DKA Case Study clinical reasoning PDF

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Diabetic Ketoacidosis Case Study...

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Jenna Vest, Kaylee Locker, Aida Gutierrez

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

© 2016 Keith Rischer/www.KeithRN.com

UNFOLDING Reasoning Case Study: STUDENT

Diabetic Ketoacidosis (DKA) History of Present Problem: 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? RELEVANT Data from Present Problem: Clinical Significance:

Missed dialysis

waste products will accumulate (including potassium) and fluid imbalance

Persistent nausea, large emesis

Red flag for DKA in a diabetic patient on dialysis

Cough, yellow sputum

Colored sputum is indicative of infection, in this case possible pneumonia. Pneumonia increases the likelihood of DKA in a diabetic patient

Missed dose of Lantus Lantus is a long acting insulin. The short acting insulin (Humalog) she took in the morning could not regain control of her blood sugar alone. Glucometer unable to register Most glucometers have an ability to read up to 500, an inability to register means an extremely high blood glucose.

RELEVANT Data from Social History:

Clinical Significance:

Inconsistent with medical/diabetic regimen

Inability to maintain health status, inability to adhere to medication regimen

Anxiety/Depression

Lack of self-care, inability to learn

Denial of issue/knowledge deficit

Inability to comprehend education, lack of knowledge on disease and appropriate treatment

Homeless/Shelter/disability Lack of resources, lack of stability © 2016 Keith Rischer/www.KeithRN.com

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. Classification: Expected Outcome: • Chronic Kidney disease 1. Salicylate 1. Low dose aspirin helps 1. Aspirin 81mg PO daily stage III (diabetic 2 .Lisinopril 10 mg PO daily 2.ACE inihibitor prevent cardiac events nephropathy) 3. Lorazepam 1mg PO bid 2.Reduce blood pressure, 3. Benzodiazepine • Anemia prn reduce CAD events 4. SSRI • Diabetes mellitus type 1 4. Citalopram 40 PO mg daily 3. Sedate/reduce anxiety 5. Nonbenzodiazepine 5. Zolpidem 10 mg PO at HS since age 12 4. Anti-depressant 6. Anticonvulsant, GABA prn • Diabetic retinopathy 5. Aid with sleep analogue • Neuropathy in lower legs 6. Gabapentin 300 mg PO bid 6. Reduce nerve pain 7. Beta Blocker 7. Labetalol 200 mg PO bid 8. 8. Proton Pump Inhibitor • Hyperlipidemia 7. Reduce Blood Pressure Omeprazole 20 mg PO daily • Hypertension 8. Reduce symptoms of 9. HMG-CoA reductase 9 .Simvastatin 40 mg PO HS • Coronary artery disease GERD inhibitor, “statin” • Gastroesophageal reflux 10. Glargine insulin 50 units 9. Reduction of cholesterol 10. Long acting Insulin SQ at HS disease (GERD) production 11. Short acting Insulin 11. Lispro insulin SQ sliding • Anxiety 10. Glucose management scale AC and HS • Depression 11. Glucose management

What medications treat which conditions? Draw a line to identify what illness is being managed by what medication?

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 --- Diabetes Type 1 • Underline what PMH problem(s) FOLLOWED as dominoes --- Everything else

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 RELEVANT VS Data: R: Temp 101.6 R: Elevated Pulse 114 R: Respiration 24 R: Low BP R: O2 Sat 90%

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: Clinical Significance: Patient has an elevated temperature which is the classic inflammatory response to infection Patient is likely dehydrated which can elevate the HR + coughing and difficulty breathing Patient has a low O2 sat, breathing quicker with pain in the right chest, evidence of pleural pain (possible pneumonia) The patient’s HR is high, trying to compensate and bring up the blood pressure. The patient is not breathing enough oxygen on her own, 90% is too low. This may be additional evidence of pneumonia

© 2016 Keith Rischer/www.KeithRN.com

What VS data is RELEVANT and must be recognized as clinically significant by the nurse?

