A 45-year-old female patient with diabetic ketoacidosis (DKA) is being treated with intravenous fluids and insulin therapy. Despite treatment, her blood pressure remains low, and she exhibits confusion and disorientation. What is the priority nursing intervention to address her current condition?

B) Increase the rate of intravenous fluid administration to manage hypovolemic shock.

A) Administer calcium gluconate to stabilize cardiac function.

B) Increase the rate of intravenous fluid administration to manage hypovolemic shock.

C) Evaluate the need for electrolyte replacement, focusing on correcting potassium levels.

D) Monitor blood glucose levels closely to ensure gradual reduction, preventing cerebral edema.

A 45-year-old female with diabetic ketoacidosis (DKA) is being treated with intravenous fluids and insulin therapy. Her blood pressure remains low at 90/58 mmHg despite aggressive fluid resuscitation, and she exhibits signs of confusion and disorientation. Which of the following interventions should the nurse prioritize to address the patient's current condition?

C) Initiate continuous cardiac monitoring and consider administering calcium gluconate.

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

B) Administer a bolus of hypertonic saline to correct electrolyte imbalances.

C) Initiate continuous cardiac monitoring and consider administering calcium gluconate.

D) Discontinue fluid resuscitation and start vasopressors immediately.

A patient with diabetic ketoacidosis (DKA) is being closely monitored for electrolyte imbalances and cardiac function. The patient's latest lab results indicate hyponatremia with a sodium level of 127 mEq/L, and the ECG shows T-wave inversions and prolonged QT intervals. Which nursing intervention is most appropriate to address the patient's current condition?

B) Initiate continuous cardiac monitoring and administer calcium gluconate as per protocol.

A) Administer a rapid infusion of normal saline to quickly correct hyponatremia.

B) Initiate continuous cardiac monitoring and administer calcium gluconate as per protocol.

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

D) Provide oral potassium supplements to prevent hypokalemia.

A patient with diabetic ketoacidosis is experiencing hyponatremia, prolonged QT intervals, and fluctuating mental status. Which of the following actions should the nurse prioritize when addressing these clinical findings?

C) Administer hypertonic saline cautiously to correct the hyponatremia.

A) Administer calcium gluconate to prevent arrhythmias due to prolonged QT intervals.

B) Initiate an insulin bolus to further reduce the blood glucose level.

C) Administer hypertonic saline cautiously to correct the hyponatremia.

D) Increase the rate of IV fluids to improve the patient's electrolyte balance.

A patient with diabetic ketoacidosis is being treated with hypertonic saline and electrolyte replacement. After initiating treatment, the patient develops hypocalcemia with a serum calcium of 7.8 mg/dL and QT interval prolongation. Which intervention should the nurse prioritize to prevent cardiac complications?

B) Administer calcium gluconate as ordered

A) Increase the rate of hypertonic saline infusion

B) Administer calcium gluconate as ordered

C) Initiate continuous ECG monitoring

D) Restrict fluid intake to prevent cerebral edema

A patient with diabetic ketoacidosis is currently being treated with hypertonic saline and electrolyte replacement. Following treatment, the patient exhibits a serum calcium level of 7.8 mg/dL and QT interval prolongation. What is the most appropriate nursing intervention to address the patient's current electrolyte imbalance and prevent potential complications?

C) Administer intravenous calcium gluconate to address hypocalcemia.

A) Administer intravenous magnesium sulfate to stabilize the cardiac rhythm.

B) Increase the rate of hypertonic saline to correct residual hyponatremia.

C) Administer intravenous calcium gluconate to address hypocalcemia.

D) Provide oral potassium supplements to ensure adequate potassium levels.

A patient with diabetic ketoacidosis (DKA) is being monitored in the ICU. The patient has an increased respiratory rate and deep, labored breathing. Arterial blood gas (ABG) analysis shows a pH of 7.30, bicarbonate level of 18 mEq/L, and pCO2 of 30 mmHg. Which nursing intervention is most appropriate in response to these findings?

C) Increase the frequency of electrolyte monitoring, focusing on potassium levels.

