A patient with diabetic ketoacidosis (DKA) is being treated with intravenous fluids and insulin therapy. Which of the following interventions is most critical to perform before initiating insulin therapy?

B) Replacing potassium to prevent hypokalemia

A) Administering sodium bicarbonate to correct acidosis

B) Replacing potassium to prevent hypokalemia

C) Checking blood glucose levels

D) Initiating a continuous ECG monitoring

A patient diagnosed with diabetic ketoacidosis is receiving treatment including intravenous fluids and insulin. Which of the following interventions is the highest priority for the nurse to perform to prevent complications associated with this condition?

D) Monitor potassium levels frequently and supplement as needed.

A) Continuously monitor the patient's heart rate and rhythm.

B) Administer a rapid-acting insulin bolus to quickly lower blood glucose levels.

C) Increase the rate of intravenous fluids to rapidly restore blood volume.

D) Monitor potassium levels frequently and supplement as needed.

A patient with diabetic ketoacidosis (DKA) is receiving treatment, including intravenous fluids and potassium supplementation. After initial improvements, the patient develops premature ventricular contractions (PVCs). What is the most appropriate nursing intervention to address this new complication?

C) Adjust the potassium replacement to ensure adequate levels

A) Increase the rate of intravenous normal saline infusion

B) Administer an additional bolus of insulin

C) Adjust the potassium replacement to ensure adequate levels

D) Increase the frequency of blood glucose monitoring

A patient with diabetic ketoacidosis (DKA) is receiving treatment that includes intravenous normal saline, insulin infusion, and potassium supplementation. Despite improvements, the patient develops premature ventricular contractions (PVCs). Which action should the nurse prioritize to address this new complication?

B) Administer additional potassium supplementation to address potential hypokalemia.

A) Increase the rate of normal saline infusion to improve circulatory support.

B) Administer additional potassium supplementation to address potential hypokalemia.

C) Assess the patient's blood glucose levels to ensure they are within the target range.

D) Consult with the healthcare provider about starting a magnesium infusion.

A patient with diabetic ketoacidosis is being treated with insulin and electrolyte supplementation. Despite treatment, the patient continues to exhibit frequent premature ventricular contractions (PVCs). Which of the following is the most appropriate nursing intervention to address the PVCs in this scenario?

C) Increase the potassium supplementation rate and ensure magnesium replacement is administered.

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

B) Administer calcium supplements to correct potential hypocalcemia.

C) Increase the potassium supplementation rate and ensure magnesium replacement is administered.

D) Decrease fluid intake to prevent overhydration and potential electrolyte imbalance.

A patient with diabetic ketoacidosis is being monitored by the nursing team. Despite treatment, the patient now presents with frequent premature ventricular contractions (PVCs), mild hypomagnesemia, and a low-normal potassium level. Which nursing intervention is most appropriate to prioritize for this patient?

C) Administer magnesium replacement to address hypomagnesemia.

A) Administer IV calcium to stabilize cardiac membranes.

B) Increase the rate of insulin infusion to quickly resolve ketoacidosis.

C) Administer magnesium replacement to address hypomagnesemia.

D) Restrict fluid intake to prevent fluid overload.

A patient with diabetic ketoacidosis (DKA) is showing signs of mild pulmonary edema after initial treatment adjustments. What is the most appropriate nursing intervention at this time?

B) Administer the prescribed diuretic to manage fluid overload.

A) Increase the rate of intravenous insulin infusion.

B) Administer the prescribed diuretic to manage fluid overload.

C) Increase the rate of intravenous fluids to ensure adequate hydration.

D) Discontinue electrolyte supplementation to prevent further complications.

A patient with diabetic ketoacidosis is showing signs of mild pulmonary edema during treatment. Which nursing intervention is the most appropriate at this stage?

B) Administer a diuretic as prescribed and monitor the patient's respiratory status closely.

A) Increase the rate of intravenous fluids to enhance renal perfusion.

B) Administer a diuretic as prescribed and monitor the patient's respiratory status closely.

C) Discontinue insulin therapy until the patient's respiratory status stabilizes.

D) Encourage the patient to increase oral fluid intake to support hydration.

A patient with diabetic ketoacidosis (DKA) exhibits Kussmaul breathing and a blood pH of 7.30. Her sodium level is 132 mEq/L, and her blood glucose is 250 mg/dL. Which action should the nurse prioritize to address the patient's current condition?

B) Administer a sodium-containing intravenous fluid to correct hyponatremia.

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

B) Administer a sodium-containing intravenous fluid to correct hyponatremia.

C) Initiate diuretic therapy to prevent potential pulmonary edema.

D) Provide supplemental oxygen to address the increased respiratory rate.

A patient with diabetic ketoacidosis is experiencing worsening respiratory status with a pronounced Kussmaul breathing pattern and a current blood glucose level of 250 mg/dL. Her arterial blood gas shows a pH of 7.30, bicarbonate of 14 mEq/L, and serum sodium of 132 mEq/L. Which nursing intervention is most appropriate to address the patient's current clinical status?

