DKA

Question 1

Outline a primary survey

Answer 1

-A: AVPU (awake, responds to verbal stimuli, responds to painful stimuli, unresponsive), continue if responsive, check for airway obstruction, is the airway patent, is the patient having trouble speaking
-B: resp rate, SpO2, clear and equal breath sounds, lung auscultation, tracheal position, adjust position of pt to help breathe
-C: skin color, sweating, capillary refills, pulse, IV access, blood pressure, ECG, elevate legs and give water to increase BP
-D: pupils, GCS (eye open spontaneously, oriented to time, person and place, obeys commands (squeeze fingers)
-E: politely ask for consent to expose skin, look for cuts and bruises, pressure sores, rashes, bleeding, wound infections, check posterior

Question 2

What do you do when you enter the room

Answer 2

-Hi Jess, my name is Stephanie, I am a junior nurse, is there anything I can do assist you

Primary survery
Airway:
-I’m checking if Jess is awake, responsive to voice, touch or stimuli or unresponsive
-I’m going to check Jess’s airway as she was admitted for nausea and vomiting
Breathing:
-Now I’m going to check Jess’s respiratory rate, oxygen saturation, clear and equal breath sounds, lung auscultation, is Jess having difficulty breathing, if so I’d like to sit her up
Circulation:
-I need to check her skin, warmth, sweating, capillary refills, pulse, IV access, blood pressure, ECG, elevate legs and give water to increase BP
-I’m going to call a MET call as her IV has become disconnected, I’m going to turn it off
Disability:
-GCS, pupils, oriented to time, place and person, can Jess squeeze my fingers
-Take her BGL and ketones
Exposure:
-expose the skin to look for rashes, bleeding, sores on the front and back
-I’m going to measure the urine output

As a result of Jess’s
-hypotension
-weakness
-rapid pulse
-vomiting
-confusion
-stupor
-urine output
-disconnection from insulin IV
-BGL

I have found that jess has diabetic ketoacidosis

Jess will need fluids, electrolyte replacement and insulin therapy

Question 3

What findings in an assessment would indicate diabetic ketoacidosis

Answer 3

-high BGL (greater than 11mmol/L)
-unresponsive
-Rapid, deep respirations
-Soft sunken eyeballs
-Hypotension, drop in BP
-Weak
-Rapid pulse
-Dry mouth
-Vomiting
-Fruit breath
-Restlessness
-Confusion
-Stupor
-coma

Question 4

What indicates Jess has DKA

Answer 4

-hypotension
-weakness
-rapid pulse
-vomiting
-confusion
-stupor
-urine output
-disconnection from insulin IV
-BGL

Question 5

What intervention does Jess require

Answer 5

fluids, electrolyte replacement and insulin therapy

Question 6

Why does Jess need fluids

Answer 6

-To replace the fluids lost through excessive urination from DKA

Question 7

Why does Jess need electrolyte replacement

Answer 7

-Too little insulin can lower the level of several electrolytes in the blood
-IV electrolytes are given to help keep the muscles, heart and nerve cells working as they should

Question 8

Why does Jess need insulin therapy

Answer 8

-Jess’s IV was disconnected
-Insulin therapy reverses DKA
-regular insulin level will be acquired when BGL is above 11mmol/L