues to drop, while also evaluating her fluid balance to determine if additional volume resuscitation is warranted. The risk of fluid overload must be carefully weighed against the need to maintain adequate tissue perfusion. Close monitoring of her cardiovascular status, along with frequent reassessment of electrolytes and acid-base balance, will be crucial in guiding further interventions as they work to stabilize her condition and prevent further complications.

Section 5

As the healthcare team continues to assess the patient, they notice a change in her status that warrants immediate attention. Her blood pressure has dropped further to 85/54 mmHg, despite ongoing fluid resuscitation efforts. The team swiftly evaluates her fluid intake and output, revealing that her urine output has significantly decreased, suggesting worsening hypovolemia or possible acute kidney injury. Her heart rate has increased to 110 beats per minute, intensifying concerns about her hemodynamic stability. The team must balance the need for additional fluid administration with the risk of exacerbating any underlying cardiac issues.

New diagnostic results provide further insight into her condition. An echocardiogram is performed, which shows a decreased ejection fraction of 45%, indicating potential cardiac dysfunction that could be contributing to her hypotension. Additionally, her repeat electrolyte panel reveals a potassium level of 3.2 mEq/L, highlighting the need for careful electrolyte management as hypokalemia could further compromise cardiac function. Her arterial blood gas shows a pH of 7.32, with a bicarbonate level now at 19 mEq/L, reflecting slow metabolic recovery but still not reaching normal levels.

In response to these findings, the healthcare team deliberates on initiating low-dose vasopressor support to stabilize her blood pressure while cautiously continuing fluid resuscitation. They also commence potassium supplementation to address her hypokalemia, monitoring her cardiac rhythm closely for any arrhythmias. This multifaceted approach requires vigilant reassessment and coordination among the team to ensure that interventions are effectively supporting her recovery without introducing additional risks. The next phase of her care will focus on closely monitoring her cardiovascular response to these interventions and adjusting the treatment plan as necessary to achieve hemodynamic stability and complete resolution of her ketoacidosis.