DKA Case Study Flashcards
S&S from case study~
Warm/flushed
nauseous
vomiting
3 day fever
diarrhea
fruity breath
did not take insulin
respirs deep and rapid
thirsty can’t keep down
trip to mexico
DM1#
What extra questions for mom~
What changes brought to ED
when did last keep down
When last dip stick urine
Last insulin
Last glucose check/what was?
Did mom notice neuro status?#
Patho DKA~
Insulin doesn’t exist
cells can’t take up glucose
body breaks down fats
produce ketones
ketones are acidic
body becomes acidotic
glucose is high
shifts water out of cells
dehydrated
body tries to blow off acidosis
breath becomes deep and rapid#
What do we produce under stress (hormones)~
Cortisol: increases glucose
Adrenal cortex: norepinephrine and epinephrine (which increase blood glucose for energy)
growth hormone
glucagon: increases glucose
counterregulatory mechanisms are adding fuel to the fire#
Why is BP low~
losing fluid - dehydration
osmotic diuresis due to fluid shift from high solutes in the bloodstream
could go into hypovolemic shock#
Why is HR high~
compensation for hypovolemia#
Why respirs are rapid and high~
compensatory to blow off CO2 and rebalance acid-base
due to metabolic acidosis#
Why fever?~
Infection
or
dehydration#
DKA is always directly correlated to glucose level (T/F)~
F
could be moderately high (300) or super high (1000)
has more to do with electrolyte imbalance#
Why potassium high?~
Hydrogen ions: low bicarb, acidosis, K+ shifts out of the cell so that H+ can go into the cell - compensation -> high K+
Insulin drives K+ into the cell so much watch#
Appropriate vs Inappropriate orders~
Appropriate:
- give 2 L NS 0.9%
- Bed rest
- Urinary OP every hour
Inappropriate:
- LR (research does say its fine)
- Lasix
- VS every SHIFT (more freq)
- 36 units of NPH SQ (too long)
- 20 units of regular SQ (IV)
- CBC, cultures, CCUA, stool, ABG (neuro status makes clean catch hard - she’ll be catheterized)
- carb controlled (she’ll be NPO)
- Tylenol PO (should be rectal)#
5 additional interventions for the patient~
Indwelling urinary catheter
Strict I&O
ABG’s
Glucose monitoring (per hour)
ABX broad spectrum
Telemetry (K+)
Zofran
CBC and other electrolytes
CMP
Insulin drip
ICU or step down#
3 priorities to fix for this patient~
Rehydration
Correct electrolytes
Before giving insulin, must check K+ (if <3.3 cannot give insulin)
correct glucose slowly (if fast, causes cerebral edema)#
Example ABG for DKA~
pH 7.26, Pao2 94, Paco2 23, HCO3 18
Low pH
Low bicarb
low CO2 (due to Kussmauls)#
What telemetry waves are expected for high K+~
Tall, tented, peaked T waves and widened QRS complexes
repolarization
(presence of a U wave and ST segment depression would be hypokalemia)#
What IV fluid changes would be needed after glucose is lower and K+ is higher after a few hours~
add D5 NS when glucose is between 250 and 300
don’t let glucose to go low too fast
add K+#
Do not hang insulin to gravity~
high risk drug
2 RNs have to sign off
(never hang U500, only U100)
(need dual sign off for U500)#
Why are neuro symptoms late symptoms for DKA~
It is not from lack of glucose, since the brain doesn’t store glucose
It is from the acidosis#
Difference between DKA and HHS~
presence of ketones#
