Diabetes Ketoacidosis - Pathophysiology, Nursing Assessment, Associated Nursing Priorities, Nursing Intervention, Fluid Replacement, Insulin Therapy - Case Study Example

Case Study Name Institution Date of submission Introduction Molly medical presentations to health facility were the indicator Diabetes ketoacidosis (DKA), which is one of the undesirable complications of type 1 diabetes. Molly presented with dry flushed Skin, the patient had Kussmauls’ Respiration pattern, the breath had Acetone smell, Tachycardia was noticed, Polyuric was present, and the blood glucose level was 42.5 mmol/L. The treatment of patients with DKA includes obtaining a methodical but swift history and carrying out physical examination in an effort to recognize probable precipitating factors. (Kasper & Braunwald, 2005). This essay presents discussion of the Pathophysiology of a client’s (patient’s name is Molly) state and medical management priorities. The essay will majorly focus on the nursing assessment, nursing diagnoses, and nursing interventions backed up with appropriate rationales in addition to evaluation of pertinent teaching and management issues for the client/patient. Pathophysiology Following the utilization of food, carbohydrates are wrecked down into glucose molecules in the gut. Glucose is rapt into the bloodstream increasing blood glucose level. This increase in glycemia stimulates the discharge of insulin from the beta cells of the pancreas. Insulin is wanted by most cells to let glucose entry. Insulin binds to specific cellular receptors and facilitates entry of glucose interested in the cell, which utilizes the glucose for energy. If insulin manufacture and secretion are distorted by disease, blood glucose dynamic will as well change. If insulin manufacture is decreased, glucose admission into cells will be introverted, resulting in hyperglycemia. The fundamental pathophysiologic imperfection in type 1 disease is an autoimmune damage of pancreatic beta cells. Ketoacidosis happens when the body is manufacturing large amounts of ketone bodies through the metabolism of ketosis (fatty acids) and the body is manufacturing inadequate insulin to sluggish this production. The surfeit ketone bodies can considerably acidify the blood. The existence of hyperglycemia (a high level of glucose in the blood) caused by the deficient in insulin can result to more acidity. As a result of acidity, the patient will present with Acetone smell on breath. Kussmaul breathing is the reimbursement for a metabolic acidosis, most frequently happening due to ketoacidosis. Blood gases on a client presenting Kussmaul breathing will reveal a less partial pressure of CO2 in combination with less bicarbonate as a result of a forced raised respiration. The client feels a push for to breathe deeply, and it appears nearly involuntary. Kussmaul breathing appears, as the acidosis becomes more severe. The therapeutic objectives for diabetic ketoacidosis (DKA) consist of enhancing circulatory volume and body tissue perfusion, decreasing serum osmolality and blood glucose toward normal and stable levels, removing ketones from urine and serum at a faster rate, correcting body electrolyte imbalances and recognizing precipitating factors (Broers, 2002) Nursing assessment In case study, objective and subjective reveals that Molly, a 21 year old, she was diagnosed of type two diabetis 8 years ago. On the subjective data of the Molly, the patient knows the problem that brought her to the health facility. The clients’ normal insulin was delivered through an insulin pump; she receives a sum of 30 unit daily as well as small boluses during meal times. The pump was established to be not working by the paramedics. The patient was in recent times diagnosed of flu like illness. On objective Data, on the physical examination patient had dry flushed Skin, the patient had Kussmauls’ Respiration pattern, the breath had Acetone smell, Tachycardia was noticed, Polyuric was present and the blood glucose level was 42.5 mmol/L. Normally, the major management of this condition is early rehydration (utilizing isotonic saline) with succeeding low-dose insulin therapy and potassium replacement. Utilization of bicarbonate is not suggested in most clients. Cerebral edema is one of the direct impediments of diabetic ketoacidosis, happens more frequently in adolescents and children than in adults (Broers, 2002). Constant follow-up of client utilizing flow sheets and treatment algorithms can help to lessen adverse outcomes. Therefore, the initial thing to perform, in Molly’s case, is to admit the patient in bed and administer intravenous fluids to reverse dehydration and to repress the creation of ketone bodies. Similarly, Molly had a serious short of insulin in her body, in order to correct the situation; insulin shots must be administered in order to get her blood glucose level to be stable. Associated nursing priorities Diabetic ketoacidosis (DKA) is a triad of ketonemia, hyperglycemia, and acidemia, in which it may be caused by other medical conditions (Clarke, 2004). Although DKA most frequently occurs in patients diagnosed with type 1 diabetes, studies that are more recent imply that it can occasionally be the presenting state in black obese patients with recently diagnosed type two diabetes (previously called non–insulin-dependent diabetes mellitus) (Gonder-Frederick, 