DIABETIC KETOACIDOSIS

Nathan Vince Cruz

Jameelah Tamayo

Jan Abigaile Salisi

Lyka Mae Retuya

Charanjit Sangar

Jaqui Villanueva

Cherry Rey

Arvy Rebamonte

Teresa Vinoya

Hazel Ydeo

Jeric Quinto

Micka Rivera

Lyceum-Northwestern UniversityCollege Of Nursing

BS Nursing - II

IntroductionThis is the case of an 18 year old male that was diagnosed with Diabetic Ketoacidosis, (commonly termed “DKA”) with preexisting Chronic Kidney Disease. Diabetic ketoacidosis (DKA) can be an acute or major complication of diabetes that mainly occurs in patients with type 1 diabetes, such as our subject “Bryan Mejia”, but it is not uncommonly seen in patients with type 2 diabetes.

This condition deals with the imbalanced metabolism of the body, more specifically the shortage of insulin, causing the rejection of glucose into the body cells. In order to make up for the energy loss, fats are broken down for energy in the liver through a process called ketogenesis, resulting in the release of the acidic compounds called “ketones” as a byproduct. As ketones build up, this causes the body to become acidic (hence the term “ketoacidosis”) putting the body at risk for serious, if not fatal complications. In this study we will take you on an in depth tour of the manifestations, signs/symptoms, diagnosis, and treatments of DKA.

Significance of the Study

As DKA effects 130,000 patients every year with a medical cost of 2.4 billion USD (₱105.6

billion), it is crucial that we understand this common complication and are competent in

aiding our clients. The purpose of selecting Diabetic Ketoacidosis with preexisted Chronic

Kidney Disease for our case presentation is so we can incorporate the knowledge gained

from this study with our future case presentations. Doing this will increase our

understanding of common diseases and will aid in determining the proper action and

maintenance taken by us nurses in the field.

By selecting subjects with multiple complications, we have the privilege of exploring the

relationship between two medical complications and the effect one has on the other. This

will be useful to us seeming as many patients have preexisting and underlying conditions

that may be difficult to dodge during treatment. In doing this, we transcend to a new level

of understanding overall patient health.

General Objective

It is the aim of those who prepared this case study to acquire knowledge, experience and learn professional approach to Diabetic Ketoacidosis (DKA) that will be useful in the future as we move forward to become effective nurse both locally and internationally.

Specific objective

•Define Diabetic Ketoacidosis (DKA)

•Raise awareness to local and international nurses so they can be better prepared

• Analysis of Physical Assessment and Laboratory results.

•Discuss the medication taken by the client, its action, side effect and nursing responsibilities.

•Explain the Anatomy and Physiology of the Endocrine System.

•Trace the Pathophysiology of Diabetic Ketoacidosis (DKA).

•Create effective and efficient nursing care plan required by a patient with the above mentioned disease process.

Goals and Objectives

Patient’s name: B.D.M.

Gender: Male

Address: Bonuan Gueset, Dagupan City, Pangasinan

Birth date: February 2, 1996

Age: 18 y/o

Father’s name: J.R.M

Mother’s name: E.D.M.

Nationality: Filipino

Civil Status: Single (child)

Religion: Roman Catholic

Patient type: Pediatric

Admission date: December 23, 2014

Admission time: 11 P.M.

Attending physician: Dr. Q

Admission diagnosis: Diabetic Ketoacidosis w/

Chronic Kidney disease (Stage V)

Final diagnosis: Diabetic Ketoacidosis w/ Chronic

Kidney disease (Stage V)

PATIENT’S PROFILE

Chief Complaint Difficulty of breathing

History of past illness Patient experienced numbness of feet and Sudden weight loss when he was 15 years old.

History of present illness

***Patient was confined 3x

1 week prior to admission- patient noted to have difficulty of breathing and numbness of feet. Consult done, Upon

admission of the patient, he was diagnosed with Diabetic Ketoacidosis (DKA). Urinalysis and blood tests done, ultrasound

done, FBS done, and was diagnosed with Chronic Kidney Disorder Stage V with the doctor’s order and a patient’s signed

consent to started hemodialysis.

