Diabetic Ketoacidosis: Nursing Focus - Essay Example

Diabetic Ketoacidosis: Nursing focus Cause and number: submitted: Diabetes is a long-lasting medical condition that is enduring to increase in the occurrence. Diabetic ketoacidosis (DKA) is the most known severe complication of diabetes. DKA is a medical emergency that is frequently perceived in the emergency department. Rapid diagnosis, laboratory values assessment, proper treatment, and immediate monitoring are indispensable issues to be considered to the successful management of the DKA. Administration of insulin and fluid repletion is props of DKA treatment (Derr, Sivanandy, Bronich-Hall, & Rodriguez, 2007). Also, nurses should put in mind that restoring of normal hemodynamic status while declining the metabolic acidosis is extremely crucial when taking care of patients with DKA. In addition, vigilant glucose monitoring, taking of vital signs, and monitoring of electrolytes is critical in preventing complications related to DKA treatment (Anthony, 2007). This paper discusses an overview of the pathophysiology, medical treatment, assessment, nursing priorities, causes, and intervention of DKA based on a case scenario of Molly a 21 year old female admitted in the emergency department (Anthony, 2007). The principal cause of diabetes is the absence of insulin in the human body. This can be absolute or relative. It can be absolute whereby there is no insulin generated, or there is no administration of insulin. On the other hand, it can be relative wherein the available insulin is not sufficient to requirements of the patient (Jamaes, & Bonnie, 2006). For instance, Molly’s confusion must have been triggered by her diabetic condition. Molly is a type 1 diabetic since the age of 8 years. She is an insulin dependant prescribed with 30 units of insulin a day. Since she is an insulin dependant patient, the malfunction of her insulin bump must have resulted to her missing a daily dose thus triggering insulin deficiency in the body (Jamaes, & Bonnie, 2006). In the case scenario, absence of insulin caused hyperglycemia which in turn initiated several pathogenic mechanisms that generated the signs and symptoms and metabolic disorders of DKA as explained in following paragraphs. Molly’s body was stimulated by the hyperglycemia which increased production of hormones glucagon, cortisol, growth hormones, and epinephrine in an attempt to generate energy. These hormones broke down fats and initiated the liver to upsurge oxidation of fatty acid. Also, they increased glucose in the blood by initiating glycogenolysis and gluconeogenesis while declining the capability of peripheral tissues to use glucose (Liang, Taichman, Hansen-Flaschen, & Fuchs, 2007). The large number of hormones produced, and the absence of insulin caused a shift in metabolism. These caused Molly’s body to rely on body fats for energy production instead of carbohydrates. Some of the byproducts from metabolism of fat are beta hydroxybutyrate, acetone, and acetoacetate which are acidic which caused a low PH of 7.25. In conclusion, the increased production of hormones and the metabolism shift elevated serum glucose and increased the load of acid (Jamaes, & Bonnie, 2006). These disorders are the source of DKA signs and symptoms. DKA occur in any individual diagnosed with diabetes; however, it is common in patients with type 1 diabetes. DKA can occur as a result of patients failing to adhere to their prescribed insulin therapy. Also, it can occur if the insulin administration is not correctly tailored to the patient’s necessities. In addition, DKA can be prompted by illness or stresses that change the balance of insulin and glucose (Ellis, Frey, Cunningham, Naar-king, Cakan, & Templin, 2005).. For instance, in the case of Molly, since she has recently had flu like illness, must have triggered DKA. Alternatively, the malfunction of her insulin pump might have caused a lack of insulin hence triggering DKA (Lien, Spratt, Woods, Osborne, & Feinglos, 2005). Treatment of DKA has been a significant concern in the world of healthcare. All patients with blood glucose levels above 250 mg/dl, blood PH below 7.3, and their urine contain moderate to high levels of ketone should be hospitalize (Micheal, & Malskovitz, 2008). For example, in the case of Molly, from the physical examination it is clear that her blood glucose was, above the normal (42.5 mmol/L) and blood PH of 7.25 is below the normal. These subjected her to receive an immediate medical emergency. The nursing priorities in such an incidence are to protect and uphold the air passage and treat any associated shock. If the fundamental cause of DKA is an illness, the nurse should treat the illness too (Micheal, & Malskovitz, 2008). Presently the standard treatment for patient with DKA involves an intravenous insulin drip (Lien, Spratt, Woods, Osborne, & Feinglos, 2005). However, in the case of Molly, the nurse should try to administer insulin through an insulin pump as prescribed by the physician. In addition, in this case, the nurse will be required to administer fluids to restore potassium balance. One of the essential nursing priorities in the case of DKA is the patient assessment. Nurses are supposed to run a physical and psychosocial assessment on patients with DKA. Physical assessment involves respiratory, cardiovascular, neurological, gastrointestinal, genitourinary, and integumentary system (Sturt et al, 2008). On the other hand, psychosocial involves patient and family members understanding and appreciative of the disease process, and patient’s previous illness. For instance, in the case of Molly, there are various physical assessments the nurse is required to assess before initiating any treatment. First, when assessing the respiratory system, the nurse should check for deep rapid respirations (kussmaul breathing), tachypnea, and acetone smelling breath (Savage, & Hilton, 2010). Second, in the