What is the primary reason for initiating fluid resuscitation with isotonic saline in a patient with Diabetic Ketoacidosis (DKA)?

B) To correct electrolyte imbalances

D) To stabilize blood glucose levels

Which of the following vital sign changes indicates an improvement in the patient's condition after treatment initiation?

A) Heart rate decreasing to 90 beats per minute

B) Respiratory rate remaining at 22 breaths per minute

C) Blood pressure stabilizing at 118/72 mmHg

D) Oxygen saturation of 98% on room air

Which of the following vital sign changes indicates an improvement in the patient's condition following treatment?

B) Heart rate decreasing to 90 beats per minute

A) Respiratory rate increasing to 30 breaths per minute

B) Heart rate decreasing to 90 beats per minute

C) Oxygen saturation decreasing to 90% on room air

D) Blood pressure dropping to 90/60 mmHg

Which laboratory value indicates that the patient's metabolic acidosis is improving?

B) Blood glucose level of 220 mg/dL

C) Creatinine level of 1.7 mg/dL

D) Potassium level of 4.5 mEq/L

A nurse is evaluating the laboratory results of a patient recovering from diabetic ketoacidosis (DKA) and acute kidney injury (AKI). Which laboratory value indicates that the patient is experiencing a positive response to insulin therapy?

A) Blood glucose level of 220 mg/dL

B) Creatinine level of 1.7 mg/dL

C) Potassium level of 4.5 mEq/L

D) Bicarbonate level of 20 mEq/L

Which of the following is the best indicator of improved renal function in this patient?

B) Creatinine level of 1.5 mg/dL

A) Blood glucose level of 180 mg/dL

B) Creatinine level of 1.5 mg/dL

C) Heart rate of 84 beats per minute

Which of the following assessments indicates that the patient is experiencing an improvement in her hydration status?

B) Presence of active bowel sounds

C) Clear breath sounds bilaterally

My patient has been diagnosed with DKA and has complicated into AKI - Nursing Case Study

Pathophysiology

• Primary mechanism: In Diabetic Ketoacidosis (DKA), the body lacks insulin, leading to increased blood glucose levels. To compensate, the liver produces ketones for energy, causing metabolic acidosis.

• Secondary mechanism: The high blood glucose levels cause osmotic diuresis, leading to significant fluid and electrolyte loss, reducing blood volume and causing dehydration.

• Key complication: Due to dehydration and reduced blood flow to the kidneys, Acute Kidney Injury (AKI) can occur as the kidneys struggle to filter waste effectively, worsening the patient's condition.

Patient Profile

Demographics:

56-year-old female, school teacher

History:

• Key past medical history: Type 1 Diabetes Mellitus

• Current medications: Insulin glargine, insulin lispro

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Fatigue and increased urination

• Key symptoms: Nausea, mild abdominal pain, dehydration

• Vital signs: Blood pressure 120/80 mmHg, heart rate 88 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F, SpO2 98% on room air

Section 1

The nursing team conducted an initial assessment upon the patient's admission to the unit. During this assessment, the patient appeared alert and oriented but was noticeably fatigued. Her skin was dry, and mucous membranes were tacky, indicative of dehydration. The capillary refill time was slightly delayed at 3 seconds. Lung sounds were clear upon auscultation, and there were no signs of respiratory distress beyond an increased respiratory rate. The patient reported mild, diffuse abdominal pain, which was non-tender upon palpation.

The laboratory results confirmed the presence of Diabetic Ketoacidosis (DKA), with a blood glucose level of 475 mg/dL and elevated ketone levels in the urine. Arterial blood gas analysis revealed a pH of 7.29, indicating metabolic acidosis, with a low bicarbonate level of 15 mEq/L. The serum creatinine was slightly elevated at 1.6 mg/dL, suggesting the onset of Acute Kidney Injury (AKI), but urine output remained adequate, at 35 mL/hour, indicating stable kidney function at this stage. Electrolyte imbalances were noted, with sodium at 130 mEq/L and potassium at 5.2 mEq/L, necessitating careful monitoring and correction.

Based on these findings, the care team initiated standard DKA protocol, involving fluid resuscitation with isotonic saline to address dehydration, and insulin therapy to gradually reduce blood glucose and ketone levels. The patient was also started on potassium supplementation to prevent hypokalemia as insulin therapy progresses. Nursing interventions focused on monitoring vital signs, intake and output, and frequent blood glucose and electrolyte checks to evaluate the patient's response to treatment. At this stage, the patient remained stable with no new complications, allowing for cautious optimism in her recovery trajectory.

Section 2

In the hours following the initiation of treatment, the nursing team closely monitored the patient's response to the interventions. The patient continued to appear alert and oriented, though she remained fatigued. Vital signs showed a slight improvement, with heart rate decreasing to 90 beats per minute and blood pressure stabilizing at 118/72 mmHg. Respiratory rate remained elevated at 22 breaths per minute, but oxygen saturation was a reassuring 98% on room air. The patient's skin appeared less dry, suggesting positive hydration status, and capillary refill time improved to 2 seconds.