PATIENT MEDICAL HISTORY

PERSONAL MEDICAL HISTORY

A. Nutritional HistoryPatient is severely underweight and presents positive signs of malnutrition. He has an imbalanced diet consisting of

salty junk food, as well as soda and fatty substances and is not eating any vegetables as stated by the mother. He also smokes and normally consumes one pack/day.

B. Family medical history

Grandfather - Hypertension and Asthma (Medications not specified) Grandmother – Hypertension and Diabetic (Medications not specified) Father – Asthma (Meds: Oregano and water) Mother –Asthma (Meds: Oregano and water)

ENVIRONMENTAL HISTORY

Patient lives with 5 household members in a congested neighborhood near sea water with no electricity. Source of drinking water and water used for the household is deepwell, garbage is thrown in the bodies of water, toilet is flush type but it is shared between 3-5 families.

FINDINGS NORMAL VALUES ( based on avg. of an 18 year old male) ANALYSIS/INTERPRETATION

HeightWeight BMI

153 cm32.9 kg 32.9 / (1.53m)2 = 14.06

69.267.1BMI:<18.518.5-24.925-29.930-34.935-39.9>40

-The patient is underweight and suffering from severe malnutrition.

Vital Signs BP- 60/30 mmHgTemp- 36.9

PR- 63RR- 20

BP- 100-145 mmHg (systolic) 50-90 mmHg (diastolic)

Temp- 36.1-37.1 (axillary)PR- 60-100RR- 12-20

Due to abnormal circulation of blood

NORMAL NORMALNORMAL

A. GENERAL APPEARANCE/ SURVEYThe client is conscious, coherent, and cognitive.

B. MEASUREMENTS

PHYSICAL ASSESSMENT

Assessment I P PE A Result Significance Indication

Neurological * Responsive GCS score 15/15

(+)conscious (+)coherent (+)cognitiveNORMAL

Skin * (-) lesions NORMAL

* (-)rashes (-)scars

(-)flushing, warm and moist

(+)poor skin turgor

NORMALNORMALABNORMAL

ABNORMAL

Skin is dry due to dehydrationDue to dehydration

Head * Symmetrical NORMAL

* Smooth NORMAL

* (-)masses and depressions NORMAL

Face ***

(-)tenderness round face

(-)no presence of nodules an infestation symmetrical(-) Facial edema

NORMAL

NORMALNORMAL

Hair * Evenly distributed NORMAL

* Fine Black in color

NORMALNORMAL

* * Coarse/dry NORMAL

* (-)lice and nits NORMAL

Scalp * (-)dandruff NORMAL

* (-)scars NORMAL

* (-)tenderness NORMAL

Eyes * (-)wearing eyeglasses NORMAL

* Symmetrical NORMAL

* (-)periorbital edema(-)redness in both eyes

NORMALNORMAL

Nose * Proper olfactory function NORMAL

* Symmetrical NORMAL

* With sense of smell NORMAL

(-)tonsilo pharyngeal congestion NORMAL

Ears * (-)tinnitus NORMAL

* (-)discharges NORMAL

* Gross hearing intact NORMAL

Lips * (-)moist and smooth (-)lesion

ABNORMALNORMAL

Due to dehydration

Mouth * (-)pain NORMAL

Assessment I P PE A Result Significance Indication* (-)lumps/masses NORMAL

* (-)stomatitis NORMAL

Tongue * (+)moist (+)pink in color

NORMALNORMAL

* (-)masses NORMAL

* (-)tenderness (-)deviation to the side of the mouth

NORMALNORMAL

Chest * *

(-)mass noted (-)dull sound

NORMALNORMAL

* Brown colored nipples NORMAL

* (-)sagging of breast NORMAL

* (-) Inversion of nipples (-)nipple discharges

(-)lesion (-)mass

NORMALNORMALNORMALNORMAL

* Symmetrical chest expansion NORMAL

Cardiovascular * Heart sounds NORMAL

Upper extremities

* * (-)lesion NORMAL

* (-)masses (-)numbness at right arm

(+)nail beds

NORMALNORMALNORMAL

Abdomen * * * * (-)large abdomen (-)peristalsis

(-)mass (-)scars

(+)tympanic sound (-)abdominal pain

NORMALNORMALNORMALNORMALNORMALNORMAL

Assessment I P PE A Results Significance Indication

Genitourinary * (+)polyuria ABNORMAL Due to excretion of important minerals along with the urine