2004) In management of patient with diabetic type 1, it is important to consider the presenting complain of the patient and manage symptoms. The first priority in management is to restore fluid, acid-base balance, and electrolyte. These can be achieved with administration of intravenous fluids. The other major or important nursing priority is to reverse or correct metabolic abnormalities. The next priority is to assist and identify the causative or the underlying cause of the disease and manage the causative factors. Diabetic is highly related to complication, it is therefore essential for a nurse to prevent complications. Patient education is other priority, it is necessary a nurse to provide health education, thus it is indispensable to provide detailed information about prognosis of the disease and disease process, treatment needs and self-care. Nursing intervention and rationale Nursing intervention for Molly dependents on presenting complain and objective assessment. For Kussmaul breathing and tachycardia, which are compensatory mechanism, the nurse have to assess the client whilst supporting or sustaining the airway and breathing, the nurse has administer oxygen. Increasing oxygenation will help to reduce metabolic acidity of the patient. It is therefore essential to obtain an ECG to determine the rhythm, and monitoring oxy-hemoglobin saturation and blood pressure. When the client tachycardia is steady, the nurse will have time to get 12-lead ECG, assess the rhythm, and identify treatment options. Fluid Replacement In Molly’s case, polyuria was one of presenting complain, therefore, the patient was passing excessive or abnormally large amount of urine. Primarily the duration of hyperglycemia, the level of renal function and the patient’s fluid intake determine the severity of fluid and sodium deficits. Dehydration may be projected by clinical assessment and by calculating entirety serum osmolality and the reverted serum sodium concentration. The preliminary priority in the management of Molly is the re-establishment of extra-cellular fluid volume via the IV administration of a normal saline (that is 0.9% sodium chloride) solution. This measure will restore re-establish her intravascular volume, reduce her counter regulatory hormones and reduce her blood glucose level (Gill, 2006). Consequently, molly’s insulin sensitivity can be increased. In cases clients with mild to moderate fluid volume diminution, the infusion rates of 7mls for every kg for each hour have been as successful as infusion rates of 14 mls for every kilogram for each hour (Plotnikoff & Karunamuni, 2009). The consequent administration of the hypotonic saline (0.45% sodium chloride) solution that is similar in component to the fluid vanished during osmotic diuresis, results to steady replacement of deficiency in both extracellular and intracellular compartments. When the blood glucose is roughly 250 mg for each dL (13.9 mmol per L), glucose must be added to a hydrating fluid (for instance, 5 % dextrose in the hypotonic saline solution) (Broers, 2002). This will allow sustained insulin administration in anticipation of ketonemia is controlled and helps to circumvent iatrogenic hypoglycemia. Another significant facet of rehydration therapy in clients with diabetic ketoacidosis (DKA) is the replacement of continuing urinary losses. Insulin Therapy In relation to Molly’s state, the patient had high level of blood sugar. Contemporary management of diabetic ketoacidosis has put emphasis on the use of lesser doses of insulin. These have been shown to be the most effective management in both adults and children with diabetic ketoacidosis (DKA). The up to date recommendation is to give less dose (short-acting standard) insulin subsequent to the diagnosis of DKA has been incorrigible by laboratory investigation and body fluid replacement has been started (Plotnikoff & Karunamuni, 2009). It is practical to hold back insulin therapy awaiting the serum potassium concentration have been estimated. In rare cases, patient who manifests with hypokalemia; insulin therapy might worsen the state and precipitate cardiac arrhythmias which is life threatening (Clarke, 2004). Typical low-dose insulin therapy comprises of an early intravenous bolus of 0.15 unit of normal insulin for every kilogram followed by the uninterrupted intravenous infusion of standard insulin prepared in hypotonic saline or normal saline solution at the rate of 0.1 units per kilogram per hour. In the situation where the blood glucose level does not reduce by 50 to 70 mg for each dL ( that is 2.8 to 3.9 mmol for every L) in the initial hour, the IV infusion rate must be doubled or extra IV 10-unit boluses of insulin must be given each hour. Whichever of these managements must be continued pending the blood glucose concentration falls by 50 to 70 mg for each dL (Varas & Brancati, 2001). Less dose of insulin therapy, classically results to a linear fall in the glucose level of 50 to 70 mg per dL for every hour. More speedy correction of hyperglycemia must be avoided since it might augment the risk of cerebral edema. This dreaded management complication happens in roughly 1% of children with DKA (Broers, 2002). The distinctive presentation is start of headache and reduced mental status happening some hours following the commencement of treatment. Cerebral edema is linked with a mortality rate of up to 70%. When blood glucose levels of 250 mg per dL have been attained, the incessant or hourly insulin dosage might be decreased to 0.05 units per kiligram per hour. The fluid and insulin regimens are sustained awaiting ketoacidosis is controlled. This necessitates the attainment of no less than two of these base-acid measurements: a serum bicarbonate level of larger than 18 mEq for each L, the venous pH of 7.3 or higher and an anion gap of lower than 14 mEq for every L (Gonder-Frederick, 2004).  