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DKA keithRN case study...

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Diabetic Ketoacidosis (DKA)

Diana Humphries, 45 years old

Primary Concept Fluid and Electrolyte Balance Interrelated Concepts (In order of emphasis) 1. 2. 3. 4. 5. 6. 7. 8.

© 2016 Keith Rischer/www.KeithRN.com

Acid-Base Balance Glucose Regulation Infection Pain Clinical Judgment Patient Education Communication Collaboration

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: 45 years old, chronic kidney disease stage 3, Pt is presenting with signs of elevated bs and diabetic ketoacidosis. type 1 diabetes, checks bs daily. Nausea 12 Missing the dose of insulin increased the bs overnight, the bs is too high hours, cough with yellow sputum 3 days. 382 for her meter to read. The pt is nausea, cannot keep any food down. The pt has increased thirst and increased urination, signs of DKA. Pt has a cough bs, missed her nighttime insulin. Abdominal pain, nausea, vomit x3. Unable to read bs due toand yellow sputum sign of infection? being too high. 10 units of Humalog. Cannot eat. Increased thirst. Increased urination. Bs still too high to be read at lunchtime.

RELEVANT Data from Social History: Clinical Significance: Anxiety, depression, worsen after mother died 3Pt is showing signs of wanting to give up, and expressing what is the point months ago. Inconsistent with meds. She feels in living since she is going to die anyway. She is homeless with no support like 200 is a good bs. Homeless, ssi, disability, system. She has an altered idea of what a good bs is, poor education? She said she said going to die anyway why does it is facing depression, which seems to be worsening. all matter?

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: NSAID Reduce chances of blood clot  Chronic Kidney disease 1. Aspirin 81mg PO daily stage III (diabetic 2 .Lisinopril 10 mg PO daily ACE Reduce bp nephropathy) Benzo Reduce anxiety 3. Lorazepam 1mg PO bid  Anemia prn  Diabetes mellitus type 1 4. Citalopram 40 PO mg SSRI Reduce depression since age 12 daily  Diabetic retinopathy Sleep aid 5. Zolpidem 10 mg PO at HS Sedative  Neuropathy in lower legs prn  Hyperlipidemia Anticonvulsant Prevent seizure, neuropathy 6. Gabapentin 300 mg PO  Hypertension pain bid  Coronary artery disease 7. Labetalol 200 mg PO bid Beta blocker Proton pump inhibitor  Gastroesophageal reflux Reduce bp 8. Omeprazole 20 mg PO disease (GERD) Reduce acid levels daily  Anxiety 9 .Simvastatin 40 mg PO HS Statin Reduce cholesterol 10. Glargine insulin 50 units Long acting insulin Reduce BS  Depression SQ at HS 11. Lispro insulin SQ sliding Rapid acting insulin Reduce BS scale AC and HS

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

See above 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 started first  Underline what PMH problem(s) FOLLOWED as dominoes high bp, anxiety, depression followed

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: Signs of infection T elevated Signs of struggling to breathe P elevated Signs of pain R evelated Bp low O2 low Pain present 5/10

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: Anxious, tense, crackles, cough with Pt is showing signs of not breathing well, having crackles in her lungs, fluid yellow sputum, nausea, frequent urination overload? clear, dry mucosa. Pt has excess clear urine, DKA Pt has dry mucosa, dehydration.

12 Lead EKG:

Interpretation: We have not done 12 leads but it looks like high potassium level with t wave peak. Looks like different rhythms going on, lack of oxygen, elevated heart rate. Clinical Significance: The strip is showing that there is dysrhythmias possible low oxygen to heart, elevated potassium, and an increased HR.

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.

Fluid or pus in lungs, matches with sputum production.

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 Low Wnl-low 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: Wbc high Hgb low Platelets wnl/low Neutrophils high Bands wnl

Improve/Worsening/Stable: All worsening

Signs of infection present

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

Low High Low High High High Low

High/Low/WNL?

Prior: 138 4.2 25 168 42 1.9 38

2.8

high

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: Sodium low Pot high Bicarb low Gluc high BUN high Creat high GFR low Lactate high

All worsening Dehydration Monitor for heart abnormalities- dehydration Acidosis Elevated bs Kindeys not working Kidneys not working Kidneys not working Lack of o2, disease worsening, lactate build up

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)

8.6 50 2.2 24

wnl high high low

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 low Potassium high Chloride high Co2 low Gluc high BUN high Creat high GFR low

Aldosterone deficiency? Dehydration “ “ Dehydration, kidney disease DKA DKA Kidney failure Kidney failure Kidney failure

Improving Improving Worsening Improving Improving Improving Improving Improving

12 Lead EKG:

Interpretation: We haven’t done 12 leads. This looks like there is depressed t waves, and possible pvcs Clinical Significance: Monitor pt electrolytes

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: Temp- high Temp improving it has decreased p- wnl Pulse improving r- wnl / high Resp improving bp- systolic high diastolic low Bp- improving but going the other way o2 low O2 worsening pain Pain improving RELEVANT Assessment Data: No distress Crackles

Clinical Significance: All symptoms improving at this point

2. Has the status improved or not as expected to this point?

Improved except bp possibly going the other way 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

Continue to monitor pt, closely monitor BP 4. Based on your current evaluation, what are your nursing priorities and plan of care?

Monitor patient for changes in mental status, monitor cardiovascular system and pulmonary system. Monitor pt bs and infection symptoms.

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: Pt presented to ER with signs of DKA, kidney failure, and infection

Day of admission/post-op #: 1

Background: Primary problem/diagnosis: DKA RELEVANT past medical history: pt has unmanaged diabetes, kidney disease, and depression

RELEVANT background data: Pt is homeless, depressed, doesn’t express a desire to continue living, and has poor understanding of diabetes management.

Assessment: Current vital signs:

T 100.2 P 88 R 20 regular Bp 124/70 O2 94% Pain 2 RELEVANT body system nursing assessment data:

Cardio, pulmonary, mental status, blood sugar, infection signs RELEVANT lab values: Sodium 125 Potassium 5.1 Chloride 106

Bicarb 18 Glucose 578 Calcium 8.6 BUN 50 Creatinine 2.2 GFR 24 TREND of any abnormal clinical data (stable-increasing/decreasing): Sodium, potassium, bicarb, glucose, calcium, bun, creat, gfr are all increasing towards stabilization. Chloride decreasing towards stabilization How have you advanced the plan of care? Continue to monitor pt and administer meds Patient response: Pt is responding well to medication management as evident of labs beginning to stabalize INTERPRETATION of current clinical status (stable/unstable/worsening): Improving slowly

Recommendation: Suggestions to advance plan of care: Continue to monitor patient closely

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?

Strict medication regimen, medication management and education

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?

Using the teach back method. Helping her come up with a plan in order to get access to her medications and how and when to take them. Get social work involved.

Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation?

Hopefully the patient is feeling more hopeful with their outcome. Since pt is homeless, they could be worried about being released from the hospital, since pt had expressed before that she was going to die anyway and didn’t know the point the patient could be wondering why it wasn’t her time to go already.

2. What can you do to engage yourself with this patient’s experience and show that he/she matters to you as a person?

Get to know her on a personal level, spend time asking her questions, answer all of her questions, take time to explain everything.

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?

How severe DKA can be, also how in combination with kidney failure and an infection there is just SO much going on, you need to really be able to prioritize and work on multiple systems all at once.

2. How can I use what has been learned from this scenario to improve patient care in the future? Realizing that just because a pt comes in for one reason doesn’t mean there isn’t more that could be going on that we didn’t see originally and working to treat it all....