* (-)pain in the suprapubic urinalysis result NORMAL

* (-)burning sensation NORMAL

* (-)involuntary movements NORMAL

Lower extremities

* * (-)bipedal edema(-)wounds

(-)pain in the lower extremities (+)ROM

(+)numbness of the legs

NORMALNORMALNORMALNORMALABNORMAL Due to abnormal circulation of

blood*

MitochondriaCell wall

insulin

Glucose

KC

KC - kreb cycleAcA - Acetyl coenzyme A or Co-AATP – Adenesine triphosphate

Glycolysis

HO

Fatty acid

AcAAcA

ATP

Pyruvate

Anatomy of the cell

PathophysiologyInsulin Deficiency

Osmotic diuresis

Glycogenolysis

Loss of electrolytes

↑ Hepatic gluconeogenesis

↑ counter-regulatory hormones

Hyperglycemia

Ketogenesis

Ketoacidosis

↑ lipolysis

Dehydration

↑ Gluconeogenic Substrates

↑ Proteolysis

Ketonuria

↓ Bicarbonate serum levels

↑ Blood glucose

↑ Urine output

Glucosuria

↑ Beta-Hydroxybutyrate

Nausea & Vomiting

↑ FFA

Acetone Breath

Kassmaul’s Respirations

Impaired kidney function

End Stage Renal Failure

Stage V Chronic Kidney Disease

Management:

Medication

Dec. 23, 2014

Pen G IM per soluset q4 ANST

Diazepam 5mg TID for restlessness

Dec. 24, 2014

Give 30 meqs of sodium hydrochloride with equal diluent to run for 1hr

Hydralazin 7mg q6

Paracetamol 200mg suppository/ 2 suppository q6 PRN

Furosemide 20mg mid and post

Dec. 25 2014

Pen G 500,000 via soluset q6

Omeprazole

Furosemide 20mg

Dec. 26 2014

Continue meds: pen G & omeprazole

Dec. 27 2014

D/c omeprazole

Hydralazine PRN

Racemic epinephrine q15 x 3 doses then q4 x 6 doses

Dec. 28 2014

Continue meds: pen G

Hydralazine

Paracetamol PRN

Dec. 30, 2014

Continue meds: Pen G

Hydralazine

Dec. 31, 2014

Continue meds: Pen G

Hydralazine

Jan. 2, 2015

Continue meds: Pen G

Hydralazine

Start kalium durule + durule 2x a day for 6 doses

NaCl tablet, 1 tablet 2x a day

Jan. 3, 2015

D/C Pen G

Kalium durule to complete 6 doses

NaCl tablet

Jan. 4, 2015

D/c kalium durule

D/c NaCl tab

Hydralazine PRN

Jan. 7 2015

Paracetamol 500mg 1 tab for temp. 37.8 ‘C

Jan 8 2015

Ceforoxine 250mg PO q12

Paracetamol 500mg PO q4 PRN for temp 37.8 ’C

Cetirizine 10mg PO OD

Start dopamine premix at 24-25cc/hr

Jan 10 2015

Cefroxine

Paracetamol

Jan 11 2015

Cont. cefuroxine

Start kalium durule, 1 durule BID PO x 6 doses NaCl tablet, 1tablet BID

IV FLUIDS

Dec 23 2014

Line 1: PNSS 650cc to run for 1hr then 350cc to run for 1hr then refer

Line 2: insert heplock

Start insulin drip PNSS 99cc + regular insulin 1cc =100cc to run for 3.3cc/hr

Dec. 24, 2014

D/c insulin drip

Shift IVF to PNSS 1 liter to run at 30cc/hr (7 to 8 gtts/min)

Dec. 25, 2014

PNSS 1L

Dec. 29, 2014

Consume IVF & insert heplock

Dec. 31 2014

Consume IVF & insert heplock

Jan. 2 to 7, 2015

Maintain heplock

Jan. 8, 2015

Give PNSS 300cc IV bolus then re check BP

Jan. 10, 2015

PNSS 350cc IV bolus then repeat BP (90/50)

