Diabetes Mellitus Type I/DKA SKINNY Reasoning Jack Anderson, 9 years old

Diabetes Mellitus Type I/DKA SKINNY 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 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%  SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data 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 -Always hungry and thirsty -was sick with a respiratory virus 2 weeks ago Fatigue is a symptom Deeper and faster is known as Kussmaul breathing, which is a symptom of DKA if insulin is unable to convert food to energy it causes increased hunger and thirst RELEVANT Data from Social History: Clinical Significance: physically active and plays soccer he is active and is getting the necessary exercise for his age group 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: Temp Pulse Respirations BP A high temperature could be a sign of an infection tachycardia kussmaul low blood pressure could be a sign of dehydration since he is urinating more often 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 Neuro HEENT Respiratory Cardiac fruity odor to breath occurs with high ketone levels lethargic- dehydrated Eyes sunken, mucus membranes dry, tacky mucosa, chapped lips- dehydration kussmaul’s respiration weak pulse, slow cap. refill- 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