Diana Humphries DKA PDF

Preview

Summary

Diana Humphries is a 45-year-old woman with chronic kidney disease stage III and diabetes mellitus type1 who checks her blood sugar daily, or whenever she feels like it. She has been feeling increasingly nauseated the past 12 hours. She has had a harsh, productive cough of yellow sputum the past thr...

Description



Diabetic Ketoacidosis (DKA)

Diana Humphries, 45 years old

Primary Concept Fluid and Electrolyte Balance Interrelated Concepts (In order of emphasis) 1. Acid-Base Balance 2. Glucose Regulation 3. Infection 4. Pain 5. Clinical Judgment 6. Patient Education 7. Communication 8. Collaboration

UNFOLDING Reasoning Case Study: STUDENT

Diabetic Ketoacidosis (DKA) History of Present Problem: © 2016 Keith Rischer/www.KeithRN.com

Diana Humphries is a 45-year-old woman with chronic kidney disease stage III and diabetes mellitus type1 who checks her blood sugar daily, or whenever she feels like it. She has been feeling increasingly nauseated the past 12 hours. She has had a harsh, productive cough of yellow sputum the past three days. She checked her blood glucose before going to bed last night and it was 382, but then she fell asleep early and missed her bedtime dose of glargine (Lantus) insulin. When she awoke this morning, she had generalized abdominal pain and continued to feel nauseated and had a large emesis. Her glucometer was unable to read her blood glucose because it was too high. She took 10 units of lispro (Humalog) insulin this morning. Her nausea has increased all morning and she has been unable to eat or keep anything down despite having an increased thirst and appetite. She also has had increased frequency of urination. When her lunchtime glucometer gave no reading because it was too high and out of range, she called 9-1-1 to be evaluated in the emergency department (ED).

Personal/Social History: Diana has been inconsistently compliant with her medical/diabetic regimen due to her struggles with anxiety and depression that have worsened since her mother died three months ago. She considers 200 a good blood sugar reading. She is divorced with no children and has been homeless and has lived in a shelter off and on the past month. She is on Social Security disability because of complications related to diabetes. At one point during the intake interview, she expressed to the nurse, “I’m going to die anyway, why does all this matter?” What data from the histories is RELEVANT and has clinical significance to the nurse? pt= patient RELEVANT Data from Present Problem: Clinical Significance: - Pt is on a deteriorative health state, non-compliant with her DM1 - female, 45 y/o. - chronic kidney disease stage III and care plan and insulin regimen. diabetes mellitus type1. - Pt is showing an acute state of hyperglycemia. - Not complain with daily glucose checks - This is an emergency because pt could go on shock or comma soon. or drug therapy. Pt is still alert and getting help from 911. - Nauseous for 12 hrs. -Pt is dehydrated since she is not able to keep anything down and - Harsh, productive cough of yellow having nausea an emesis (vomiting). sputum the past three days. -Pt shows some DKA symptoms : Polyuria, dehydration. Glycosuria - Last night glucose level 382, pt felt sleep expected on urine lab results. forgot administering insulin (Lantus). - This morning pt has a large emesis, generalized abdominal pain/nauseous. - ↑ glucose level, not able to read by the glucometer. - Pt took 10 units of lispro (Humalog) this morning. - ↑nausea not able to eat or keep anything down even when pt is hungry and thirsty. - ↑ frequent urination. -Called 911 for an evaluation in the ER due to her ↑glucose level.

RELEVANT Data from Social History: - Pt not compliant with care plan. - Pt has anxiety and depression. - Pt’s mother pass 3 months ago. - Divorce, no kids. - Homeless living on a shelter/street for a © 2016 Keith Rischer/www.KeithRN.com

Clinical Significance: - Pt is depressed, has no backup support, is homeless which indicated she is lacking many needs. Health is not a priority right now. - -Pt was no reason to keep trying … neglecting her health. - Risk for suicide.

-

month. She is on a limited income due to DM complications. Pt is hopeless and depressed.

-

Pt need a care plan that offers community services to meet basic needs.