A) Decrease the insulin infusion rate to prevent hypoglycemia.

B) Administer sodium bicarbonate to correct the acidosis.

C) Increase the frequency of electrolyte monitoring, focusing on potassium levels.

D) Initiate mechanical ventilation to support respiratory function.

A patient with diabetic ketoacidosis (DKA) is being treated with insulin and IV fluids. An arterial blood gas shows a pH of 7.30, bicarbonate level of 18 mEq/L, and pCO2 of 30 mmHg, indicating partially compensated metabolic acidosis. The patient is breathing rapidly at 28 breaths per minute. Which of the following actions should the nurse prioritize to address the patient's current condition?

C) Monitor the patient's potassium levels closely and administer potassium supplements as needed.

A) Increase the insulin infusion rate to correct the acidosis more rapidly.

B) Administer sodium bicarbonate to immediately correct the acidosis.

C) Monitor the patient's potassium levels closely and administer potassium supplements as needed.

D) Decrease the insulin infusion rate to prevent hypoglycemia.

A patient with diabetic ketoacidosis is receiving insulin therapy and has developed hypokalemia. What is the most important nursing action to perform when initiating potassium replacement therapy in this patient?

C) Continuously monitor the patient's cardiac rhythm and assess for arrhythmias.

A) Monitor the patient's blood glucose levels every hour.

B) Administer potassium chloride via an intravenous push to rapidly correct hypokalemia.

C) Continuously monitor the patient's cardiac rhythm and assess for arrhythmias.

D) Encourage the patient to increase oral fluid intake to help with electrolyte balance.

A patient with diabetic ketoacidosis is experiencing hypokalemia with a potassium level of 3.2 mEq/L. The clinical team has started intravenous potassium chloride replacement. Which nursing intervention is most critical to ensure patient safety during this treatment?

C) Continuously monitor the patient's cardiac rhythm via ECG.

A) Encourage the patient to increase oral fluid intake.

B) Monitor the patient's urine output every 4 hours.

C) Continuously monitor the patient's cardiac rhythm via ECG.

D) Check the patient's blood glucose level every hour.

Diabetic ketoacidosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency leads to the breakdown of fat into free fatty acids, which the liver converts into ketone bodies, resulting in metabolic acidosis due to the accumulation of acidic ketones in the blood.

• Secondary mechanism: Concurrently, insulin deficiency and elevated counter-regulatory hormones (glucagon, cortisol) increase gluconeogenesis and glycogenolysis, causing hyperglycemia. This leads to osmotic diuresis, dehydration, and electrolyte imbalances as glucose and ketones draw water and electrolytes out of the body.

• Key complication: The combination of metabolic acidosis, dehydration, and electrolyte imbalances can lead to altered mental status, cardiac dysrhythmias, and ultimately, if untreated, can progress to shock or coma.

Patient Profile

Demographics:

45-year-old female, office manager

History:

• Key past medical history: Type 1 Diabetes Mellitus for 20 years, hypertension, hyperlipidemia

• Current medications: Insulin glargine, insulin lispro, lisinopril, atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Nausea and abdominal pain for the past 24 hours

• Key symptoms: Polyuria, polydipsia, weakness, shortness of breath, confusion

• Vital signs: Temperature 101.2°F (38.4°C), Heart rate 118 bpm, Respiratory rate 28 breaths per minute, Blood pressure 95/60 mmHg, Oxygen saturation 92% on room air

Section 1

As the clinical team assessed the 45-year-old female patient with suspected diabetic ketoacidosis (DKA), further diagnostic results highlighted several concerns. Blood gas analysis revealed a severe metabolic acidosis with a pH of 7.21 and a bicarbonate level of 11 mEq/L, confirming the presence of significant acidosis. Serum glucose levels were critically elevated at 550 mg/dL, and ketone bodies were markedly increased, indicative of ongoing ketosis. The electrolyte panel showed a sodium level of 130 mEq/L, potassium level of 5.8 mEq/L, and an anion gap of 22, consistent with an anion-gap metabolic acidosis. These results suggest significant electrolyte disturbances, particularly hyperkalemia, which may predispose the patient to cardiac complications.

