Sim lab diabetic ketoacidosis-2 PDF

Preview

Summary

simulation lab
diabetic ketoacidosis DKA
Nursing 300 N300 Gates...

Description

Catherine Preli Nursing 300 ● Describe the pathophysiologic changes in DKA. ○ Marked by the absence or inadequate presence of insulin ○ Features include: hyperglycemia, dehydration and electrolyte loss, and acidosis ● What are the commonly seen blood glucose levels? ○ Blood glucose levels vary between 300-800 mg/dL ○ Some have lower, some have values of 1000 mg/dL (usually depending on the degree of dehydration ● What fluid and electrolyte disturbances commonly occur and why? ○ With severe DKA may lose up to 6.5 L of water and up to 400-500 mEq each of sodium, potassium, and chloride. In an attempt to rid the body of excess glucose, kidneys excrete more (this includes glucose, water, and electrolytes). ● What acid-base disturbances commonly occur and why? ○ The lack of glucose being brought into the cells leave a need for energy, so there is a breakdown of fat that turns into free fatty acids and glycerol. The free fatty acids are converted into ketone bodies, which are acids. This leads to metabolic acidosis. ○ The commonly seen ones are HCO3, serum P ● Describe the medical management and nursing management of a patient in DKA. ○ Rehydration to maintain tissue perfusion and enhance excretion of excessive glucose ■ May need as much as 6-10 L of IV fluid to replace fluid losses ■ Start with .9% sodium chloride (NS) at a rapid rate (~ .5-1 L per hour for 2-3 hours) ■ .45% solution (hypotonic saline) for continue rehydration if BP is stable and sodium levels are low ● Moderate to high rates 200-500 mL per hour ● When BG reaches 300 mg/dL or less, IV solution may be changed to D5W to slow decline of glucose ■ Important to monitor signs of fluid overload ○ Restoring Electrolytes ■ Major concern is potassium, tends to be high ● Can be decreased by rehydration ● Cautious but timely potassium replacement is vital to avoid dysrhythmias that may occur with hypokalemia ○ Reversing Acidosis ■ Ketone bodies accumulate as a result of fat breakdown causing acidosis. This is reversed by insulin which inhibits fat breakdown, ending ketone production and acid buildup. ■ Regular insulin is the only type of insulin approved for IV use. ● How is fluid status monitored in the acute stage of DKA?

●

●

● ●

●

●

●

●

●

○ Frequent measurements of vital signs this includes monitoring for orthostatic changes in blood pressure and heart rate, lung assessment, and monitoring of intake and output are needed. How is hypovolemia corrected? How rapidly is uid volume replaced? Why? ○ Hypovolemia should be corrected by the administration of 1 L NS over 30-60 min and add a second L if needed ○ Then ½ NS should be administered. ○ D5 ½ NS should be administered when BG is 250 mg/dL or higher. How are the complications of fluid replacement prevented? ○ Plasma expanders may be needed to correct severe hypotension that isn’t corrected by IV fluid treatment. ○ A nurse needs to monitor for signs of fluid overload is really important for older patients, or who have renal impairment, or for patients who are at risk for heart failure. How are blood glucose levels monitored? How often? ○ Ever hour blood glucose levels should be monitored. How are elevated blood glucose levels corrected? ○ They are given insulin drip until ready to give a subcutaneous insulin injection. When the patient has bowel sounds, is awake, and is able to tolerate food, insulin is administered subcutaneously as prescribed. What is the relationship between insulin and IV tubing? ○ Regular insulin is the only insulin that is approved for IV administration. ○ Also when hanging an insulin drip, a nurse needs to flush the insulin solution through the entire IV infusion set and discard the first 50 mL of fluid. Insulin molecules adhere to the inner surface of plastic IV infusion sets; therefore, the initial fluid may contain a decreased concentration of insulin. How quickly is blood glucose corrected? Why? ○ The onset of regular insulin IV is 10-30 min, the peak is 15-30 min, and the duration is 30-60 minutes after administration. What electrolytes are monitored in the acute stage of DKA? Why? ○ Potassium, sodium, and chloride are monitored since they are excreted frequently and depleted. ○ Potassium needs to be monitored to prevent dysrhythmias that could occur with hypokalemia. ○ Frequent electrocardiograms and measures of potassium are used to monitor possible complications. How are electrolyte imbalances corrected? How rapidly is this accomplished? Why? How are complications of electrolyte replacement prevented? ○ Administration of potassium is necessary. This is aided by rehydration. Also insulin administration causes the movement of potassium into cells. ○ As much as 40 mEq per hour of K may be needed. Potassium must be infused even if plasma level is normal since it is depleted with treatment. ○ Sodium levels are corrected with the fluid replacement of normal saline. How are acid-base disturbances monitored? How often? ○ Hourly blood glucose levels are measured since insulin reverses the acidosis.

○ Sodium bicarbonate levels are monitored, we want it to be at least 15-18 mEq/L before stopping IV insulin. ● How are acid-base disturbances corrected? How quickly is this accomplished? Why? How are complications of acid-base correction prevented? ○ Insulin reverses the acidosis. It is infused at a slow, continuous rate, like about 5 units per hour. ○ IV fluid solution with higher concentrations of glucose (like D5NS or D5.45NS) are used when BG levels reach 240-300 mg/dL to avoid a drop and hypoglycemia. ○ IV insulin is continued for 12-24 hours until sodium bicarbonate is at an appropriate level. ● Define the following terms and describe how the results of each are used: anion gap, serum osmolality and venous carbon dioxide. ○ Anion gap: the measured difference between positively charged ions and negatively charged ions in blood serum, used to identify the type of metabolic acidosis (if the gap is greater than normal, high anion gap metabolic acidosis is present) ■ Normal range: 8-12 mmol/L ■ lactic acidosis, ketoacidosis, toxins, renal failure causes a high anion gap metabolic acidosis ○ Serum osmolality: ■ Normal range: 285-293 mOsm/kg H2O ■ The osmotic concentration of serum ■ Lower would be present in overhydration, or edema and increased would indicate fluid volume deficit ■ In DKA, it is commonly 300-350 mOsm/L ○ Venous carbon dioxide: ■ Normal: 23-29 mEq/L ■ Determines if there is excessive or insufficient CO2 levels ■ Would be decreased in DKA as a response to build up of ketoacids...