Line 1: PNSS 1 liter 350cc FD then KVO

Line 2: Dopamine premix at 24 to 25cc/hr

Jan. 11, 2015

Continue IV line PNSS 350cc once with BP less than 90/60 if not, at KVO

DIET

Dec.23 to 26, 2014: NPO

Dec. 27, 2014

Start NGT feeding at 30cc q4 (6AM)

NPO temporarily (11:50 AM)

Dec. 28, 2015

Resume NGT feeding (6:40PM)

May try oral/ feeding (9AM)

Remove NGT once feeding well

Dec.29, 2014

Low salt low fat diet

Dec. 30, 2014

Diet as Tolerated (DAT)

Dec. 31, 2014

Low salt, low fat diet

Jan. 1, 2015

Diet as Tolerated (DAT)

Increase oral fluid intake

Jan. 2, 2015

Diet as Tolerated (DAT)

Jan.3, 2015

Diet as tolerated (DAT)

Jan. 8, 2015

Low salt, low fat diet

Jan. 11, 2015

NPO

LABORATORY EXAMINATION

Dec. 23, 2014

Complete blood count

Blood typing

ABG (arterial blood gas)

Urinalysis

Serum electrolytes

RBS q6

Dec. 24, 2014

Repeat CBC 6 hours post BT (blood transfusion)

D/c q6 of CBC, serum electrolytes, RBS

D/c q1 of HGT

Dec. 29, 2014

Repeat Creatinine

Jan. 1, 2015

Repeat CBC, Creatinine

Leptospira test

Jan. 2, 2015

Repeat serum electrolyte after 24 hrs.

Jan. 3, 2015

Repeat serum electrolyte (10PM)

Jan. 10, 2015

Serum electrolytes, BUN, Creatinine, CBC, CKMB (7:15 AM)

Repeat CBC w/ PTT, serum electrolytes, BUN, creatinine, HGT

Jan. 11, 2015

Repeat serum electrolytes after 24 hrs.

DIAGNOSTIC EXAMINATION

Dec. 23, 2014

Chest Xray APL

Dec.24, 2014

BUN, Creatinine q6, repeat serum electrolytes

KUB (Kidney Ureter Bladder)

Ultrasound

TREATMENT

Insert IJ Catheter

Hemodialysis 3x a week

PATIENT’S NAME: B.D.M.GENDER: MALE AGE: 18Y/OMEDICAL DIAGNOSIS: DIABETIC KETOACIDOSIS W/ STAGE V CHRONIC KIDNEY DISEASE

TEST NORMAL VALIES ACTUAL RESULT INTERPREATTION

HEMOGLOBIN 140-180g/L 103 g/L Below normal. This indicates less oxygen in the blood and possibility of iron deficiency in the body which leads to anemia.

HEMATOCRIT 0.400-0.540 0.30 Decrease hematocrit level indicates anemia which can be result of hemolysis.

RED BLOOD CELLS 4.3-5.6x10^12/L 3.58 Decrease in RBC’s may indicate anemia.

WHITE BLOOD CELLS 4.00 – 10.00 x 10^9/L 9.19 NormalPLATELET COUNT 150,000 – 450,000 x 10^9/L 111 Low platelet level indicates

thrombocytopenia

LABORATORY EXAM RESULT

LABORATORY EXAM RESULT

DIFFERENTIAL COUNT

NEUTROPHILS 50.0-70.0 94.1 Above normal. May indicate acute bacterial infection.

LYMPHOCYTES 20.0-40.0 2.9 Below normal indicates leukopenia.

MONOCYTES 3.0-12.0 2.5 Below normal indicates leukopenia.

EOSINOPHILS 0.5-5.0 0.4 Below normal indicates leukopenia.

LABORATORY EXAM RESULTFULL NAME RESULT UNITS REMARK REFERENC

E VALUEINTERPRETATION

POTASSIUM 2.69 mmol/L Low 3.5-5.3 Below normal. Indicates hypokalemia which can be cause by low intake protracted vomiting, renal loss, cirrhosis and others.

CHLORIDE 93.7 mmol/L Low 98-107 Below normal which indicates hypochloremia. Chloride is normally loss in the urine, sweat and stomach secretions. Excessive loss can occur from heavy sweating, vomiting and adrenal and kidney disease.