cardiovascular system the nurse should check for tachycardia, increased Capillary refill time, dry skin, and increased blood pressure. Third, in the case of neurologic system, the nurse should be concerned with alteration of mental status that may progress to coma or seizures (Micheal, & Malskovitz, 2008). Fourth, assessing the gastrointestinal and genitourinary system the nurse should be concerned with the complaints of increased thirst. Lastly, when assessing integumentary system the nurses should check for dry brittle hair, alopecia and hot dry skin (Savage, & Hilton, 2010). Also, it is vital for the nurse to collect the Molly’s psychosocial issues. In this case, psychosocial issues include the molly and family awareness of the disease process. In addition, the nurse should collect Molly’s and her family coping strategies over the DKA (Savage, & Hilton, 2010). DKA is allied with a range of signs and symptoms that should be deliberated by the nurse while taking care of the patient with DKA. DKA signs and symptoms may involve, vomiting, acetone breath, polyuria, dehydration, polydipsia, hyperventilation, and abdominal pain (Micheal, & Malskovitz, 2008). DKA symptoms may mimic medical condition or other disease states. Non-specific symptoms involve weakness, headache, and malaise (Wallymahmed, 2004). DKA should be a concern in any individual with diabetes, especially if vomiting and nausea are present (Thompson, Dunn, Kearns, & Braithwaite, 2005). Some of the symptoms included in the case of Molly are debated in detail, in the following texts. Polyuria is defecation of a large amount of urine. This is caused by a condition denoted as osmotic diuresis, or large volumes of substances in the kidney tubules. This upsurges modifications of the osmotic pressure within the tubules, thus encouraging water retention. The extra volume is then expelled as urine. In patients with DKA, hyperglycemia grounds glucose to collect in the tubules within kidney, hence resulting to osmotic diuresis to occur secondarily to hyperglycemia. Polydipsia is associated with polyuria. It is the state of thirst caused by excess emission of urine. In most cases intake of large volumes of fluid may be either a cause or an impact to the polyuria experienced by DKA patients (Zyl, 2008). Molly’s blood PH of 7.25 is below the norms and blood glucose of 42.5 mmol/L. These occurred as a result of absence of insulin in the body, which in turn permitted sugar to enter cells resulting blood glucose to rise above 250 mg/dl. On the other hand, too much presence of ketone in DKA patient’s blood causes acidity in their blood streams, thus lowering blood PH below 7.3 (Thompson, Dunn, Kearns, & Braithwaite, 2005). Peripheral neuropathy, experienced in the extremities of Molly’s body, is a common symptom of DKA. This is due to the accumulation of sorbitol, a product of glucose transformation in the sensory nerves of the periphery. The nurses taking care of Molly should be checking for numbness and tingling sensation in the Molly’s hands and feet. The nurse should note that, extremities are always affected in glove and stocking design (Zyl, 2008). There are quite number of nursing intervention that can be applied when dealing with patients with DKA. DKA patients are normally semiconscious with marked hypotension and severe acidosis. Within the first 24 hours, patients with DKA are critical and need close monitoring by nurse (Uplinger, Turkel, Adams, & Nelson-Slemmer, 2009). Taking care of patients with DKA may present a challenging situation. For instance, In the case of Molly, general aims of care should be to reduce serum glucose, correct dehydration, identify triggering causes and correct metabolic acidosis. Some of the nursing interventions are discussed in the following texts. First and foremost nursing intervention is the vital signs management. Airway assessment and management are essential if the patient is unconscious. In the presence of vomiting, the nurse should indulge intubation to protect the airway. The nurse should closely monitor for vital signs such as pulse rate, central venous pressure, and arterial pressures. This should be initially done every 15-30 minutes depending on the harshness of the patient’s condition (Wright, & Katz, 2005). Also, the patient should be monitored for cardiac dysrhythmias related with initial hyperkalemia. For example, in the Molly’s situation the nurse should maintain a continuous observation by using a cardiac monitor. The nurse should run potassium analysis at regular intervals for hypokalemia and hyperkalemia as these disorders can have potentially fatal magnitudes. Another essential intervention nurses should be put into contemplation when caring for patients with DKA is the replacement of body fluids. Resuscitation includes the addition of electrolyte and fluid replacement to insulin administration. In the given case scenario, for treatment to be achieved, the nurse should identify and treat the underlying cause (Uplinger, Turkel, Adams, & Nelson-Slemmer, 2009). By rehydrating Molly, hyperglycemia should be decreased as a result of improved filtration within the glomerular. However, when conducting fluid replacement the nurse should consider the patient’s age, degree of dehydration. In Mollys case, the nurse should promptly infuse isotonic saline to restore renal blood flow. Within the first two hours of admission, the nurse should administer 1-2 Liters and a total of 6-8 Liters in the first 6-8 hours. The nurse should pay attention to fluid balance as impaired renal function can lead to hypotension or circulatory overload (Umpierrez, Palacio, & Smiley, 2007). The nurse should check the Molly’s fluid balance by finishing a fluid balance chart after every one hour. Signs of dehydration should be documented, for example, decreased blood pressure, dry skin and furred tongue. Serum potassium levels should be monitored when conducting rehydration. Rehydration