NIGHTINGALE COLLEGE
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
Name: Click or tap here to enter text.
Course Click or tap here to enter text.
:
Client Information (SBAR) Concept of the Map
T.S. Madison is a 50-year-old female who came to the Emergency Glucose Regulation
Department with extremely high blood sugar levels of 675 mg/dL.
Situation She reports constant thirst, frequent urination, nausea, blurred
vision, and severe fatigue. On arrival, she appears dehydrated,
weak, and lethargic, showing signs of diabetic ketoacidosis (DKA).
The patient has a known history of Type 2 Diabetes Mellitus for
the past eight years but has been noncompliant with her
prescribed metformin due to financial difficulties. She also reports
Background
a recent viral illness and poor food and fluid intake. She has not
taken insulin for three days. There are no known drug allergies.
Family history is positive for diabetes in her mother
Vital signs:
Temperature: 99.2°F (37.3°C)
Heart Rate: 112 bpm (tachycardic)
Blood Pressure: 98/60 mmHg (hypotensive)
Respiratory Rate: 26 breaths/min (deep and rapid
Kussmaul respirations)
SpO₂: 96% on room air
Physical findings: Dry mucous membranes, poor skin turgor, fruity
(acetone) breath odor, confusion, and general weakness.
Laboratory results:
Glucose: 675 mg/dL
Assessment
Sodium: 130 mEq/L
Potassium: 5.6 mEq/L
BUN: 38 mg/dL
Creatinine: 1.8 mg/dL
CO₂: 12 mEq/L
pH: 7.20
HCO₃: 10 mEq/L
Urinalysis: positive for glucose and ketones
Elevated anion gap
Nursing impression: Findings are consistent with Diabetic
Ketoacidosis (DKA) due to severe insulin deficiency, dehydration,
and metabolic acidosis.
Recommendation Begin aggressive fluid replacement with 0.9% normal saline at
15–20 mL/kg/hr to restore intravascular volume. Once potassium
levels are verified as above 3.3 mEq/L, initiate IV regular insulin
infusion at 0.1 unit/kg/hr. Monitor blood glucose hourly, adding
dextrose to fluids once glucose drops below 250 mg/dL to
prevent hypoglycemia. Continue frequent monitoring of
electrolytes, anion gap, and ABG every 2–4 hours. Place the
patient on continuous cardiac monitoring and maintain accurate
intake and output documentation. Provide education once
stabilized about the importance of medication adherence and
, diabetes management.
Recognize Cues Analyze Cues
Objective: Diabetic Ketoacidosis (DKA):
Severely elevated blood glucose level of 675 mg/dL — The combination of a critically high blood glucose
indicates uncontrolled hyperglycemia due to lack of insulin, level (675 mg/dL), metabolic acidosis (pH 7.20,
placing the patient at high risk for diabetic ketoacidosis HCO₃ 10 mEq/L), elevated anion gap, positive
(Gosmanova et al., 2021). urine ketones, Kussmaul respirations, and fruity
breath odor clearly indicate DKA. This is the
Vital signs showing tachycardia (HR 112 bpm), hypotension primary condition caused by insulin deficiency,
(BP 98/60 mmHg), and tachypnea (RR 26/min with leading to fat breakdown and ketone accumulation
Kussmaul respirations) — suggest dehydration, metabolic (Dhatariya et al., 2020).
acidosis, and compensatory respiratory response (Patti et al.,
2025; Sharma et al., 2023; Park & Khattar, 2024). Fluid Volume Deficit (Dehydration):
Hypotension (BP 98/60 mmHg), tachycardia (HR
Physical findings: dry mucous membranes, poor skin turgor,
112 bpm), dry mucous membranes, and poor skin
and fruity (acetone) odor on breath — consistent with
turgor reflect severe dehydration due to osmotic
dehydration and ketone buildup from fat metabolism.
diuresis, where excess glucose draws water out of
Laboratory abnormalities: low CO₂ (12 mEq/L), low pH
the body through urine (Sharma et al., 2023).
(7.20), low bicarbonate (HCO₃ 10 mEq/L), elevated anion
gap, and positive ketones in urine — confirm metabolic Electrolyte Imbalance (Hyperkalemia risk shifting
acidosis secondary to DKA. to Hypokalemia):
Initial potassium elevation (5.6 mEq/L) is due to
Subjective: insulin deficiency and acidosis causing potassium
Subjective complaints of excessive thirst, frequent urination, to move out of cells. However, insulin and fluid
nausea, blurred vision, and fatigue — demonstrate classic therapy will shift potassium back intracellularly,
symptoms of hyperglycemia and osmotic diuresis due to creating a risk for dangerous hypokalemia and
glucose spilling into the urine. arrhythmias (Sanorwski et al., 2022).
Metabolic Acidosis:
The low pH (7.20), low bicarbonate (10 mEq/L),
and low CO₂ (12 mEq/L) indicate metabolic
acidosis resulting from ketone accumulation and
bicarbonate loss. This condition triggers
compensatory deep, rapid respirations (Kussmaul
breathing) as the body attempts to correct the
acid-base imbalance (Melamed & Raphael, 2021).
Impaired Tissue Perfusion (Cellular level):
Hypotension, tachycardia, and altered mental
status suggest decreased perfusion to vital organs
and tissues. Hyperosmolar blood and dehydration
reduce circulating volume, impairing oxygen
delivery at the cellular level and contributing to
confusion and weakness (Gosmanov et al., 2021).
Prioritize Hypotheses Generate Solutions
1. Diabetic Ketoacidosis (DKA): 1. Diabetic Ketoacidosis (DKA):
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
Name: Click or tap here to enter text.