SODIUM 125.1 mmol/L Low 135-148 Below normal. Indicates hyponatremia which may be cause by vomiting, diarrhea, gastric suction, excessive perspiration, continuous IV 5% dextrose/water: low sodium diet, burns inflammatory reactions, tissue injury.

BLOOD UREA NITROGEN

44.6 mmol/L High 3.2-7.4 Above normal. Test results may indicate liver or urinary tract issues. Elevated BUN can be caused by the following health conditions: heart disease, heart failure, heart attack, bleeding in the digestive tract, dehydration, kidney failure, stress, urinary tract problems such as obstruction and shock. Further test maybe needed.

CREATANINE 1032.3 umol/l HIgh 63.6-110.5 Above normal. The test is issued to assess renal glomerular filtration and screen for renal damage because renal impairment is virtually the only cause of creatinine elevation.Elevated levels usually indicate diminished renal function.Too high creatinine level indicates that the patient has renal disease that has seriously damaged nephrons of the kidney.

LABORATORY EXAM RESULT

RESULT NORMAL VALUE INTERPRETATION SIGNIFICANCE

COLOR Light Yellow Pale to DarkYellow to Amber

Normal

TRANSPARENCY Turbid Clear Abnormal Indicates the presence of crystals deposits, white cells, red cells, epithelial cells or fat globules.

SPECIFICGRAVITY

1.010 1.010-1.020 Normal

Ph 6.0 Acidic 5.0-6.0 Normal

SUGAR 395 mg/dl 120-160 mg/dl Abnormal Indicates renal glycosuria, hyperglycemia, and increased osmotic diuresis

URINALYSIS

TEST NORMAL VALUES ACTUAL RESULT INTERPRETATION

SODIUM 3.5-5.3 125.1 Above normal, indicates hypernatremia which can cause edema

POTASSIUM 98-107 2.69 Below normal. Indicates hypokalemia which can be cause by low intake protracted vomiting, renal loss, cirrhosis and others.

CHLORIDE 135-148 93.7 Below normal which indicates hypochloremia. Chloride is normally loss in the urine, sweat and stomach secretions. Excessive loss can occur from heavy sweating, vomiting and adrenal and kidney disease.

TEST NORMAL VALUES RESULT INTERPRETATION

BUN 3.2-7.4 44.6 Above normal. Test results may indicate liver or urinary tract issues. Elevated BUN can be caused by the following health conditions: heart disease, heart failure, heart attack, bleeding in the digestive tract, dehydration, kidney failure, stress, urinary tract problems such as obstruction and shock. Further test maybe needed.

CREATININE 63.6-110.5 1023.3 Above normal. The test is issued to assess renal glomerular filtration and screen for renal damage because renal impairment is virtually the only cause of creatinine elevation.Elevated levels usually indicate diminished renal function.Too high creatinine level indicates that the patient has renal disease that has seriously damaged nephrons of the kidney.

LABORATORY EXAM RESULT

RESULT NORMAL VALUE INTERPRETATION SIGNIFICANCE

LEUKOCYTES +++ 4.00-11.0 x 109/L

No result Leukocytes in the urine is a sign of damaged kidneys, urethra or bladder

RBC /uL 6 /uL 0-11 Normal Signifies lost blood in the lower urinary tract

EPITHELIAL CELLS 0 o/hpf 0-1.8 epithelial cells/hpf

Normal Epithelial cells in the urine may indicate a tumor

DRUG ORDER MECHANISM OF ACTION

INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING RESPONSIBILITY

PRECAUTION

GENERIC NAME:Potassium Chloride BRAND NAME:Kalium Durule CLASSIFICATION:Electrolytes DOSAGE:10 meqs/durule FREQUENCY:1 durule 3x/day ROUTE:PO

Maintain acid-base balance,Isotonicity, and electrophysiologic balance of the cell. Activator in many enzymatic reactions; essential to transmission of nerve impulses; contraction of cardiac, skeletal, and smooth muscle; gastric secretion; renal function; tissue synthesis; and carbohydrate metabolism.Therapeutic effect: Replacement. Prevention of deficiency.

Treatment/ Prevention of potassium depletion.