Molly is at risk for Infection one of the nursing, risk factors to infection associated with type one may include decreased leukocyte function, high glucose levels, and alterations in circulation. Preexisting urinary tract infection and respiratory infection predisposes patients to infection. The nurse should observe for signs of inflammation and infection, for example, flushed, fever, appearance, purulent sputum, wound drainage, cloudy urine. The rationale of the intervention is that client might be admitted with infection that could be the impetuous to the ketoacidotic state, or may extend the nosocomial infection. Infection can be curbed by promoting good hand washing by patient and staff; this reduces danger of cross-contamination. The nurse should maintain aseptic technique for the intravenous insertion process, administration of drugs, and providing site care. This can be achieved through rotating intravenous sites as indicated.in diabetic patient high level of glucose in the blood creates a brilliant medium for bacterial multiplication. This can be curbed by Providing catheter and perineal care (Fineberg & Finco-Kent, 2007). The nurse must educate the female serene to clean from front to the back after execration; it will minimize risk of urinary tract infection. Comatose client might be at finicky risk if urinary retention occurred prior to hospitalization. Aged female diabetic patients are particularly prone to urinary tract and vaginal yeast infection. Disturbed Sensory Perception Other priority nursing Diagnosis is Sensory Perception; disturbed sensory perception. According to scenario, molly was in confusion state. The risk factors to the diagnosis include endogenous chemical adjustment: glucose or insulin and electrolyte inequity. To avert the risks, the nurse should monitor patient’s vital signs and their mental status. The vital sign will provides a baseline from which the nurse will compare from the abnormal findings, for example, fever might influence mentation. It is essential for scheduling nursing occasion to provide for unremitting rest epochs. It will also encourage restful reduces fatigue, sleep, and may perk up cognition (Clarke, 2004). Other nursing intervention is to shield patient from body injury (avoid or limit utilization of fetters as able) when level of awareness is impaired. This can also attained by placing bed in lowest position. Nurse should pad bed rails and offer soft airway if client is susceptible to seizures. Disoriented patients are at risk to injury, particularly during the night, and precautions necessitate to be employed as indicated. Seizure safety measures require to be taken as apposite to avert physical injury and aspiration. The nurse should address the patient by his or her own name; reorient as considered necessary to person, place, and time. The nurse should give brief explanations, talking gradually and enunciating evidently. This will decrease in confusion and helping in maintaining contact with realism. The health care practitioner should investigate information of pain, hyperesthesia, or sensory failure in the patients’ feet and legs. Nurse to look for reddened areas, ulcers, loss of pedal pulses, and pressure points. Peripheral neuropathies might lead in rigorous discomfort, distortion of or lack of tactile sensation, potentiating threat of dermal damage and unequal balance. Thus, the nurse must keep patients schedule as consistent as possible. The patient should be encouraged in the participation of duties of daily living (ADLs) as able. Patients’ involvement will assist to keep client in touch with realism and retain orientation to the surroundings. The nurse should monitor patients laboratory values, for instance, serum osmolality, blood glucose, BUN/Cr,and Hb/Hct. The rationale for monitoring the values is that, the Imbalances will impair mentation. The nurse should note that if intravenous fluid is replaced too hastily, the excess water might enter into brain cells and result in the alteration of the level of perception (fluid overload is referred as water intoxication) (Broers, 2002). Preventing alteration of perception, the nurse should carry out prearranged regimen for correcting diabetes ketoacidosis (DKA) as indicated. The rationale is that the modification in thought processes or possible for convulsion activity is typically alleviated once the hyperosmolar state of the patient is corrected. As indicated, the nurse should evaluate visual acuity of patient with type one diabetes. The reason is that retinal detachment or edema, bleeding, presence of cataracts or impermanent paralysis of the extra ocular muscles might impair vision, necessitating remedial therapy and patient supportive care (Clarke, 2004). Imbalanced Nutrition Less Than Body Requirements Most priority nursing diagnosis is imbalanced nutrition less