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: Occasional Grimacing Pain in right chest consistent with pleural pain, not cardiac, suggestive of pneumonia Coarse Crackles, harsh productive cough, Evidence of an infection in the lungs, suggestive of pneumonia yellow thick phlegm Persistent nausea Minimal Urine Output

A diabetic with uncontrolled high blood sugar levels will have persistent nausea Compromised kidney function, fluid overload

Dry-tacky mucosa

Suggestive of dehydration

12 Lead EKG:

Interpretation: Tall tented T waves © 2016 Keith Rischer/www.KeithRN.com

U waves, ST elevation Clinical Significance: Tall tented T waves are consistent with Hyperkalemia U waves are consistent with an electrolyte imbalance ST elevation

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.

Consistent with finding of crackles upon auscultation Evidence of 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? High WNL WNL High WNL

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: Improve/Worsening/Stable: WBC

High, expected due to infection

Worsening

Neutrophils

High, first responders to an infection

Worsening

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

High/Low/WNL? Low High Low High High High Low

Prior: 138 4.2 25 168 42 1.9 38

2.8

WNL

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:

© 2016 Keith Rischer/www.KeithRN.com

Sodium Potassium CO2 Glucose

Low due to loss of free water High- causing dysrhythmias in the heart Low- patient is acidotic High- patient is diabetic, missed insulin doses Consistent with DKA High- missed dialysis, consistent with patient With CKD High- Consistent with CKD, DKA Low- Consistent with CKD

Creatinine BUN GFR

Urine Analysis (UA): Color (yellow) Clarity (clear) Specific Gravity (1.015–1.030) Protein (neg) Glucose (neg) Ketones (neg) Bilirubin (neg) Blood (neg) Nitrite (neg) LET (Leukocyte Esterase) (neg) MICRO RBCs (60 mL/min)

Current: 125 5.1 106 18 578 8.6 50 2.2 24

High/Low/WNL? Low WNL WNL Low High WNL High High Low

Prior: 122 6.4 98 11 729 8.4 56 2.4 20

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Sodium Potassium CO2 Glucose BUN Creatinine GFR

Low due to loss of free water Within normal range Low- patient is acidotic High- Consistent with DKA High- missed dialysis, consistent with CKD High- Consistent with CKD, DKA Low- Consistent with CKD

12 Lead EKG:

© 2016 Keith Rischer/www.KeithRN.com

Improving Stable Improving Improving Improving Improving Improving

Interpretation: No tenting in T waves ST elevation Clinical Significance: Heart rate is coming down, trying to regulate

Current VS:

Most Recent:

Current WILDA:

T: 100.2 F/37.9 C (oral) P: 88 (regular) R: 20 (regular) BP: 124/70 O2 sat: 94% 2 liters n/c

T: 101.6 F/38.7 C (oral) P: 114 (regular) R 24 (regular) BP: 102/66 O2 sat: 95% 2 liters n/c

Words: Intensity: Location: Duration: Aggravate: Alleviate:

sharp 2/10 Right chest Intermittent Coughing and deep breathing Not coughing and breathing shallow

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

Resting comfortably, appears in no acute distress Breath sounds clear coarse crackles RLL, nonlabored respiratory effort Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, 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, no nausea or abdominal pain Urine clear and yellow. 250 mL the past 8 hours Skin integrity intact, lips dry, but oral mucosa is moist

1. What clinical data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: © 2016 Keith Rischer/www.KeithRN.com

D: Temp R: Pulse R: Respirations R: BP R: O2 Sat

Has infection, temp will be elevated HR in normal range Improved, less difficulty breathing Improved, within a more normal range vs. low Improved, O2 supplementation, less difficulty breathing

RELEVANT Assessment Data: General Appearance

Clinical Significance: Patient does not appear in pain, resting comfortably, treatment improving state Crackles remain due to pneumonia, nonlabored breathing, O2 helping Improved pulse, sounds, no edema Relief from nausea Increased quality and output Increased hydration

Resp Cardiac GI GU Skin

2. Has the status improved or not as expected to this point? Patient status has improved, trending in the right direction 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? Patient is still volume depleted and glucose is still very high. Need to continue to treat patient, assess, and monitor progress. 4. Based on your current evaluation, what are your nursing priorities and plan of care? Monitor vitals, monitor glucose, monitor patient psychosocial status and comfort.

Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient in ICU:

Situation: Name/age: Diana Humphries 45 years old BRIEF summary of primary problem: Patient presented with complications of CKD due to missed dialysis treatment, as well as DKA from ineffective treatment adherence. Patient had cardiac irregularities from hyperkalemia and fluid imbalance complications. Glucose was over 700, last check was 578, potassium level has stabilized. Patient presented with 90% O2 sat that has improved with supplementation to 94%, evidence of pneumonia in the RLL with crackles upon auscultation. Patient due for dialysis treatment. Patient is trending in the right direction but needs close monitoring of respiratory and cardiac systems as well as recurrent vitals and labs.

Day of admission/post-op #: 1

Background: © 2016 Keith Rischer/www.KeithRN.com

Primary problem/diagnosis: RELEVANT past medical history: History of CKD, history of Diabetes type 1, since age 12.

RELEVANT background data: History of poor health maintenance, ineffective medication and treatment adherence, history of homelessness, depression, and anxiety.

Assessment: Current vital signs: Temp 100.2, pulse 88, resp 20, BP 148/84, O2 sat 95%

RELEVANT body system nursing assessment data: respiratory, cardiac, vitals

RELEVANT lab values: Potassium 5.1, Glucose 578, Sodium 125, Creatinine 2.2, BUN 50

TREND of any abnormal clinical data (stable-increasing/decreasing): Potassium stable, Sodium increasing, Glucose decreasing, Creatinine decreasing, BUN decreasing How have you advanced the plan of care? Patient remains on therapeutic plan and is trending in the right direction, will continue to treat and monitor Patient response: Patient is less anxious, appears in less pain, is resting comfortably, is Alert and Oriented X 3, is tolerating treatment well, and steadily improving INTERPRETATION of current clinical status (stable/unstable/worsening): Stable

Recommendation: Suggestions to advance plan of care: Follow up with collaborative team, repeat labs, reassess patient status

Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with her medical condition to prevent future readmission with the same problem? Patient teaching about current chronic diseases and appropriate maintenance, therapeutic actions to take, medication adherence, and social support. 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? Include the patient in your teaching and discussion. Find out simple ways it may be easier for her to adhere to treatment that fit into her lifestyle. Give the patient tips for remembering her medications and appointments like a Pill box by day of the week and a planner. Have the patient write things down and read them back to you.

© 2016 Keith Rischer/www.KeithRN.com

Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? The patient may be feeling anxious and overwhelmed- like this is all too much for her to handle, especially if she has limited resources and/or support. 2. What can you do to engage yourself with this patient’s experience and show that he/she matters to you as a person? Talk with the patient about what obstacles she faces in caring for herself and adhering to treatment. Empathize with her situation and try to provide easy logical solutions. Provide the patient with emotional support and any information about resources that may help her once she is discharged,

Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? The patient’s situation makes it hard for her to adhere to her treatment. Her chronic conditions can cause a quick overall decline and cascade of issues if she misses her daily treatments and medications. The patient needs support and guidance in order to adhere to ger treatment. The patient needs additional resources and social and emotional support. 2. How can I use what has been learned from this scenario to improve patient care in the future? This scenario highlights what to look for in diabetic patients and patients with chronic kidney disease. It is easy to see how one issue can cause a series of subsequent problems, and how daily treatment is vital to the patient’s overall health. This scenario taught what values and signs and symptoms to look for, prioritize, and address from beginning to end.

© 2016 Keith Rischer/www.KeithRN.com...