DKA Simulation - SCJHAKJDHA PDF

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Location: Emergency Department

Diabetic Ketoacidosis, Care of the Adult Patient in

ECS® Program for Nursing Curriculum Integration (PNCI™)

Si m u l a t e d C l i n i c a l E x p e r i e n c e ( SC E ™ ) O v e r v i e w

History/Information: A 36 year old man, was admitted to the Emergency Department after his wife found him confused and agitated in their apartment. According to his wife, he was diagnosed with Type I (insulin-dependent) diabetes mellitus 12 months ago. He was taking 48units of insulin daily: 12units of Humulin Regular plus 20units of Humulin NPH before breakfast; 8units of Humulin Regular before dinner; and 8units of Humulin NPH at bedtime. She states he has had "the flu" for 5 days with vomiting and anorexia and stopped taking his insulin 2 days ago when he was unable to eat. The paramedics started a saline lock in the right forearm and administered 250mL of 0.9% NS en route to the hospital.

Learning Objectives

1. Formulates a nursing plan of care based upon the pathophysiology of DKA (SYNTHESIS). 2. Designs an individualized plan of care for the nursing management of a patient in DKA (SYNTHESIS). 3. Prioritizes the implementation and approach to the nursing care of a patient in DKA (ANALYSIS). 4. Evaluates the patient’s response to interventions and modifies the nursing care as appropriate for the patient in DKA (EVALUATION).

Healthcare Provider’s Orders: Capillary glucose STAT Urine dipstick for ketones STAT CBC, electrolytes, BUN, creatinine, glucose, phosphate, magnesium, calcium, and anion gap STAT ABG STAT Urinalysis STAT Blood cultures x2 now Urine culture and sensitivity now Portable chest x-ray STAT 12-lead ECG STAT Urinary catheter Continuous SpO2 monitoring O2 per nasal cannula at 2LPM Maintain SpO2 greater than 92% Continuous cardiac monitoring Vital signs and level of consciousness every 1 hour Intake and Output every 1 hour Electrolytes, BUN, creatinine, glucose, and anion gap every 1 hour IV #1 0.9% NS at rate of 1L/hour

Learner

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2. Describe the medical management of a patient in DKA. a. How is fluid status monitored in the acute stage of DKA? b. How is hypovolemia corrected? How rapidly is fluid volume replaced? Why? c. How are blood glucose levels monitored? How often? d. How are elevated blood glucose levels corrected? e. How quickly is blood glucose corrected? Why? 3. What electrolytes are monitored in the acute stage of DKA? Why? a. How are electrolyte imbalances corrected? How rapidly is this accomplished? Why? b. How are acid-base disturbances monitored? How often? c. How are acid-base disturbances corrected? How quickly is this accomplished? Why? 4. Describe the nursing management of a patient in DKA. a. How is fluid status assessed? How often? b. What are the complications of fluid replacement and how are they prevented? c. How are blood glucose levels assessed? How often? d. What are the complications of lowering blood glucose levels and how are they prevented? e. How are electrolyte disturbances assessed? How often? f. What are the complications of electrolyte replacement and how are they prevented? g. How are acid-base disturbances assessed? How often? h. What are the complications of acid-base correction and how are they prevented? i. Define anion gap, serum osmolality and venous CO2. j. How are serial anion gaps, serum osmolalities and venous CO2 results used?

ACP’s PIER: The Physician’s Information and Education Resource. (2004). Diabetic ketoacidosis. Retrieved August 11, 2004, from STAT! Ref Online Electronic Medical Library at http://pier.acponline.org Bernal-Mizrachi, E., and Bernal-Mizrachi, C. (2004) Diabetes mellitus and related disorders. In G. B. Green, I. S. Harris, G. A. Lin, and K. Moylan (Eds.). The Washington manual of medical therapeutics (31st ed.) (pp. 470-487). Philadelphia: Lippincott Williams and Wilkins. Chansky, M. E., and Lubkin, C. L. (2004). Diabetic ketoacidosis. In Emergency medicine: A comprehensive study guide. Retrieved August 11, 2004, from STAT! Ref Online Electronic Medical Library at http://pier.aconline.org Giles, H., and Vijayan, A. (2004). Fluid and electrolyte management. In G. B Green, I. S. Harris, G. A. Lin, and K. Moylan (Eds.). The Washington manual of medical therapeutics (31st ed.) (39-71). Philadelphia: Lippincott Williams and Wilkins. Guyton, A. C., and Hall, J. E. (2006). Textbook of medical physiology (11th ed.). Philadelphia: W. B. Saunders Company. Joanna Briggs Institute for Evidence Based Nursing and Midwifery. (1999). Best practice: Vital signs, 3(3). Retrieved May 30, 2005 from http://www. joannabriggs.edu.au/best_practice/bp8.php McGee, S. (2001). Evidence-based physical diagnosis. Philadelphia: Saunders. Pagana, K. D., and Pagana, T. J. (2006). Mosby's manual of diagnostic and laboratory tests (3rd ed.). St. Louis: Mosby, Inc. Springhouse. (2003). Best practices: A guide to excellence in nursing care. Philadelphia: Lippincott Williams and Wilkins.

Learner

© 2005 METI, Sarasota, FL; Authors: Dr. Christine Garza, Texas Woman’s University-Dallas and Thomas J. Doyle, METI. Rev 2 December 2005

1. Describe the pathophysiologic changes in DKA. a. Why do blood glucose levels increase? b. What are commonly seen blood glucose levels? c. What fluid and electrolyte disturbances commonly occur? d. What causes the fluid and electrolyte disturbances? e. What acid-base disturbances are commonly seen? f. Why do the acid-base disturbances occur?

References

Diabetic Ketoacidosis, Care of the Adult Patient in

Q u e s t i o n s t o P r e p a r e f o r t h e Si m u l a t e d C l i n i c a l E x p e r i e n c e

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