Contraindicated in

patient with oliguria, anuria,; patient with untreated Addison’s disease or with acute dehydration, heat cramps,

Use cautiously with

patient with cardiac disease and renal impairment.

Nausea and Vomiting

Arrhythmias Heart block Hypotension Cardiac arrest Hyperkalemia Respiratory

paralysis Nausea and

vomiting Abdominal pain

Make sure the

powder are completely dissolve before giving.

Monitor renal

function. After surgery, don’t give drug until urine flow is established, tell patient to take drug with or after meals with full glass of water or fruit juice to lessen GI distress.

DRUG ORDER MECHANISM OF ACTION

INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING RESPONSIBILITYPRECAUTION

GENERIC NAME:Omeprazole BRAND NAME:Omepron CLASSIFICATION:Proton Pump Inhibitor DOSAGE:1 CAP FREQUENCY:2x/day 0700-1900H ROUTE:G-TUBE

Reduces Gastric Acid Secretion and increases Gastric mucus and bicarbonate production, creating protective coatingon gastric mucosa and easing discomfort from excess gastric acid.

GERD, Erosive Esophagitis, Short term treatment Duodenal ulcer, Gastric ulcer, Pathologic hypersecretory condition, including Zollinger-Ellison Syndrome, frequent heart burn

Hypersensitivity Hepatic Disease Pregnancy Children Posterior Laryngitis Nausea and

Vomiting

Dizziness Headache Asthenia Nausea Vomiting Diarrhea Constipation Abdominal

Pain Back Pain Cough Upper

Respiratory Infection

Rash

Assess vital signs Check for abdominal pain,

emesis, diarrhea or other Constipation. Evaluate fluid and intake Watch for elevated liver

function test results Tell patient to take 30-60

minutes before meal, preferably in morning.

Instruct patient to swallow capsules or tablets whole and no to chew or crash them

Caution patient to avoid driving and other hazardous activities until he know drug effects concentration and alertness.

DRUG ORDER MECHANISM OF ACTION

INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTs NURSING RESPONSIBILITYPRECAUTION

Generic Name:Penicillin GTrade Name:PenadurClassification:Pharmacologic Classification PenicillinTherapeutic ClassAnti-ineffective, antibioticPregnancy Risk FactorBRoute:IntravenousMaximum Dose:2-4 million units IM weekly for 3 weeksMinimum Dose300,000 Units IM

Interferes with bacterial cell wall synthesis during active multiplication, causing cell wall death and resultant bactericidal activity against susceptible bacteria.

General Indications: Severe infections

caused by sensitive organisms (streptococci)

URTI caused by sensitive streptococci

Treatment of syphilis, bejel, congenital syphilis, pinta, yaws

Prophylaxis or rheumatic fever and chorea

Contraindications Concentrations: Allergies to

penicillins, cephalosporins, or other allergens

Precaution: Renal disorder Pregnancy LactationDrug interaction drug to drug: Deceased

effectiveness with tetracylines

Inactivation of parenteral amino glycosides.

lethargy, hallucinations, seizures, glossitis, stomatitis, gastritis, sore mouth, furry tongue, nausea, vomiting, diarrhea, abdominal pain, colitis, nonspecific hepatitis, nephritisThrombocytopenia, anemia, leukopenia, neutropenia, prolonged bleeding timeRash, fever, wheezing, anaphylaxisPain, phlebitis, thrombosis at injection siteSuperinfections, sodium overload leading to heart failure

Before: Observe 15 rights of administration Reduce dosage with hepatic or renal failure Assess for any contradictions to the drug Educate about side effects of drugDuring: Do not inject or mix with other IV solutions Give IM injections in upper outer quadrant of

the buttock Avoid contact with the needle Withdraw the needle as quickly as possible to

avoid discomfort Stay with the patient throughout whole

duration of administrationAfter: Monitor client for at least 30 minutes Arrange for regular follow-up, including blood

tests, to evaluate effects Instruct to report difficulty breathing, rashes,

severe pain at injection site, mouth sores Instruct to take medications as directed for the

full course of therapy, even if feeling better Do proper documentation

Assessment Diagnosis Planning intervention Rationale EvaluationUPON ADMISSIONSubjective:‘’manutay anako insan agko nakatungtung ya masimpit ‘’as verbalized by the mother.

objective:-polyuria-weak-dry mouth-deep & rapid breathing

Blood glucose level:= 395 mg/dL BP: 80/30 mmHgPR: 48 BPMRR: 41 CPMT: 36.9 C ̊�

Fluid & electrolyte imbalance related todiabetes as evidence by glucose 395 mg/dl and K+ 2.69

Insufficient insulin↓

Lack of glucoseUtilization in muscle

and adipose↓

Hyperglycemia

Short term goal:-patient’s blood glucose will be 180 mg/dl within 24hours.