Course Click or tap here to enter text.
:
Client Information (SBAR) Concept of the Map
T.S. Madison is a 50-year-old female who came to the Emergency Glucose Regulation
Department with extremely high blood sugar levels of 675 mg/dL.
Situation She reports constant thirst, frequent urination, nausea, blurred
vision, and severe fatigue. On arrival, she appears dehydrated,
weak, and lethargic, showing signs of diabetic ketoacidosis (DKA).
The patient has a known history of Type 2 Diabetes Mellitus for
the past eight years but has been noncompliant with her
prescribed metformin due to financial difficulties. She also reports
Background
a recent viral illness and poor food and fluid intake. She has not
taken insulin for three days. There are no known drug allergies.
Family history is positive for diabetes in her mother
Vital signs:
Temperature: 99.2°F (37.3°C)
Heart Rate: 112 bpm (tachycardic)
Blood Pressure: 98/60 mmHg (hypotensive)
Respiratory Rate: 26 breaths/min (deep and rapid
Kussmaul respirations)
SpO₂: 96% on room air
Physical findings: Dry mucous membranes, poor skin turgor, fruity
(acetone) breath odor, confusion, and general weakness.
Laboratory results:
Glucose: 675 mg/dL
Assessment
Sodium: 130 mEq/L
Potassium: 5.6 mEq/L
BUN: 38 mg/dL
Creatinine: 1.8 mg/dL
CO₂: 12 mEq/L
pH: 7.20
HCO₃: 10 mEq/L
Urinalysis: positive for glucose and ketones
Elevated anion gap
Nursing impression: Findings are consistent with Diabetic
Ketoacidosis (DKA) due to severe insulin deficiency, dehydration,
and metabolic acidosis.
Recommendation Begin aggressive fluid replacement with 0.9% normal saline at
15–20 mL/kg/hr to restore intravascular volume. Once potassium
levels are verified as above 3.3 mEq/L, initiate IV regular insulin
infusion at 0.1 unit/kg/hr. Monitor blood glucose hourly, adding
dextrose to fluids once glucose drops below 250 mg/dL to
prevent hypoglycemia. Continue frequent monitoring of
electrolytes, anion gap, and ABG every 2–4 hours. Place the
patient on continuous cardiac monitoring and maintain accurate
intake and output documentation. Provide education once
stabilized about the importance of medication adherence and
, diabetes management.
Recognize Cues Analyze Cues
Objective: Diabetic Ketoacidosis (DKA):
Severely elevated blood glucose level of 675 mg/dL — The combination of a critically high blood glucose
indicates uncontrolled hyperglycemia due to lack of insulin, level (675 mg/dL), metabolic acidosis (pH 7.20,
placing the patient at high risk for diabetic ketoacidosis HCO₃ 10 mEq/L), elevated anion gap, positive
(Gosmanova et al., 2021). urine ketones, Kussmaul respirations, and fruity
breath odor clearly indicate DKA. This is the
Vital signs showing tachycardia (HR 112 bpm), hypotension primary condition caused by insulin deficiency,
(BP 98/60 mmHg), and tachypnea (RR 26/min with leading to fat breakdown and ketone accumulation
Kussmaul respirations) — suggest dehydration, metabolic (Dhatariya et al., 2020).
acidosis, and compensatory respiratory response (Patti et al.,
2025; Sharma et al., 2023; Park & Khattar, 2024). Fluid Volume Deficit (Dehydration):
Hypotension (BP 98/60 mmHg), tachycardia (HR
Physical findings: dry mucous membranes, poor skin turgor,
112 bpm), dry mucous membranes, and poor skin
and fruity (acetone) odor on breath — consistent with
turgor reflect severe dehydration due to osmotic
dehydration and ketone buildup from fat metabolism.
diuresis, where excess glucose draws water out of
Laboratory abnormalities: low CO₂ (12 mEq/L), low pH
the body through urine (Sharma et al., 2023).
(7.20), low bicarbonate (HCO₃ 10 mEq/L), elevated anion
gap, and positive ketones in urine — confirm metabolic Electrolyte Imbalance (Hyperkalemia risk shifting
acidosis secondary to DKA. to Hypokalemia):
Initial potassium elevation (5.6 mEq/L) is due to
Subjective: insulin deficiency and acidosis causing potassium
Subjective complaints of excessive thirst, frequent urination, to move out of cells. However, insulin and fluid
nausea, blurred vision, and fatigue — demonstrate classic therapy will shift potassium back intracellularly,
symptoms of hyperglycemia and osmotic diuresis due to creating a risk for dangerous hypokalemia and
glucose spilling into the urine. arrhythmias (Sanorwski et al., 2022).
Metabolic Acidosis:
The low pH (7.20), low bicarbonate (10 mEq/L),
and low CO₂ (12 mEq/L) indicate metabolic
acidosis resulting from ketone accumulation and
bicarbonate loss. This condition triggers
compensatory deep, rapid respirations (Kussmaul
breathing) as the body attempts to correct the
acid-base imbalance (Melamed & Raphael, 2021).
Impaired Tissue Perfusion (Cellular level):
Hypotension, tachycardia, and altered mental
status suggest decreased perfusion to vital organs
and tissues. Hyperosmolar blood and dehydration
reduce circulating volume, impairing oxygen
delivery at the cellular level and contributing to
confusion and weakness (Gosmanov et al., 2021).
Prioritize Hypotheses Generate Solutions
1. Diabetic Ketoacidosis (DKA): 1. Diabetic Ketoacidosis (DKA):
