A patient with diabetic ketoacidosis (DKA) presents with a pH of 7.25, bicarbonate level of 12 mEq/L, and a potassium level of 5.8 mEq/L. After initiating treatment with intravenous fluids and insulin, what should the nurse prioritize when managing this patient?

B) Frequently monitor serum potassium levels to prevent hypokalemia.

A) Continuously monitor blood glucose levels to prevent hypoglycemia.

B) Frequently monitor serum potassium levels to prevent hypokalemia.

C) Administer sodium bicarbonate to correct metabolic acidosis.

D) Start broad-spectrum antibiotics to address a potential infection.

A patient with diabetic ketoacidosis (DKA) presents with a pH of 7.25, bicarbonate level of 12 mEq/L, sodium of 130 mEq/L, and potassium of 5.8 mEq/L. What is the priority nursing intervention to address the patient's electrolyte imbalance?

C) Start aggressive IV fluid therapy with normal saline

A) Administer intravenous insulin to decrease serum potassium levels

B) Initiate sodium bicarbonate therapy to correct the acidosis

C) Start aggressive IV fluid therapy with normal saline

D) Administer calcium gluconate to protect the heart from hyperkalemia

A patient with diabetic ketoacidosis is receiving treatment with intravenous fluids and insulin. After several hours, her heart rate is 115 beats per minute, blood pressure is 100/60 mmHg, respiratory rate is 24 breaths per minute, and she appears somnolent. Blood tests show a potassium level of 4.5 mEq/L. What is the most appropriate nursing action at this time?

C) Evaluate for possible infection and notify the healthcare provider

A) Administer a potassium supplement to prevent hypokalemia

B) Increase the rate of intravenous fluid administration

C) Evaluate for possible infection and notify the healthcare provider

D) Decrease the insulin infusion rate to prevent further potassium drop

A patient with diabetic ketoacidosis (DKA) is experiencing an increase in heart rate, a drop in blood pressure, and somnolence following initial treatment. Which nursing intervention is the highest priority at this time?

A) Administer a fluid bolus of normal saline

B) Increase the insulin infusion rate

C) Prepare to intubate the patient

D) Administer potassium chloride intravenously

A patient with diabetic ketoacidosis (DKA) is being treated with insulin therapy and has recently been started on broad-spectrum antibiotics due to suspected pneumonia. Her potassium level has dropped to 3.8 mEq/L. Which nursing intervention is most appropriate to prioritize at this time?

B) Administer potassium supplements as ordered to prevent hypokalemia.

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

B) Administer potassium supplements as ordered to prevent hypokalemia.

C) Discontinue the antibiotics until blood culture results confirm bacterial infection.

D) Initiate fluid restriction to manage potential fluid overload from treatment.

A patient with diabetic ketoacidosis (DKA) and suspected pneumonia has been started on insulin therapy and broad-spectrum antibiotics. Her potassium level has further dropped to 3.8 mEq/L. Which nursing intervention is most appropriate to prioritize in this situation?

B) Administer potassium supplements as per protocol to prevent hypokalemia

A) Increase the rate of insulin infusion to manage ketoacidosis more effectively

B) Administer potassium supplements as per protocol to prevent hypokalemia

C) Encourage the patient to increase oral fluid intake to manage dehydration

D) Obtain a repeat chest X-ray to assess the progression of infiltrates

A patient with pneumonia and diabetic ketoacidosis (DKA) is showing signs of septic shock with increasing heart rate, hypotension, and somnolence. After initiating broad-spectrum antibiotics and potassium replacement, which of the following interventions should the nurse prioritize to stabilize the patient's condition?

A) Administer a bolus of intravenous fluids to improve blood pressure

B) Increase the rate of insulin infusion to manage hyperglycemia

C) Prepare for endotracheal intubation due to increased respiratory rate

D) Initiate vasopressor support to address hypotension

A patient with suspected pneumonia is experiencing hemodynamic instability with increased heart rate, decreased blood pressure, and elevated respiratory rate. In addition to broad-spectrum antibiotics and potassium replacement, what is the next priority in managing this patient’s condition?

A) Administer a vasopressor to stabilize blood pressure

B) Increase the rate of fluid resuscitation to improve hemodynamic status

C) Initiate mechanical ventilation to support respiratory function

D) Broadening the antibiotic regimen to cover atypical organisms

A patient with pneumonia and sepsis is suspected to have developed acute respiratory distress syndrome (ARDS). Her arterial blood gas analysis shows a pH of 7.28, PaCO2 of 50 mmHg, and PaO2 of 60 mmHg, indicating respiratory acidosis. As her nurse, what is the most appropriate initial intervention to support her respiratory function?

C) Initiate continuous positive airway pressure (CPAP) therapy.

A) Increase the supplemental oxygen flow rate to 6 liters per minute via nasal cannula.

B) Prepare the patient for immediate intubation and mechanical ventilation.

C) Initiate continuous positive airway pressure (CPAP) therapy.