-Patient’s K+ level will be 3.5 -5.0 within 12 hours.

Long term goal: -patient’s will demonstrated to the nurse in-charge how to take his blood sugar & how to get himself insulin injections by discharge.

Independent:1. The nurse will verbalize &

provide printed material to pt. on the side effects of an managed diabetes.

2. The nurse will demonstrate

to the pt how to check blood sugars and give insulin injection properly and will ask the patient to reciprocate

dependent:3. Patient will be started on an

insulin drip and blood sugars will be checked every hour per md order

4. Patient will be given

potassium supplementation per physicians order.

- To give knowledge to the client for the side effects that may occur.

- To give the patient enough knowledge on how to check blood sugars and give insulin injection independently by discharge. - To determine if blood glucose is stable or not.

- Potassium works to maintain proper fluid balance between cells & body fluids.

After 12 hours of nursing intervention, the patient’s K+ level is 3.6 and blood glucose of 104 mg/dl. The patient was able to take his own blood sugar and insulin injections by himself.

Assessment Diagnosis Planning Intervention Rationale EvaluationUPON ADMISSIONSubjective:‘’manutay anako insan agko nakatungtong ya masimpit” as verbalized by the mother.

objective:-3x vomiting-weakness-increased urination (+) decreased fluid intake (+) dry lips

Blood glucose level:= 395 mg/dL

BP: 80/30 mmHgPR: 48 BPMRR: 41 CPMT: 36.9 C ̊�

Deficient fluid volume as evidenced by increased urine output, vomiting, poor skin turgor and dry mucous membranes.

High blood glucoseLevel

↓Increase in urination

↓dehydration

Short term goal: After 12 hrs. of nursing interventions, no signs of dehydration will be noted.

long term goal: During the patient’s stay in the hospital, the patient will have appropriate knowledge regarding dehydration.

Independent:1. assess patient

condition

2. increase fluid intake & encourage to eat foods w/ high fluid

3. ensure accurate intake and output monitoring

dependent:4. Administer 0.9%

sodium chloride as ordered.

- To monitor for other signs and symptoms - Content to promote hydration.

- Accurate records are critical in assessing the patient’s fluid

- To rehydrated the patient.

After 12 hours of nursing interventions, no signs of dehydration were noted and the mucosa of patient was moist.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONUPON ADMISSIONSUBJECTIVE:“hindi ako makahinga” as verbalized by the patient OBJECTIVE:-dyspnea-difficulty speaking-restlessness-productive cough-pale in appearance Hemoglobin level:= 103 g/L(normal range: 120-160)

BP: 80/30 mmHgPR: 48 BPMRR: 41 CPMT: 36.9 C ̊�

Abnormal breathing pattern due to low hemoglobin level

Low hemoglobin level

↓Insufficient O₂

circulating in the body

↓Difficulty of breathing

Short term Goal:-The patient will have a normal respiratory rate of 12 – 20 breathes per minute and signs of dyspnea will regress after 2 hours of nursing interventions Long term Goal:-During the patient’s stay in the hospital, he will be able to maintain patent airway as manifested by:-independence from O2 and ventilator support -Normal breathing pattern of 12 – 20 CPM

Independent1. Auscultate

breath sounds

2. Monitor respiratory patterns

3. Position

client to optimize respiration

Dependent 4. Administer

O₂ inhalation as ordered.

- Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. Presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction. - Normal RR of an adult is 12 – 20 CPM. With secretions in the airway, the respiratory rate will increase.- An upright position allows for

maximal air exchange and lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe.