C) Initiate a sodium-containing IV fluid to address the hyponatremia and support cellular function.

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

B) Administer IV sodium bicarbonate to correct the metabolic acidosis.

C) Initiate a sodium-containing IV fluid to address the hyponatremia and support cellular function.

D) Administer a diuretic to prevent pulmonary edema due to fluid overload.

Diabetic Ketoacidosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Insufficient insulin levels prevent glucose uptake by cells, leading to hyperglycemia. As cells are starved of glucose, the body initiates lipolysis, breaking down fats into free fatty acids, which are converted into ketones by the liver, causing ketoacidosis.

• Secondary mechanism: Elevated ketone levels result in metabolic acidosis, as the blood becomes more acidic. This acidosis is compounded by dehydration due to osmotic diuresis caused by high blood glucose, leading to loss of electrolytes like potassium.

• Key complication: Without prompt intervention, the combination of acidosis and electrolyte imbalance can lead to severe dehydration, altering consciousness, and potential progression to diabetic coma or death. Early recognition and treatment are critical to prevent these outcomes.

Patient Profile

Demographics:

45-year-old female, school teacher

History:

• Key past medical history: Type 1 Diabetes Mellitus diagnosed 20 years ago, hypertension

• Current medications: Insulin glargine, lisinopril, metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Nausea and abdominal pain

• Key symptoms: Polyuria, polydipsia, fatigue, shortness of breath

• Vital signs: Temperature 99.5°F, heart rate 110 bpm, respiratory rate 28/min, blood pressure 95/60 mmHg, blood glucose 350 mg/dL

Section 1

As the nursing team begins the initial assessment, the patient's condition appears to be deteriorating. Her vital signs indicate worsening hypotension with a blood pressure now reading 88/55 mmHg. The patient's heart rate remains elevated at 115 bpm, and her respiratory rate has increased to 32/min, suggesting compensatory Kussmaul breathing as her body attempts to counteract the acidosis. The patient is visibly fatigued, appears more lethargic, and her skin is cool and clammy, indicating potential shock from severe dehydration. This requires immediate intervention to prevent further decline.

Laboratory results reveal a blood pH of 7.18, confirming significant metabolic acidosis. Serum potassium levels are 3.0 mEq/L, demonstrating hypokalemia likely due to osmotic diuresis. The nurse also notes an elevated anion gap, consistent with diabetic ketoacidosis. The patient's serum ketone levels are markedly high, and urinalysis confirms ketonuria. These findings suggest the need for urgent electrolyte replacement and fluid resuscitation to restore hemodynamic stability and correct the acid-base imbalance.

The healthcare team collaborates to initiate a treatment plan. Intravenous fluid therapy is started with normal saline to address dehydration and improve perfusion. A potassium supplement is added to the treatment regimen to correct hypokalemia, which is crucial before initiating insulin therapy to prevent further potassium shifts that could precipitate cardiac arrhythmias. The patient's physician orders a continuous intravenous insulin infusion to gradually reduce blood glucose levels and ketone production. Close monitoring of vital signs, glucose levels, and electrolytes is essential to evaluate the patient's response to interventions and guide further management.

Section 2

As the treatment progresses, the nursing team observes the patient's response to the interventions. After an hour of intravenous normal saline administration, the patient's blood pressure shows slight improvement, rising to 95/60 mmHg. Her heart rate decreases to 105 bpm, indicating a partial response to fluid resuscitation. However, despite these improvements, her respiratory rate remains elevated at 30/min, and her Kussmaul breathing persists, suggesting ongoing metabolic acidosis. The patient's level of consciousness remains diminished; she is still lethargic but arouses with stimulation.

Lab results obtained two hours post-intervention reveal slight improvements in the patient's acid-base balance. Her blood pH has increased to 7.24, indicating a response to treatment, although full correction has not yet been achieved. Serum potassium levels have risen to 3.4 mEq/L after potassium supplementation, moving towards the normal range but still requiring careful monitoring. Blood glucose levels have decreased from an initial 475 mg/dL to 320 mg/dL, showing that the insulin infusion is effective. However, the anion gap remains elevated, and ketonuria persists, signaling that ongoing management is necessary to fully resolve the diabetic ketoacidosis.

Despite these positive trends, the patient develops a new complication: electrocardiogram (ECG) monitoring shows the emergence of premature ventricular contractions (PVCs). This arrhythmic event raises concerns about potential cardiac instability due to the persistent electrolyte imbalance, particularly the still-low potassium level. The healthcare team must reassess the treatment plan, potentially adjusting the rate of potassium replacement and ensuring continuous cardiac monitoring. This development prompts a critical discussion among the team regarding the balance between aggressive management of the patient's acidosis and careful correction of her electrolyte levels to prevent further cardiac complications.