D) Encourage the patient to perform deep breathing exercises.

A patient with pneumonia and sepsis has developed acute respiratory distress syndrome (ARDS) and is now experiencing both metabolic and respiratory acidosis. Which of the following nursing interventions is most appropriate to address the patient's respiratory status at this time?

C) Collaborate with the respiratory therapist to initiate non-invasive ventilation

A) Increase the flow rate of the nasal cannula to 6 liters per minute

B) Administer bronchodilators to improve airway patency

C) Collaborate with the respiratory therapist to initiate non-invasive ventilation

D) Position the patient in a high Fowler's position to facilitate lung expansion

Dka - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency leads to decreased glucose uptake by cells, causing hyperglycemia and triggering lipolysis, which releases free fatty acids.

• Secondary mechanism: The liver converts free fatty acids into ketone bodies, resulting in metabolic acidosis as ketones accumulate in the bloodstream.

• Key complication: Elevated blood glucose and ketone levels lead to osmotic diuresis, causing dehydration, electrolyte imbalances, and further exacerbation of acidosis.

Patient Profile

Demographics:

45-year-old female, office manager

History:

• Key past medical history: Type 1 Diabetes Mellitus, hypertension

• Current medications: Insulin glargine, lisinopril, metformin

• Allergies: Sulfa drugs

Current Presentation:

• Chief complaint: Nausea and abdominal pain

• Key symptoms: Frequent urination, excessive thirst, confusion, fatigue

• Vital signs: Temperature 100.5°F, heart rate 115 bpm, respiratory rate 24 breaths/min, blood pressure 100/60 mmHg, blood glucose 450 mg/dL

Section 1

New Diagnostic Results:

As the medical team continues to evaluate the patient, they obtain critical laboratory results that provide further insight into her condition. The arterial blood gas analysis reveals a pH of 7.25, indicating metabolic acidosis, with a bicarbonate level of 12 mEq/L, confirming the presence of diabetic ketoacidosis (DKA). Additionally, serum electrolytes highlight significant abnormalities: sodium is slightly low at 130 mEq/L, potassium is elevated at 5.8 mEq/L, and there is a marked anion gap of 22 mmol/L. These findings confirm the severity of her acidotic state and guide the need for immediate therapeutic interventions.

Furthermore, a urinalysis shows large amounts of ketones and glucose, corroborating the diagnosis of DKA and providing evidence of the body's ongoing catabolic state. Serum osmolality is elevated, consistent with the osmotic diuresis she is experiencing. The laboratory team also reports a high white blood cell count of 15,000 cells/mm³, suggesting a potential underlying infection or stress response, which may have precipitated her current diabetic crisis. These findings warrant further investigation into potential infectious sources and reinforce the need for comprehensive management strategies to address both her metabolic derangements and potential complications.

The integration of these diagnostic results emphasizes the critical need for rapid rehydration and electrolyte correction to stabilize the patient's condition. The medical team initiates aggressive intravenous fluid therapy and carefully monitors her potassium levels to prevent cardiac complications. The results also prompt a review of her insulin regimen, highlighting the importance of optimizing her insulin therapy to achieve better glycemic control and prevent future episodes of DKA. This comprehensive approach aims to correct her metabolic imbalances while addressing potential precipitating factors, setting the stage for her eventual recovery and discharge planning.

Section 2

As the medical team implements the initial interventions for the patient with diabetic ketoacidosis, they carefully monitor her response to treatment. After several hours of aggressive intravenous fluid therapy and insulin administration, there are notable changes in her clinical status. Repeat arterial blood gas analysis reveals an improved pH of 7.32, although it remains mildly acidotic. Her bicarbonate levels have increased to 16 mEq/L, indicating a partial correction of her metabolic acidosis, but her anion gap remains elevated at 20 mmol/L. While these improvements suggest a positive response to treatment, they also highlight the ongoing need for continued monitoring and adjustment of therapy.

Despite these initial improvements, the patient's vital signs reveal potential signs of developing complications. Her heart rate has increased to 115 beats per minute, and her blood pressure has dropped slightly to 100/60 mmHg, raising concerns about possible hypovolemia or sepsis. Her respiratory rate remains elevated at 24 breaths per minute, and she appears somnolent, a change from her earlier more alert state. These findings prompt the team to reassess her fluid status and consider additional diagnostic workup for underlying causes, such as infection, that may be impacting her recovery.

Further laboratory tests reveal a decrease in her potassium level to 4.5 mEq/L, reflecting the cellular uptake of potassium as acidosis begins to resolve. However, the team remains vigilant for potential hypokalemia as insulin therapy continues. A chest X-ray and additional cultures are ordered to investigate possible sources of infection, given her elevated white blood cell count and changes in vital signs. The careful balance of maintaining fluid and electrolyte homeostasis, alongside addressing potential infectious causes, becomes critical in her management. This evolving scenario underscores the complexity of DKA treatment and the need for ongoing clinical reasoning to anticipate and address new complications as they arise.