Blood glucose levels gradually decreased to 280 mg/dL after several hours of insulin therapy, signaling a positive response to treatment. Repeat electrolyte testing showed potassium levels trending downward to 4.8 mEq/L, verifying the effectiveness of potassium supplementation in preventing hypokalemia. The sodium level rose slightly to 133 mEq/L, indicating an improvement in electrolyte balance. Follow-up ABG analysis showed a pH increase to 7.32 and bicarbonate levels at 18 mEq/L, reflecting a slow correction of metabolic acidosis.

Despite these improvements, the patient reported a new onset of mild nausea, which the care team attributed to electrolyte shifts and metabolic changes during treatment. Antiemetic therapy was administered as needed, and the team continued to monitor the patient's symptoms closely. The nursing team remained vigilant, conducting hourly assessments and ensuring effective communication with the interdisciplinary team to address any potential changes in the patient's condition promptly. With careful management, the patient remained on track for recovery, and the primary focus was on maintaining stability and preventing further complications.

Section 3

As the nursing team continued to monitor the patient, the focus shifted to evaluating her response to the interventions and ensuring the stability of her condition. The patient maintained alertness and orientation, though she expressed persistent fatigue, which was expected given her recent DKA and AKI diagnoses. Her vital signs remained stable, with a heart rate of 88 beats per minute and blood pressure holding steady at 116/70 mmHg. Her respiratory rate slightly decreased to 20 breaths per minute, while her oxygen saturation stayed at 98% on room air, indicating adequate respiratory function and oxygenation.

Laboratory results from another round of testing provided new insights into the patient's condition. Her blood glucose level further decreased to 220 mg/dL, demonstrating continued improvement with insulin therapy. Potassium levels stabilized at 4.5 mEq/L, showing effective maintenance within normal limits. However, the creatinine level was noted to be 1.7 mg/dL, a minor improvement from previous values, but still elevated, reflecting that the acute kidney injury was in the early stages of recovery. The latest ABG analysis revealed a pH of 7.35 and bicarbonate levels at 20 mEq/L, suggesting ongoing correction of the metabolic acidosis.

Despite these encouraging signs, the patient reported a mild headache, which the care team considered to be associated with the electrolyte shifts and the ongoing metabolic adjustments. The nursing team responded by ensuring the patient's comfort, providing adequate hydration, and closely monitoring her neurological status. They also reviewed medication administration to manage her symptoms effectively. Continued vigilance and collaboration with the interdisciplinary team remained essential to guide the patient towards a full recovery, with the next goals focused on further improving renal function and ensuring complete metabolic balance.

Section 4

As the patient continued under close observation, the nursing team noted a positive response to the interventions. Her blood glucose levels gradually approached the target range, now at 180 mg/dL, suggesting effective glycemic control with the current insulin regimen. The team was encouraged by the patient's steady progress and her ability to maintain adequate hydration, as evidenced by a sustained urine output of 45 mL/hour, indicating improved renal function. Her creatinine level showed further improvement, now at 1.5 mg/dL, pointing towards a gradual recovery from the acute kidney injury.

Throughout the day, the patient began to express a renewed sense of energy, reporting reduced fatigue and increased alertness. Her vital signs remained stable, with a heart rate of 84 beats per minute, blood pressure at 114/72 mmHg, and respiratory rate maintained at 18 breaths per minute. The headache she experienced earlier subsided with proper hydration and rest, and her neurological assessment remained within normal limits with the patient remaining oriented to person, place, and time.

The interdisciplinary team decided to focus on optimizing the patient's nutritional intake to support her recovery process. A dietitian was consulted to tailor a meal plan that balanced her caloric needs while managing her blood glucose levels effectively. The plan included a moderate carbohydrate intake with an emphasis on complex carbohydrates and lean proteins. As the patient adapted to this dietary regimen, her clinical team remained vigilant, ensuring that any new or subtle changes in her condition were promptly addressed, setting the stage for her continued improvement and eventual discharge planning.

Section 5

As the patient continued to show signs of improvement, the nursing team conducted another round of assessments to ensure her progress remained consistent. During the initial assessment, the nurse noted that the patient's skin turgor had improved, indicating that her hydration status was stabilizing. Lung auscultation revealed clear breath sounds bilaterally, with no signs of fluid overload or respiratory distress. Additionally, the patient reported no abdominal discomfort, and bowel sounds were present and active upon examination, suggesting normal gastrointestinal function.

New diagnostic results further supported the patient's positive trajectory. Her latest electrolyte panel revealed a potassium level of 4.2 mEq/L, within the normal range, indicating that the careful balance of insulin therapy and fluid management was effectively restoring her electrolyte balance. Her bicarbonate level had increased to 19 mEq/L, reflecting a correction of the metabolic acidosis associated with diabetic ketoacidosis (DKA). These lab results, along with the patient's stable glucose levels and improved creatinine, provided reassurance that the current treatment plan was appropriate and effective.

With the patient responding well to interventions, the healthcare team discussed transitioning her from the intensive monitoring setting to the regular medical unit. This decision was based on her stable vital signs, improved metabolic parameters, and the absence of new complications. The team emphasized continued monitoring of her blood glucose levels and renal function, while also reinforcing education on the importance of adherence to her new dietary plan and insulin regimen. As she moved towards recovery, the team prepared to involve her in discharge planning, ensuring she had the necessary support and resources for managing her condition at home.