- To correct the patient’s breathing pattern

- After 2 hours of nursing intervention, airway patency maintainedand signs of dyspnea disappeared. -Client’s respiratory rate is within normal range: RR- 12 – 20 CPM -Remained calm: allay restlessness.

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:‘’ agto gabay so pising mapilid sira balet agto met papaulyanan ya manpaeras‘’as verbalized by the mother .Objective:-the patient doesn’t look like his age (18)-impaired mobility-the pt is thin, has dry skin-patient frequently experiences numbness of feet

weight: 32.9 kgHeight: 153 cm BP: 80/30 mmHgPR: 60 BPMRR: 23 CPMT: 36.9 C ;

Imbalanced nutrition related to imbalance of insulin ,food and physical activity.

Nutritional imbalance↓

Inability of the body to absorb nutrients

↓Weight loss

Short term goal:after 4 hours of nursing intervention, the patient will be able to eat food given by him

long term goal:during the patient’s stay to the hospital , there will be a reversal of weight loss.

Independent:1. take into consideration

about the patient’s lifestyle, cultural background, activity level and food preference

2. encourage the patient to to eat full meals and snacks as prescribed in the diet prescription

3. control the glucose level4. provide an appropriate

caloric intake.Dependent:5. implement meal

planning

6. provide for an extra snacks before increased physical activity as ordered by the dietitian.

- To have a background about the patient and how to manage him - It is the first step towards the desired body weight

- To determine if blood glucose is stable or not.- It allows the patient to achieve and maintain the desired body weight.

- To monitor the food intake the patient is about to receive each day. - To keep blood glucose on safe range.

After nursing interventions, the patient achieves metabolic balance as manifested by:-the patient is able to eat his full meals and snacks given to him each day. -the patient exhibits glucose levels within target range -avoids further weight loss and begins to approach desired weight.

MEDICATION

Penicillin G- to prevent recurrence of streptococcal infection Omeprazole- used for treating acid-induced inflammation

and block the production of acid Potassium Chloride- to prevent or to treat low blood levels

of potassium (hypokalemia).

DISCHARGE PLAN

HEALTH TEACHING/HYGIENE

• Describe to the client the sign and symptoms to be reported immediately. High glucose level, dry mouth, weakness/fatigue, shortness of breath, nausea and vomiting, and abdominal pain. ( Chronic Kidney Failure- blood in urine, dark urine, swelling of feet and ankle, persistent itching, and chest pain.)

• Clearly and specifically explain the nature of disease, its’ coarse and eventual prognosis of the condition to the child (if old enough to understand), parents or caregivers. They need to understand that, while complete resolution is expected, a small possibility exists for a persistent disease and an even smaller possibility exists that it will progress. The information is necessary for some patient to ensure the compliance with the follow up program.

• Remind the patient or the family members to have check up or to consult the physician once a while to monitor the patients condition.

DISCHARGE PLAN

TREATMENT

Ensure follow up and self-care Advise the client to take the prescribed

medicines Ensure dietary restriction to carbohydrates,

salts and proteins Tell the patient or family member to monitor

for signs of developing diabetes and kidney failure

Maintain a steady, normal patient blood glucose/sugar under control

SPIRITUAL

COUNSELLING: Tell the patient that neither she/he nor GOD will not given you a problem that you cant handle.

Advice relatives, friends or significant others to provide moral support and widen their understanding.

Tell them to pray for the client faster recovery.

DISCHARGE PLAN

http://emedicine.medscape.com/

http://www.ncbi.nlm.nih.gov/

http://www.drugs.com/

http://www.diabetesselfmanagement.com/

http://www.bd.com

http://www.wisegeek.com/

Ketones—in particular, beta-hydroxybutyrate—induce nausea and vomiting that consequently aggravate fluid and electrolyte loss already existing in DKA. 

When blood sugar levels are so high, some sugar "overflows" into the urine. As sugar is carried away in the urine, water, salt and potassium are drawn into the urine with each sugar molecule, and your body loses large quantities of your fluid and electrolytes, which are minerals that play a crucial role in cell function. As this happens, you produce much more urine than normal. Eventually it may become impossible for you to drink enough fluids to keep up with amounts that you urinate. Vomiting caused by the blood's acidity also contributes to fluid losses and dehydration.

Reference ̊Page