Section 3

As the nursing team continues to monitor the patient, they notice a change in her status indicating potential complications. Over the next hour, her respiratory rate slightly decreases to 28/min, but she still exhibits Kussmaul breathing, suggesting that significant acidosis persists. The patient's level of consciousness improves marginally; she now responds more readily to verbal stimuli, although she remains confused. Despite these subtle improvements, her ECG shows an increase in the frequency of PVCs, occurring every few minutes, which raises concern for potential progression to more serious arrhythmias.

The healthcare team decides to obtain additional diagnostic tests to assess her cardiac function and electrolyte status in more detail. A repeat serum electrolyte panel shows that her potassium level has increased to 3.6 mEq/L, yet it remains on the lower side of normal. Serum magnesium and calcium levels are also checked given their role in cardiac stability, and results indicate mild hypomagnesemia with a level of 1.7 mg/dL. Her anion gap has decreased slightly but is still elevated, suggesting ongoing ketoacid presence.

In response to these findings, the team adjusts the treatment plan. They increase the rate of potassium supplementation while also starting magnesium replacement to address the hypomagnesemia, both critical for cardiac function. The insulin infusion rate is carefully titrated to continue lowering her blood glucose while avoiding rapid shifts in her electrolyte balance. Continuous cardiac monitoring is maintained to detect any further arrhythmic events. The team discusses the importance of closely observing the patient's cardiac and neurological status as her treatment progresses, recognizing that stabilization of electrolytes is crucial to prevent further complications and to fully resolve the diabetic ketoacidosis.

Section 4

Over the next few hours, the patient's response to the adjusted treatment plan becomes evident. Her respiratory pattern begins to normalize, with her respiratory rate decreasing to 24 breaths per minute, though she still exhibits a mild form of Kussmaul breathing. This indicates some improvement in her acid-base balance as the insulin therapy continues to reduce her blood glucose and, consequently, the ketoacid levels. Her level of consciousness improves further; she is now oriented to person and place, though she occasionally struggles with time orientation, suggesting gradual neurological recovery as her metabolic derangements are corrected.

The cardiac monitoring reveals fewer premature ventricular contractions (PVCs), which is a promising sign that the electrolyte adjustments, particularly the magnesium supplementation, are starting to stabilize her cardiac rhythm. However, the healthcare team remains vigilant, recognizing that the patient remains at risk for further arrhythmic events until her electrolyte levels are fully normalized. A repeat serum electrolyte panel shows that her potassium level has increased to 4.1 mEq/L, moving comfortably within the normal range, and her magnesium level has risen to 1.9 mg/dL, indicating a positive response to the supplementation.

Despite these improvements, the patient develops a new complication: she begins to exhibit signs of mild pulmonary edema, with bilateral crackles heard upon auscultation and a slight increase in her heart rate to 105 bpm. This prompts the team to reassess her fluid management strategy, recognizing the delicate balance required between rehydration and preventing fluid overload, especially in the context of potential cardiac compromise. Adjustments are made to her intravenous fluids, and a diuretic is considered to manage the fluid retention while continuing to support her recovery from diabetic ketoacidosis. The team emphasizes the importance of ongoing close monitoring and reassessment, understanding that managing DKA is a dynamic process requiring constant vigilance and timely interventions.

Section 5

As the healthcare team continues to manage the patient's condition, they notice a change in her status that requires immediate attention. Over the next few hours, the patient's respiratory status begins to deteriorate again, with her respiratory rate increasing to 28 breaths per minute. The Kussmaul breathing pattern becomes more pronounced, indicating a potential setback in her acid-base balance. This change raises concerns about the effectiveness of the current insulin regimen and prompts the team to reassess her insulin infusion rate and review recent blood glucose and ketone levels to ensure that her metabolic state is continuously improving.

A repeat arterial blood gas analysis reveals a slight increase in her blood pH to 7.30, though her bicarbonate level remains low at 14 mEq/L, evidencing ongoing metabolic acidosis. Her blood glucose level, now at 250 mg/dL, suggests that while there is progress, the metabolic derangements have not yet fully resolved. Additionally, the patient's latest serum electrolyte panel shows that while potassium and magnesium levels remain stable, her sodium level has decreased to 132 mEq/L, potentially contributing to her altered respiratory pattern and neurological status.

In light of these findings, the clinical team decides to adjust the insulin infusion to optimize glucose and ketoacid management while carefully titrating her fluid therapy to address the hyponatremia. They initiate a sodium-containing intravenous fluid to help correct the electrolyte imbalance and enhance cellular function. The decision is made to hold off on the diuretic for now, considering the need to maintain hemodynamic stability while closely monitoring her fluid status to prevent worsening pulmonary edema. This careful balance highlights the critical nature of individualized patient care in managing complex cases like diabetic ketoacidosis, where evolving clinical presentations necessitate dynamic and thoughtful interventions.