Diabetic Ketoacidosis (DKA)
Diana Humphries, 45 years old
Primary Concept
Fluid and Electrolyte Balance
Interrelated Concepts (In order of emphasis)
1. Acid-Base Balance
2. Glucose Regulation
3. Infection
4. Pain
5. Clinical Judgment
© 2016 Keith Rischer/www.KeithRN.com
, RAPID Reasoning Case Study: STUDENT
Diabetic Ketoacidosis (DKA)
History of Present Problem:
Diana Humphries is a 45-year-old woman with chronic kidney disease stage III and diabetes mellitus type1 who checks
her blood sugar daily, or whenever she feels like it. She has been feeling increasingly nauseated the past 12 hours. She has
had a harsh, productive cough of yellow sputum the past three days. She checked her blood glucose before going to bed
last night and it was 382, but then she fell asleep early and missed her bedtime dose of glargine (Lantus) insulin. When
she awoke this morning, she had generalized abdominal pain and continued to feel nauseated and had a large emesis. Her
glucometer was unable to read her blood glucose because it was too high. She took 10 units of lispro (Humalog) insulin
this morning. Her nausea has increased all morning and she has been unable to eat or keep anything down despite having
an increased thirst and appetite. She also has had increased frequency of urination. When her lunchtime glucometer gave
no reading because it was too high and out of range, she called 9-1-1 to be evaluated in the emergency department (ED).
Personal/Social History:
Diana has been inconsistently compliant with her medical/diabetic regimen due to her struggles with anxiety and
depression that have worsened since her mother died three months ago. She considers 200 a good blood sugar reading.
She is divorced with no children and has been homeless and has lived in a shelter off and on the past month. She is on
Social Security disability because of complications related to diabetes. At one point during the intake interview, she
expressed to the nurse, “I’m going to die anyway, why does all this matter?”
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
- Chronic Kidney Disease - Decreased function of the kidneys and if the patient is in DKA
(diabetic ketoacidosis) there is an increase load on the kidneys due
- Type 1 Diabetes, checks BG daily or to polyuria.
whenever she feels like it - This puts her at risk for developing DKA especially since she
doesn’t check her BG regularly sometimes
- BG of 382, fell asleep and didn’t take - Blood glucose already high before bed so we know it was high for
her long-acting (Lantus) insulin at a while before she called (9-1-1) emergency.
bedtime
- Generalized abdominal pain, nausea, - Signs and symptoms of hyperglycemia
emesis
- Increased thirst, appetite and urination - Signs and symptoms of hyperglycemia
- At lunchtime she use her glucometer
and gave no reading because it was too - Severe hyperglycemia sign
high to measure
RELEVANT Data from Social History: Clinical Significance:
- Divorced/ no children - Lacks family support
- Homeless, lives in a shelter for the past - Other struggles to deal with on top of her illness
month
- Inconsistent with medication regimen - She is non-compliant
- Considers a BG of 200 to be good - Lack of education/non-compliance
- Death of mother - Feeling hopeless which could contribute to her non-compliance
- Suicidal ideation - Feeling hopeless which could contribute to her non-compliance
- Struggles with anxiety & depression - This can also contribute to non-compliance
Patient Care Begins
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 101.6 F/38.7 C (oral) Provoking/Palliative: Coughing and deep breathing/Not coughing
P: 114 (regular) Quality: Sharp
Diana Humphries, 45 years old
Primary Concept
Fluid and Electrolyte Balance
Interrelated Concepts (In order of emphasis)
1. Acid-Base Balance
2. Glucose Regulation
3. Infection
4. Pain
5. Clinical Judgment
© 2016 Keith Rischer/www.KeithRN.com
, RAPID Reasoning Case Study: STUDENT
Diabetic Ketoacidosis (DKA)
History of Present Problem:
Diana Humphries is a 45-year-old woman with chronic kidney disease stage III and diabetes mellitus type1 who checks
her blood sugar daily, or whenever she feels like it. She has been feeling increasingly nauseated the past 12 hours. She has
had a harsh, productive cough of yellow sputum the past three days. She checked her blood glucose before going to bed
last night and it was 382, but then she fell asleep early and missed her bedtime dose of glargine (Lantus) insulin. When
she awoke this morning, she had generalized abdominal pain and continued to feel nauseated and had a large emesis. Her
glucometer was unable to read her blood glucose because it was too high. She took 10 units of lispro (Humalog) insulin
this morning. Her nausea has increased all morning and she has been unable to eat or keep anything down despite having
an increased thirst and appetite. She also has had increased frequency of urination. When her lunchtime glucometer gave
no reading because it was too high and out of range, she called 9-1-1 to be evaluated in the emergency department (ED).
Personal/Social History:
Diana has been inconsistently compliant with her medical/diabetic regimen due to her struggles with anxiety and
depression that have worsened since her mother died three months ago. She considers 200 a good blood sugar reading.
She is divorced with no children and has been homeless and has lived in a shelter off and on the past month. She is on
Social Security disability because of complications related to diabetes. At one point during the intake interview, she
expressed to the nurse, “I’m going to die anyway, why does all this matter?”
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
- Chronic Kidney Disease - Decreased function of the kidneys and if the patient is in DKA
(diabetic ketoacidosis) there is an increase load on the kidneys due
- Type 1 Diabetes, checks BG daily or to polyuria.
whenever she feels like it - This puts her at risk for developing DKA especially since she
doesn’t check her BG regularly sometimes
- BG of 382, fell asleep and didn’t take - Blood glucose already high before bed so we know it was high for
her long-acting (Lantus) insulin at a while before she called (9-1-1) emergency.
bedtime
- Generalized abdominal pain, nausea, - Signs and symptoms of hyperglycemia
emesis
- Increased thirst, appetite and urination - Signs and symptoms of hyperglycemia
- At lunchtime she use her glucometer
and gave no reading because it was too - Severe hyperglycemia sign
high to measure
RELEVANT Data from Social History: Clinical Significance:
- Divorced/ no children - Lacks family support
- Homeless, lives in a shelter for the past - Other struggles to deal with on top of her illness
month
- Inconsistent with medication regimen - She is non-compliant
- Considers a BG of 200 to be good - Lack of education/non-compliance
- Death of mother - Feeling hopeless which could contribute to her non-compliance
- Suicidal ideation - Feeling hopeless which could contribute to her non-compliance
- Struggles with anxiety & depression - This can also contribute to non-compliance
Patient Care Begins
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 101.6 F/38.7 C (oral) Provoking/Palliative: Coughing and deep breathing/Not coughing
P: 114 (regular) Quality: Sharp