can cause serum potassium levels to fall, hence risking the patient to cardiac dysthymia and cardiac arrest (Mei-lun, & Chuan, 2005). The nurse should consistently monitor laboratory findings of potassium to check the levels and potassium replacement therapy should be initiated when required. Insulin replacement is also a vital intervention and nurses are supposed to pay a close attention in administering insulin to patients with DKA. The patient should be administered with an intravenous (IV) infusion of insulin (Mei-lun, & Chuan, 2005). Nurses are normally advised to administer 50 units of soluble insulin in 50ml normal saline. Before infusion of insulin to the patient, the nurse should run 50-100ml of the solution through the tubing; this is because insulin is absorbed by polyvinyl chloride in both the bag and IV tube. Nurses are supposed to use infusion sliding-scale. Sliding-scale insulin regimen assists in the lowering of serum glucose, hindering of ketogenesis and reversing the process for metabolic acidosis (Umpierrez, Palacio, & Smiley, 2007). In the case of molly, the nurse should test Capillary blood at appropriate intervals and adjust IV infusion of insulin according to Molly’s blood glucose levels. The nurse should analyze serum glucose in the laboratory instead of a portable glucometer to ensure the accuracy of the outcome. Acidosis and counter-regulatory hormones may result to insulin resistance (Umpierrez, Palacio, & Smiley, 2007). This may be substantial to nurses when weaning the patient IV to subcutaneous insulin administration. In most emergency cases like in the case of Molly, the patient may require a 10% upsurge in his/her prescribed insulin dose after the onset of DKA. Administration of insulin through IV should not be terminated abruptly as the patient can become insulin deficient within a short time. To halt such complication the nurse should reduce the infusion dosage on an hourly basis. In the case of molly, despite normal blood sugar levels, the nurse should not terminate the insulin infusion until her urine is free of ketones. The nurse can commence administration of insulin subcutaneously once the urine is free of ketone, and the blood sugar is sustained within the normal limits (Mei-lun, & Chuan, 2005). The regimens of IV infusion should not be terminated at the same time as the initial subcutaneous insulin dose is administered. The Insulin infusion should be terminated at least 30 minutes later. Another intervention is the correcting of metabolic acidosis. Modification of metabolic acidosis is vital when taking care of patients with DKA. Application of insulin therapy is the best known process in correcting metabolic acidosis (Patricia, 2005). When applying this procedure, the nurse should keep a consistent monitoring of arterial blood gas to institute the degree of metabolic acidosis and assess acid base balances. It is advisable that the nurse use the arterial blood gas monitoring in order to establish the degree of metabolic acidosis and to analyze the balance of acid base (Mei-lun, & Chuan, 2005). When dealing with patients with blood PH of 6.9-7.0 like Molly, the nurse should dilute 50mmol/l of sodium bicarbonate in normal saline. If Molly’s blood PH goes down to less than 6.9 the nurse should double the dosage; two ampoules of sodium bicarbonate diluted in normal saline. Patient education is a substantial part of nursing care when taking care of patients affected by DKA. Once a patient is recovered, and he or she is ready to be discharged, he or she should be educated on how to prevent recurrence of DKA. For instance, in the given case scenario, the nurse should advise Molly on how to keep consistent function of her insulin pump. Also, the nurse should teach Molly the importance of correctly adhering to her prescribed insulin regimen (Patricia, 2005). This should be stressed by the nurse when advising molly, especially if the poor adherence triggered DKA episode. In addition, molly should be advised to monitor her blood glucose levels carefully and check for the availability of ketones in her urine if her blood glucose level is elevated (Martin, Whitehead, Southall, Shea, & Liveley, 2009). Also, the nurse should advise her to schedule and attend regular checkups with so that her condition may be monitored by her healthcare professional. Lastly, the nurse should advise Molly to adjust to her normal eating habits especially if the insulin dose was adjusted. In this case, the volume of additional quick acting insulin relies on the level of ketones opposed to blood sugar levels. In conclusion, DKA is an extreme in the field of decompensated diabetes mellitus. Even though, research suggests that mortality caused by DKA is decreasing, excess mortality is still experienced around the globe (Kopeski, 2006). Advanced healthcare providers and patient understanding of the precipitating conditions of DKA may further decline the incidences of DKA. Also, advanced early recognition and treatment may decline DKA incidences and improve the result of patients with DKA. Patient characteristics can help healthcare providers to identify the individual who might be at increased risks for DKA, thus enabling healthcare providers to focus on significant educational efforts in this field. Even in the presence of promising therapy people still die during the course of DKA (Elizabeth, 2010). There are no researches that have been published to analyze the prime role of the laboratory in patients with this medical emergency. Consequently, judicious and frequent use of the laboratory is essential with sequential measurement to monitor electrolyte, fluid, and insulin replacement. The successful with DKA outcome requires the healthcare providers to take a compulsive comprehensive approach to forestall, diagnose and successfully treat the complicating factor. References Anthony M. (2007). 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