Section 3

As the medical team continues to evaluate the patient with diabetic ketoacidosis, new diagnostic results bring additional insights into her condition. The chest X-ray shows mild infiltrates in the right lower lobe, raising the suspicion of an incipient pneumonia, which could be contributing to her somnolence and altered vital signs. Blood cultures are pending, but the preliminary findings prompt the team to initiate broad-spectrum antibiotics to address any potential bacterial infection. This decision underscores the importance of addressing secondary complications that can arise during DKA management, such as infections that may exacerbate metabolic derangements.

Simultaneously, her laboratory results indicate a further drop in potassium levels to 3.8 mEq/L. This decline is concerning, as insulin therapy can drive potassium into cells, risking hypokalemia, which could lead to cardiac arrhythmias. The team decides to initiate a potassium replacement protocol, carefully titrating to maintain her levels within a safe range. This highlights the balance needed to correct acidosis while preventing electrolyte imbalances. Her anion gap remains elevated, indicating that ketoacid production is still outpacing her body's ability to clear it, necessitating continued insulin therapy and careful monitoring of her metabolic status.

The patient's response to these interventions will be critical in guiding ongoing management. The team remains vigilant for any signs of deterioration, such as worsening hypotension or further mental status changes, which would necessitate a reevaluation of her treatment plan. These new findings and interventions are pivotal, as they reflect the dynamic and multifaceted nature of DKA management, requiring a combination of careful monitoring, timely diagnostics, and precise therapeutic adjustments to ensure successful patient recovery. The next steps will involve close monitoring of her clinical status, with the potential for further escalation of care if needed.

Section 4

As the medical team continues to monitor the patient, a change in her clinical status becomes apparent. Within a few hours of initiating broad-spectrum antibiotics and potassium replacement, the patient's vital signs show emerging instability. Her heart rate has increased to 110 beats per minute, and her blood pressure has dipped further to 92/58 mmHg, indicating a possible progression towards septic shock. Her respiratory rate has also increased to 24 breaths per minute, and she remains somnolent, with a Glasgow Coma Scale score of 12. These changes prompt the team to consider the potential progression of an underlying infection, likely the pneumonia suggested by the chest X-ray findings, as a contributing factor to her hemodynamic compromise.

The laboratory results further corroborate the clinical picture. Her white blood cell count has risen to 16,000 cells/microliter, supporting the suspicion of an infectious process. Despite continued insulin therapy, her anion gap remains elevated at 18, and her blood glucose levels have decreased but remain high at 280 mg/dL, indicating that while there is partial metabolic improvement, the underlying infection may be hindering complete resolution of the DKA. The repeat potassium level, however, shows improvement at 4.2 mEq/L, suggesting that the replacement protocol is effectively mitigating the risk of hypokalemia.

These developments necessitate an escalation in the patient's management plan. The team discusses the potential need for vasopressor support to address her hypotension and considers broadening the antibiotic regimen to ensure coverage of atypical organisms. Close monitoring of her fluid status is critical, as both volume resuscitation and electrolyte balance need to be maintained to manage the dual challenges of sepsis and DKA effectively. The patient's response to these adjustments will be pivotal in her trajectory, as the team remains vigilant for further signs of compromise or improvement, preparing to adjust the therapeutic approach as needed to support her recovery.

Section 5

As the medical team intensifies its efforts to stabilize the patient, a new complication emerges. Despite the adjustments to her management plan, the patient's condition remains precarious, and a further deterioration in her respiratory status is noted. Her oxygen saturation has decreased to 88% on room air, prompting the initiation of supplemental oxygen therapy via nasal cannula at 4 liters per minute. Auscultation of her lungs reveals diffuse crackles bilaterally, indicating potential worsening of pulmonary function. The team suspects the development of acute respiratory distress syndrome (ARDS) as a complication of her underlying pneumonia and sepsis.

In light of these respiratory changes, a repeat arterial blood gas analysis is performed, revealing a pH of 7.28, PaCO2 of 50 mmHg, and PaO2 of 60 mmHg. These results confirm the presence of respiratory acidosis, complicating the metabolic acidosis from the DKA. The combination of metabolic and respiratory acidosis places further stress on the patient's already compromised physiological state, necessitating more aggressive respiratory support. The team contemplates the need to escalate to non-invasive ventilation or even intubation if her respiratory effort does not improve with current measures.

These developments underscore the importance of a multidisciplinary approach to her care, with close coordination between the medical, nursing, and respiratory therapy teams. As the team continues to monitor her response to the current interventions, they remain poised to adjust the treatment strategy, including optimizing her fluid and electrolyte management, ensuring adequate antibiotic coverage, and addressing her respiratory needs. The evolving picture of her condition highlights the complexity of managing coexisting DKA and septic shock, emphasizing the critical need for vigilant monitoring and timely therapeutic adjustments to guide her toward recovery.