As the team initiated treatment with intravenous fluids and insulin therapy, the patient's status began to evolve, presenting new challenges. Despite aggressive fluid resuscitation, her blood pressure remained low at 90/58 mmHg, raising concerns of progressing hypovolemic shock due to severe dehydration. Concurrently, the patient's mental status fluctuated, with periods of increasing confusion and disorientation, potentially exacerbated by cerebral edema or the rapid shift of electrolytes during treatment. The clinical team was prompted to reassess their management strategy, emphasizing the need for careful monitoring of fluid balance, electrolytes, and cardiac function, while considering the addition of electrolyte replacement and potential use of inotropic support to stabilize her hemodynamics.

These developments necessitate a thorough re-evaluation of the patient's treatment plan, with an emphasis on titrating insulin therapy to gradually lower blood sugar and ketone levels while avoiding rapid shifts that could lead to further complications such as cerebral edema. The team must remain vigilant for signs of cardiac dysrhythmias due to electrolyte imbalances, particularly hyperkalemia, and prepare to intervene with appropriate measures such as calcium gluconate or sodium polystyrene sulfonate. The unfolding case highlights the complexity of managing DKA and the importance of a multi-faceted approach to address the interconnected pathophysiological changes in this condition.

Section 2

As the clinical team continued to monitor the patient's condition, new diagnostic results revealed additional complications. A repeat electrolyte panel indicated that while the potassium level had decreased to 4.5 mEq/L after initial insulin and fluid therapy, the sodium level had further dropped to 127 mEq/L, raising concerns about hyponatremia. The patient's blood glucose level had decreased to 320 mg/dL, showing a positive response to insulin, but further monitoring was required to avoid causing cerebral edema due to overly rapid glucose reduction. The bicarbonate level had improved slightly to 15 mEq/L, yet the metabolic acidosis persisted, necessitating continued vigilance.

During this period, an electrocardiogram (ECG) was performed to assess cardiac function, revealing new-onset T-wave inversions and prolonged QT intervals, which could be indicative of electrolyte imbalance or myocardial ischemia. These findings prompted the team to intensify cardiac monitoring and consider the cautious administration of calcium gluconate to stabilize cardiac membranes and prevent arrhythmias. The patient's fluctuating mental status remained a concern, as she exhibited increased periods of lethargy and confusion, requiring a neurological evaluation to rule out cerebral edema or other central nervous system complications.

Given these developments, the clinical team adjusted the treatment plan by carefully titrating the insulin infusion to avoid rapid metabolic shifts and introducing hypertonic saline to address the hyponatremia. They also initiated magnesium and phosphate replacement to support cellular function and prevent further electrolyte-related cardiac issues. This strategic approach aimed to stabilize the patient's condition while minimizing the risk of additional complications, highlighting the dynamic nature of managing diabetic ketoacidosis and the importance of comprehensive and nuanced clinical reasoning in guiding therapeutic decisions.

Section 3

As the clinical team continued their vigilant monitoring, new complications emerged, adding layers of complexity to the patient's condition. Within hours of initiating hypertonic saline and electrolyte replacement, the patient's serum sodium level improved to 130 mEq/L. However, the electrolyte correction unmasked a mild yet significant decrease in the patient's serum calcium level, now at 7.8 mg/dL. This hypocalcemia, combined with the existing QT interval prolongation observed on the ECG, raised additional concerns for potential cardiac arrhythmias. Vital signs showed a heart rate of 105 bpm, blood pressure of 110/70 mmHg, and a temperature of 98.6°F, but the presence of new muscle twitching and increased irritability further underscored the need for cautious electrolyte management.

In response to these developments, the clinical team decided to reassess the balance of electrolyte replacement therapies. The administration of calcium gluconate was adjusted to address the emerging hypocalcemia, with careful monitoring of the patient's cardiac status to prevent potential arrhythmogenic events. Meanwhile, the neurological evaluation revealed no overt signs of cerebral edema, but the patient's fluctuating mental status warranted continued observation. Her Glasgow Coma Scale (GCS) score remained at 13, indicating mild impairment but stable overall cerebral function.

