Type 1 Diabetes Mellitus Type I/DKA UNFOLDING Reasoning

Type 1 Diabetes Mellitus Type I/DKA UNFOLDING Reasoning Jack Anderson, 9 years old Primary Concept Glucose Regulation Interrelated Concepts (In order of emphasis) ● Fluid and Electrolyte Balance ● Acid-Base Balance ● Clinical Judgment ● Patient Education ● Communication ● Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment Management of Care 17-23% Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity Basic Care and Comfort 6-12% Pharmacological and Parenteral Therapies 12-18% Reduction of Risk Potential 9-15% Physiological Adaptation 11-17% History of Present Problem: Jack Anderson is a 9-year-old boy who presents to the emergency department because he has been more sleepy and his breathing is “not normal;” it is deeper and faster, according to his parents. Jack was sick with a respiratory virus two weeks ago but has since recovered. Jack began feeling more tired a few days ago when he started to complain of abdominal pain, headache, muscle aches, and consistently being hungry and thirsty. He is urinating more frequently during the day and at night. His mother reports a normal full-term pregnancy and Jack has been healthy with no known medical conditions. Personal/Social History: Jack lives with both parents and two siblings; a younger sister four years old and a 12-year-old brother. Both parents work as middle school teachers in the community. Jack is in the 4th grade and earns above-average marks. He is physically active and plays soccer on the school team. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: He's more sleepy His breathing is "not normal" it's deeper and faster Was sick with a respiratory virus 2 weeks ago Always hungry and thirsty Fatigue is a common symptom and can result from high blood sugar levels Kussmaul breathing is rapid or labored breathing, a symptom of DKA Lack of insulin or insulin resistance helping convert food to energy causes increased hunger and thirst RELEVANT Data from Social History: Clinical Significance: Has a support system from family Physically active, plays soccer Shows he will get the care he needs with his support system Being active can lead to hypoglycemia once he manages his diabetes Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 100.4 F/38.0 C (oral) Provoking/Palliative: Made worse with solid food. P: 136 (regular) Quality: Dull and aching R: 44 (deep/rapid) Region/Radiation: Confined to abdomen, generalized within abdominal region BP: 80/48 Severity: He states his pain is a 4/10 on the numeric scale. O2 sat: 98% on RA Timing: States, “All the time” Weight: 64.0 lbs/29.1 kg What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: T: 100.4 F (oral) High temperature could be a sign of infection P: 136 (regular) Tachycardia is present R: 44 (deep/rapid) Kussmaul respirations is present BP: 80/48 Very low blood pressure, could be a sign of dehydration with the excessive urination Pain: Made worse with solid food, dull and aching, generalized within abdominal region, states pain is all the time Abdominal pain could be a side effect of not getting enough insulin Current Assessment: GENERAL SURVEY: Lying on the bed with eyes closed, whimpers with touch, recognizes mom and dad. Fruity odor to the breath. NEUROLOGICAL: Lethargic, responding to parents with one-word phrases. Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Eyes appear “sunken,” mucus membranes dry, tacky mucosa, chapped lips. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, respirations are deep and rapid CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses slightly weak/thready, equal with palpation at radial/pedal/post-tibial landmarks, cap refill 2 seconds. Heart tones audible and regular, S1 and S2, noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. ABDOMEN: Abdomen round, soft, and tender to light palpation. BS active in all four quadrants, feeling nauseated GU: Voiding large amounts of clear light yellow urine INTEGUMENTARY: Skin warm, dry, itchy, flushed, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor nonelastic, tenting present. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: General Survey – whimpers with touch,fruity odor to the breath Neurological – lethargic HEENT – eyes appear sunken, mucus membranes dry, tacky mucosa, chapped lips Respiratory – respirations are deep and rapid Abdomen – tender to light palpation, feeling nauseated GU – voiding large amounts of clear light yellow urine Integumentary – warm, dry, itchy, flushed, turgor nonelastic, tenting present Fruity odor to breath is when ketones rise to unsafe levels Lethargic is caused by dehydration Sunken eyes, mucus membranes dry, tacky mucosa, and chapped lips are caused by dehydration Weak/thready pulse and possibly cap refill being slow is caused by dehydration Being tender is a sign of insulin deficiency Urinating a lot is a sign of diabetes All of these are an indication of dehydration Based on the clinical cues collected so far by the nurse, what additional data is needed ASAP to determine the most likely problem and identify the nursing priority? What orders should the nurse anticipate? Additional Clinical Data Needed: Orders to Anticipate: Blood glucose IV fluids and insulin Lab Results: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 6.2 16.1 252 58 0 Most Recent: 7.2 14.2 210 52 0 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Hgb 14.2 Increased Hgb due to dehydration Worsening Basic Metabolic Panel (BMP) Na K Gluc. Creat. CO2 (Bicarb) Current: 130 5.5 680 1.4 16 Most Recent: 138 4.1 118 0.7 22 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Na 130 Hyponatremia occurs may be the cause of the nausea All worsening K 5.5 Hyperkalemia may make your heart beat irregularly Gluc 680 Hyperglycemia cause increase hunger, thirst, fatigue Creat 1.4 This elevated is the new onset of diabetes CO 2 16 This may be the cause of the abdominal pain DKA Magnesium Phosphorus Beta- hydroxybutyrate Current: 2.4 2.8 Positive What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: Beta-hydroxybutyrate If this lab is positive DKA is present Urinalysis + UA Micro Color: Clarity: Sp. Gr. Protein Gluc. Ket. Nitr. LET RBCs WBCs Bact. Epi. Current: Lt. yellow Clear 1.015 Neg 4+ 4+ Neg Neg 0 3 None none What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: Specific Gravity This is increased when dehydration is present Glucose High blood sugar Ketones DKA and dehydration WBC Infection is present Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation) Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Potassium Value: 5.5 mmol/L Critical Value: >5.5 mmol/L This value is critically high with symptoms of irregular heartbeat and slow, weak, or even absent pulse. Monitor cardiac rhythms and give insulin Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Glucose Value: 680 mg/dL Critical Value: >200 mg/dL This value is high also with symptoms of frequent urination, fatigue, increased thirst IV fluids and monitor glucose levels Clinical Reasoning Begins… 1. Interpreting relevant clinical data, what is the primary problem(s)? What primary health-related concepts does this primary problem represent? (NCSBN: Step 2 Analyze cues/NCSBN: Step 3 Prioritize hypotheses Management of Care/Physiologic Adaptation) Problem(s): Pathophysiology of Problem in OWN Words: Primary Concept: DKA with new onset of diabetes mellitus type 1 The body has an insulin deficiency causing high levels of glucose. The lack of insulin in the body is causing the body to metabolize fats and proteins for energy. This starts the form of ketones. Blood glucose management 2. Is this patient at risk for a change in status that could lead to an adverse outcome due to age, susceptible host, or other factors? (NCSBN: Step 2 Analyze cues/Management of Care) Risk Factors for Developing Complication: Rationale: Age His smaller body increases the risk almost complete volume depletion due to the dehydration 3. What is the worst possible/most likely complication(s) to anticipate based on the primary problem of this patient? (NCSBN: Step 2 Analyze cues/Reduction of Risk Potential/Physiologic Adaptation) Worst Possible/Most Likely Complication to Anticipate: Hypovolemic shock Nursing Interventions to PREVENT this Complication: Assessments to Identify Problem EARLY: Nursing Interventions to Rescue: Fluid replacement therapy Accurate I&O Urinalysis, elevated potassium, serum lactate, and blood urea nitrogen levels, increased partial pressure of carbon dioxide. Monitor weight, monitor vital signs, safe administration of fluids Collaborative Care: Medical Management 4. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: Establish two large bore peripheral IVs Admit to the Pediatric ICU NPO Vital signs every 30 minutes with neurological checks every Hour Continuous cardiac monitor STAT finger stick for blood glucose then every one hour Administer NS 20 mL/kg IV BOLUS (over one hour) then begin ½ NS with 20 mEq KCL at maintenance rate (1,000 mL for first 10 kg + 500 mL for next 10 kg over 24 hours) After fluid bolus start IV Regular insulin infusion at 0.05unit/kg/hour Getting as much fluid in the patient as possible Nurses and doctor specialize in pediatric care Stabilizes blood glucose Vitals and neuro checks can present early signs of any changes Monitor for any dysrhythmias caused by the increased potassium levels Need to check blood glucose ASAP for levels Need to rehydrate the patient Insulin is needed to regulate the blood glucose levels IV in place Healthcare team can monitor closely Blood glucose stabilizes Vitals and neuro checks will be normal Will have normal sinus rhythms during the monitoring Levels within normal limits Levels that are high or low will be brought back to normal due to the rehydration The blood glucose won't get too low Once blood glucose level is less than 300 mg/dL or the blood glucose fall is more than 100 mg/dL, change IV fluids above to Dextrose 5% in 0.45 NaCl Help balance out the blood glucose levels Stabilize blood glucose levels with 20 mEq KCL Strict I &O and daily weight Ondansetron 2 mg/mL IV push prn every 4 hours nausea Acetaminophen suppository per rectum 350 mg PRN every 4 hours comfort or temp > 38.5 C (>101.3 F) Daily weight monitors any changes that could be caused Ondansetron helps with nausea Acetaminophen helps with the abdomen pain Weight will be stable Patient will experience no nausea Patients abdomen pain will subside PRIORITY Setting: 5. Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: Order of Priority: Rationale: ● Obtain finger stick blood glucose ● Start IV insulin after bolus is given and monitor blood glucose carefully ● Obtain VS ● Accurate I and O ● Place on a cardiac monitor ● Initiate two large bore IVs and administer fluid bolus followed by maintenance/replacement 1. Initiate two large bore IVs and administer fluid bolus followed by maintenance/replacement 2. Obtain finger stick blood glucose 3. Obtain VS 4. Place on a cardiac monitor 5. Start IV insulin after bolus is given and monitor blood glucose carefully 6. Accurate I and O 1. Have to correct the dehydration 2. Monitor the blood glucose levels 3. Monitor vitals and making sure they are within normal limits 4. Monitor for any dysrhythmias caused by the increased potassium levels 5. Monitor to make sure the insulin is effective 6. Making sure there are no changes from the fluid being pumped in the body Collaborative Care: Nursing 6. What nursing priority (ies) will guide your plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action Management of Care) Nursing PRIORITY: Risk for Unstable Blood Glucose Level PRIORITY Nursing Interventions: Rationale: Expected Outcome: Monitor blood glucose level prior meals and at bedtime. Administer insulin as directed Blood glucose should be between 140 to 180 mg/dL. Brings blood glucose levels down Maintained blood glucose levels Decreased blood glucose levels 7. What body system(s) will you assess most thoroughly based on the primary/priority concern? (Reduction of Risk Potential/Physiologic Adaptation) PRIORITY Body System: PRIORITY Nursing Assessments: Cardio Neuro Renal Heart rate and blood pressure LOC and breathing patterns I&O and daily weights 8. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES: Stress management PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT: Show the pt you care and make sure he is comfortable To break the stress the patient is experiencing so he can be happier and healthier Faster improvement EMOTIONAL (How to develop a therapeutic relationship): By starting to talk about the patient's hobbies and interests and trying to maintain healthy communication between you and his family By talking about his hobbies and interest will help him open up to you so he will feel comfortable asking questions and talking to you He will talk and understand what is going on Dosage Calculations ● Weight 64 lbs. Convert to kg: 29.1 kg. ● Administer 0.9% NS 20 mL/kg bolus over one hour. Calculate IV bolus: 582 mL. ● Administer regular insulin infusion at 0.05 units/kg/hour. Calculate units/hour: 1.5 units/hr. ● Regular insulin IV is 250 units/250 mL 0.9% NS. Calculate hourly IV drip rate: 2 mL/hr Evaluation: Four hours later… Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Current VS: Admission (4 hours): Current PQRST: T: 98.9 F/37.2 C (oral) T: 100.4 F/38.0 C (oral) Provoking/Palliative: P: 92 (reg) P: 136 (regular) Quality: Dull and aching R: 24 (reg) R: 44 (deep/rapid) Region/Radiation: Confined to abdomen, generalized within abdominal region BP: 100/60 BP: 80/48 Severity: 2/10 numeric scale O2 sat: 98% on RA O2 sat: 98% on RA Timing: States “All the time” Blood Glucose: 442 Current Assessment: GENERAL SURVEY: Pleasant, in no acute distress, calm, body relaxed, no grimacing, appears to be resting comfortably. NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. ABDOMEN: Abdomen round, soft, and nontender. BS active in all 4 quadrants GU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present. 