than body requirements. The impairment may be related to insulin deficit (reduced utilization and uptake of glucose by the body tissues, leading in raising fat metabolism or protein). Diminished oral intake related to nausea, anorexia, abdominal pain, gastric fullness, and altered level of consciousness lastly nutritional impairment might be linked to hyper-metabolic state of the patient, this is connected to release of stress hormones (for example, cortisol, epinephrine, and escalation of hormone), communicable process (Klaus, 2007) The nurse should weigh the patient daily or as indicated or prescribed. This will help to assess sufficiency of nutritional intake (that is utilization and absorption).It is essential for medic to find out clients dietary plan and customary pattern; one should compare with recent patient intake. This will help to identify deviations and deficits from therapeutic requirements. Health care provider should auscultate patients bowel sounds. On auscultation, one should note reports of bloating, abdominal pain, and vomiting of undigested foodstuff. The patient should maintain nothing by mouth (NPO) status as prescribed. Hyperglycemia and electrolyte and fluid disturbances might reduce gastric motility or function, distressing option of interventions. The patient should be provided with liquids having nutrients and electrolytes the instant a patient can endure oral fluids. This will progress to more heavy food as endured. Oral route of administration is favored when client is aware and bowel function or bowel sound is restored (Broers, 2002). Management Issues and Health education Admission to an intensive care unit or step-down must be considered for clients with oliguria or hypotension refractory to early rehydration and for clients with mental obtundation or unconsciousness with hyperosmolality that is the total osmolality of higher than 330 mOsm for every kilogram of water. Most clients may be managed in step-down units or on the general medical wards in which medical staffs have been educated in on-site blood glucose management and constant IV insulin administration (Broers, 2002). Milder forms of DKA can be managed in the emergency unit using the same management guidelines in intensive care unit. Successful outpatient therapy necessitates the lack of severe inter-current infirmity, aware clients who are capable to resuming oral intake and the occurrence of mild DKA. An educational plan for clients such as Molly, in this situation, should incorporate sick-day treatment instructions, including utilizing of short-acting insulin, urinary ketone and blood glucose monitoring. In the case of patient with diabetes type one require adequate health education. Health education will enable the patient adopted healthy life after being discharged from the hospital. The patient should be educated on self-care, this comprises of personal hygiene; that is foot care. On self-care, the patient should be educated on the administration of insulin. Insulin administration is part of patient’s life (Gill, 2006). Exercise is essential to diabetic patient; the nurse should educate the patient the type of exercise they should carry out and how often. Since the patient is at risk of nutritional impairment, they should be educated on the type of food. Knowing the type of food will prevent causing increase in level of body tissues sugar. Lastly, patient should be educated on the type of lifestyle to adopt. The patient should be discouraged from smoking and drinking alcohol (Plotnikoff & Karunamuni, 2009). Conclusion Type 1 diabetes is one of the endocrine disorder where there is lack of or insufficient amount insulin secretion to digest or metabolize carbohydrates. The successive lack of insulin results to increased urine and blood glucose. The cause of type 1 diabetes is idiopathic or unknown, it is supposed to be caused by more one of the following that is, a diabetogenic, genetic susceptibility, and exposure to a driving antigen (Varas & Brancati, 2001). The first priority in management is to restore fluid, acid-base balance, and electrolyte. These can be achieved with administration of intravenous fluids. The other major or important nursing priority is to reverse or correct metabolic abnormalities. Patient health education is one of nurses’ responsibility and duty. In the case of patient with diabetes type one require adequate health education (Moshe-Berant, 2001). Bibliography Broers, S. (2002). Blood glucose awareness training in Dutch type 1 diabetes patients". . Diabet. Med. , 67-89. Clarke. (2004). "Long-term follow-up evaluation of blood glucose awareness training". Diabetes Care , 34- 67. Di-Battista, A. M., & Hart, T. (2009). Type 1 Diabetes among adolescents: Reduced Diabetes self-care caused by social fear of hypoglycemia. . The Diabetes Educator , 50- 70. Fineberg, K. T., & Finco-Kent. (2007). Immunological Responses to Exogenous Insulin. Endocrine Reviews , 625–52. Gill. (2006). "Mortality and outcome of patients with brittle diabetes and recurrent ketoacidosis". . The Lancet , 344 (8925): 778. . Gonder-Frederick, J. D. (2004). "Long-term follow-up evaluation of blood glucose awareness training". Diabetes Care , 1–5. Kasper, D. L., & Braunwald, E. (2005). Harrison's Principles of Internal Medicine . New York: McGraw-Hill. Klaus, U. 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