These new complications emphasized the importance of a meticulously balanced approach to electrolyte and fluid management, along with a heightened awareness of the interconnected nature of metabolic and cardiac dynamics in diabetic ketoacidosis. The clinical team remained focused on adjusting interventions based on the evolving clinical picture, ensuring that each therapeutic decision was informed by comprehensive assessment and real-time data analysis. As the patient journeyed through this critical phase, the team continued to strategize and prioritize interventions to mitigate risks and promote recovery, underscoring the necessity for agile clinical reasoning in the face of complex, multifaceted challenges.

Section 4

As the clinical team continued to manage the patient’s condition, a new complication emerged, highlighting the intricate balance required in managing diabetic ketoacidosis. Overnight, the patient developed a gradual increase in respiratory rate, reaching 28 breaths per minute, accompanied by a deeper, more labored breathing pattern. Concerned about the possibility of metabolic acidosis worsening or a compensatory respiratory response, the team ordered an arterial blood gas (ABG) analysis. The ABG results indicated a pH of 7.30, a bicarbonate level of 18 mEq/L, and a pCO2 of 30 mmHg, confirming a partially compensated metabolic acidosis. This finding suggested that while some metabolic derangement remained, the patient's respiratory system was attempting to compensate by eliminating CO2, albeit insufficiently.

In light of these results, the team decided to reassess the insulin infusion rate, ensuring that it was optimally titrated to address the persistent acidosis while avoiding hypoglycemia. The patient's serum glucose level had stabilized at 250 mg/dL with the treatment thus far, indicating progress in resolving the hyperglycemia, but the ongoing acidosis required careful management. Additionally, the team increased the frequency of electrolyte monitoring, especially focusing on potassium levels, given the risk of hypokalemia during insulin therapy and its potential impact on cardiac function.

The patient’s respiratory status and ABG findings underscored the dynamic nature of diabetic ketoacidosis management, where interventions must be continuously evaluated and adjusted based on real-time clinical data. The team's decision to fine-tune the insulin therapy and closely monitor electrolytes demonstrated a nuanced understanding of the interconnected physiological processes at play. As the patient continued to stabilize, the clinical team remained vigilant for any further complications, prepared to adjust their strategies as needed to navigate the complexities of her recovery journey.

Section 5

As the clinical team continued to monitor the patient, a new complication emerged in the early hours of the morning. The patient's heart rate, which had been stable at around 90 beats per minute, began to increase gradually, reaching 115 beats per minute. Concurrently, the patient reported feeling palpitations and appeared more restless. A repeat electrolyte panel revealed a potassium level of 3.2 mEq/L, confirming hypokalemia, a known risk during insulin therapy for diabetic ketoacidosis. The team recognized the urgency of correcting this electrolyte imbalance, given the potential for cardiac arrhythmias associated with low potassium levels.

In response to these findings, the team promptly initiated a potassium replacement protocol, administering potassium chloride intravenously while carefully monitoring the patient's cardiac rhythm through continuous ECG. The nursing staff also increased the frequency of vital sign assessments, watching closely for any signs of further cardiac instability or shifts in the patient's condition. As the potassium supplementation began, the team observed a gradual decrease in heart rate, stabilizing back to 95 beats per minute, and the patient's palpitations subsided. This positive response to the intervention was reassuring, yet the team remained cautious, understanding the delicate balance required in managing both the acidosis and the associated electrolyte disturbances.

These developments highlighted the complexity of diabetic ketoacidosis management, where addressing one aspect of the condition, such as hyperglycemia, can inadvertently affect other physiological parameters like electrolyte balance. The team's proactive approach to re-evaluating treatment strategies and closely monitoring the patient underscored the importance of continuous assessment and adaptation in clinical practice. As the patient's condition stabilized, the focus shifted to ensuring sustained recovery and preventing any further complications, with regular reassessment of both metabolic and cardiac status as the patient progressed through her treatment plan.