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable: P: 92 R: 24 BP: 100/60 Glucose 442 pain is still dull and aching and in abdomen region Vitals are improving with treatment and blood glucose is decreasing Still high and may need more insulin therapy This could still be from being dehydrated All are improving RELEVANT Assessment Data: Clinical Significance: TREND: Improve/Worsening/Stable: General survey HEENT Cardiac Integumentary Patient not in any pain as he is resting comfortably Mucous membranes are moist Pulses are strong Still dry but showing improvement with hydration All are improving 2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (NCSBN: Step 6 Evaluate outcomes/Management of Care, Physiological Adaptation) Evaluation of Current Status: Modifications to Current Plan of Care: Everything has improved with the treatment No modifications 3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/Management of Care) CURRENT Nursing PRIORITY: Maintain all levels PRIORITY Nursing Interventions: Rationale: Expected Outcome: Continue doing everything that has been done Doing all the current interventions is improving the levels Levels continue improving It is now the end of your shift. Effective and concise handoffs are essential to excellent care and, if not done well, can adversely impact the care of this patient. You have done an excellent job to this point; now finish strong and give the following SBAR report to the nurse who will be caring for this patient: (Management of Care) Situation: Name/age: Jack Anderson, 9 y.o. male BRIEF summary of primary problem: Jack is lethargic, has deep rapid respirations, abdomen pain and signs of dehydration. Blood glucose levels are extremely high 680 mg/dL Background: Primary problem/diagnosis: DKA RELEVANT past medical history: Pt. had a respiratory infection two weeks ago that he has since recovered from. RELEVANT background data: Has a very active lifestyle Assessment: Most recent vital signs: T: 98.9°F, P: 92 (reg), R: 24 (reg), BP: 100/60, O2 Sat: 98% on RA, Continuous generalized abdominal pain described as dull and aching rated at a 2/10 with no specific provoking or palliative actions RELEVANT body system nursing assessment data: Alert & oriented x3, mucous membranes moist, respirations normal, and blood pressure is within a normal limit. RELEVANT lab values: Blood glucose is now 442 TREND of any abnormal clinical data (stable-increasing/decreasing): All abnormal data are improving How have you advanced the plan of care? He will start getting insulin regularly Patient response: His levels are maintaining good levels INTERPRETATION of current clinical status (stable/unstable/worsening): His current clinical status is stable Recommendation: Suggestions to advance the plan of care: Continue with the plan of care Education Priorities/Discharge Planning What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance) Education PRIORITY: Managing blood glucose levels PRIORITY Topics to Teach: Rationale: Insulin administration Signs & symptoms of hyper/hypoglycemia He needs to know how to administer his own insulin if the situation arises nobody else can He needs to know what to look out for when something is going wrong and how to correct it quickly Caring and the “Art” of Nursing What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? (Psychosocial Integrity) What Patient is Experiencing: How to Engage: He is scared and has anxiety due to not knowing what is going on Let him know that these things do happen and it's okay. Educate him and encourage him to ask questions about anything Use Reflection to Develop Clinical Judgment What did you do well in this case study? What knowledge deficits did you identify? I want to work in the peds area so I think my area I did well in was being able to talk to the pt and try to calm him down and reassure him that everything was going to be okay. I am still learning about DKA because I did not know much about it in the first place. What did you learn? How will you apply learning caring for future patients? Diabetes is very complex and that there are a lot of things that can trigger it. Definitely knowing the signs and symptoms of this and explain things to my pt in ways they can understand because if their age.