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect) PMH: Home Meds: Pharm. Expected Outcome: Classification: • Chronic Kidney disease stage 1. Aspirin 81mg PO daily ↓ risk of stroke/heart attack Salicylate & NSAID III (diabetic nephropathy) • Anemia

2 .Lisinopril 10 mg PO daily

Angiotensin converting enzyme (ACE) inhibitor

Control ↑BP for pt at risk management including DM.

3. Lorazepam 1mg PO bid prn

Antianxiety

Mgmt Anxiety and stress

SSRI

↓risk of chronic depression. (40mg max dose allowed)

• Diabetic retinopathy • Neuropathy in lower legs (6)

4. Citalopram 40 PO mg daily • Hypertension (2)(7) 5. Zolpidem 10 mg PO at HS prn • Coronary artery disease (1)(7) 6. Gabapentin 300 mg PO bid • Gastroesophageal reflux disease (GERD) (8) 7. Labetalol 200 mg PO bid • Anxiety (3)(5) • Depression (4)

8. Omeprazole 20 mg PO daily

9 .Simvastatin 40 mg PO HS

• Hyperlipidemia (9)

10. Glargine insulin 50 units SQ at HS

Sedative (hypnotic) ↓ insomnia when deeded/↓ anxiety to pt can rest. Anticonvulsant/ neuropathic pain (nerve pain) Non-cardio selective beta blocker

Pump inhibitor ↓acid produced in stomach

Statin/reductase inhibitor

• Diabetes mellitus type 1 since11. Lispro insulin SQ sliding scale age 12 (10) (11) Insulin long acting AC and HS

↓ restless/pain on lower extremities To treat coronary artery disease. ↓blood sugar ( listed as a side effect)

Take only for 14 days to ↓ Acid reflux. Within 4months break before next dose. ↓bad cholesterol ( low-density lipoprotein or LDL) ↑ good cholesterol ( high-density lipoprotein or HDL) Treat DM1. Used from children 6y/o and up. Long lasting -keeps working evenly for 24hrs, no peaks Pt will maintain adequate

© 2016 Keith Rischer/www.KeithRN.com

levels of blood sugar at night. Fast-acting insulin No meds to treat HX of: *Anemia *diabetic retinopathy, or diabetic nephropathy. Both can be mngt or slow effects by pt compliance with insulin regimen.

One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her life? • •

Circle what PMH problem started FIRST NM1 at 12 y/o. hyperlipidemia, anxiety Underline what PMH problem(s) FOLLOWED as dominoes diabetic retinopathy, diabetic nephropathy, hypertension, neuropathy, coronary artery disease, depression, anemia

Patient Care Begins Current VS: T: 101.6 F/38.7 C (oral) P: 114 (regular) R: 24 (regular/deep) BP: 102/66 O2 sat: 90% Room air

P-Q-R-S-T Pain Assessment (5th VS): Provoking/Palliative: Coughing and deep breathing/Not coughing Sharp Quality: Right chest Region/Radiation: 5/10 Severity: Intermittent Timing:

What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: ↑temp Signs of infection. Body is fighting it. Probably respiratory infection as evidence of ↓ oxygen sat ↓oxygenation due to impaired gas exchange. ↑pulse

Tachycardia and tachypnea due to infection and ↑of glucose on blood. Blood is thick, hard to be pump it by the heart (tachycardia).

↑respirations Pt hyperventilating ↓BP BP is low indicative of lack of fluid/dehydration/fluid volume deficit

Pain assessment: Sharp R chest pain 5/10 Intermittent

Pain does not allow pt to breath normal, fluid on lungs impair gas exchange Pt has symptoms of DKA : hard respirations, ↓ O2, ↓BP, chest pain

© 2016 Keith Rischer/www.KeithRN.com

Cough/deep breathing

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN:

Appears anxious and uncomfortable, body tense, occasional grimacing Breath sounds clear with coarse crackles in RLL , nonlabored respiratory effort, harsh productive cough with thick yellow phlegm visualized Pink, warm & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants, nausea is persistent Frequency of urination, urine clear in color, denies painful or burning when voids Skin integrity intact, lips dry, oral mucosa dry–tacky

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: - Pt in pain - Pt anxious, uncomfortable, tense, occasional grimacing - Respiration normal with coarse - Pt has a lower resp infection, it may be pneumonia. crackles on RLL, nonlabored resp - No cardiac abnormalities, able to palpate radial and pedal pulse, no effort, cough with yellow sputum edema - Cardiac normal findings -

Neuro LOCx4

-No abdominal pain, soft-tender. nausea -

No UTI present, pt urinating frequently Skin integrity intact but dry lips and mucosa

12 Lead EKG:

© 2016 Keith Rischer/www.KeithRN.com

-

Pt is current able to understand and cooperate during her visit. No indicative of shock, or coma.

-

Nausea and vomit due to metabolic acidosis/DKA. Pt mentioned she has been vomiting, fluid depletion, electrolyte imbalance.

-

Pt losing fluids through urine. Flushing out electrolytes

-

Pt is dehydrated

Interpretation: Hr 140 Clinical Significance:

Radiology Reports: Chest x-ray What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: Right lower lobe infiltrate. Sign of lung infection: pneumonia

Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Complete Blood Count (CBC): WBC (4.5–11.0 mm 3) Hgb (12–16 g/dL) Platelets (150–450x 103/µl) Neutrophil % (42–72) Band forms (3–5%)

Current: 15.2 11.8 155 92 3

High/Low/WNL? ↑ ↓ Normal trending ↓ ↑ Normal trending ↑

Prior: 9.8 11.2 162 70 1

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: WBC & Neutrophil ↑

Pt’s immune system is fighting infection

Hgb ↓

Levels are low but slowly ↑ from last lab due to the body’s need to get O2, since impaired gas in present. Body producing Hgb to compensate for the lack of O2 on tissues, body thinks it need to produce more to carry O2 due to the

© 2016 Keith Rischer/www.KeithRN.com

Improve/Worsening/Stable: Worsening Improving

starving cells for O2 Platelets and band form Within normal limits

Band forms ↑ due to production of WBC to combat infection Worsening due to pt combating infection for a while

Basic Metabolic Panel (BMP): Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) CO2 (Bicarb) (21–31 mmol/L) Glucose (70–110 mg/dL) BUN (7–25 mg/dl) Creatinine (0.6–1.2 mg/dL) GFR (>60 mL/min) Misc. Labs: Lactate (0.5–2.2 mmol/L)

Current: 122 6.4 11 729 56 2.4 20 2.8

High/Low/WNL? ↓ ↑ ↓ ↑ ↑ ↑ ↓ ↑

Prior: 138 4.2 25 168 42 1.9 38 n/a

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Na ↓

Pt losing fluid due to emesis, dehydration, ↑glucose levels on blood, constant urination. pt in DKA electrolyte imbalance

K↑

hyperkalemia, heart failure

CO2 ↓

metabolic acidosis/ buffer system trying to compensate to raise pH levels to normal.

ALL worsening

RESOURCE: https://acutecaretesting.org/en/articles/diabeticketoacidosis

Glucose ↑ DKA crisis, risk for coma BUN/Creatine ↑ & GFR Kidney failure, congruent with Pt diagnosis Lactate↑ potential sepsis/shock

RELEVANT Lab(s): Na ↓ Urine Analysis (UA):

Clinical Significance:

TREND: Improve/Worsening/Stable: Pt losing fluid due to emesis, dehydration, ALL worsening ↑glucose levels on blood, constant Current: WNL/Abnormal?

Color (yellow) Clear hyperkalemia, heart failure Clarity (clear) Cloudy K↑ Specific Gravity (1.015–1.030) 1.005 metabolic acidosis Protein Positive CO2 ↓ (neg) Glucose (neg) >1000 DKA crisis, risk for coma Ketones ↑(neg) Large Glucose Bilirubin (neg) Negative BUN/Creatine dehydration Blood (neg) ↑ & GFR Kidney failure, Negative Nitrite (neg) Negative Lactate↑ potential sepsis/shock LET (Leukocyte Esterase) (neg) Negative MICRO RBCs (...