Transcript Peds Case Study #3: DKA - My Nursing Portfolio

*
DKA
Diabetic Ketoacidosis
*
*Ryan is a 5 year old male transferred from the PICU to the
med/surg unit
*Dx:
* Diabetic ketoacidosis
* Diabetes type 1 (new diagnosis)
*Hx:
* Lethargic and decreased LOC this afternoon with increased
appetite and fluid intake x 3 days. No other hospital
admissions/surgeries
*Objective Findings:
*
*Vitals:
*BP 110/56, HR 88, RR 20, Temp 98.5 PO
*Wt:
*36.2kg or 79.64lbs
* Percentile on growth chart for Wt: >99%
*Subjective Findings:
*Patient active and playful.
*No c/o pain
*Labs:
*
*Blood sugar =115-225
*Urine dip sticks=positive for ketones
*Other blood work within normal
limits
*Other:
*Parents present at bed side; father is
a RT. While admitted in PICU, family’s
home burned down along with the
loss of two pets and pt is unaware
*
*Humulin-R (sliding scale) SC
*70-130=0 unit
*131-180=2 units
*181-240=4 units
*Lantus
*7 units SC q morning
*Tylenol
*360mg PO pain/fever
*Diet:
*Regular for age, limit sweets
*Activity:
*Ad lib (as desired)
*Vitals:
*Every 4 hours
*BS check ac (TID) and HS
*Daily weight
*Initial diabetic educator
consultation
* nutrition, insulin administration,
and location sites reviewed.
*Call physician with any concerns or
change in patient condition
*
*
*Patient assessment this
morning:
*BS at 0730 is 142
*Vital signs are stable
*Lungs: clear
*Heart: regular rhythm, no abnormal
sounds
*Patient is alert, playful, but appears
to be afraid of needles
*Patient’s mother is at bedside and
appears exhausted but pleasant.
*
*BS 142 @ 0730
*Blood work within normal limits
*Vital signs stable
*Lung and Heart assessments within normal limits
*Pt is alert and playful
*Pt is fearful of needles
*
*Additional data to obtain before you notify the physician
about this patient includes:
*The trend of the patients weight since admission
*If Ryan has a change in hunger and thirst since admission
*Any change in LOC
*The trend of ketones in the urine
*
*It is not an emergency, just calling to update the
physician about Ryan’s current status.
*Patient's blood glucose is under control
*Patient is stable and he does not show any signs or
symptoms of DKA
*Vital signs are stable
*Assessment within normal limits
*If any signs and symptoms of hypoglycemia,
hyperglycemia and complications of DKA (cerebral
edema) occurs, the physician and neurosurgeon will
be notified immediately
*
Nurse: “Hello Dr. Scarlett I’m Emma, the nurse taking care of Ryan, a 5 year
old admitted the other day in the PICU for DKA. Ryan is newly dx with type 1
diabetes. Ryan is currently stable on the med surg floor. At 07:30AM this
morning, Ryan’s BS was 142, his heart sounds are regular rhythm, no
abnormal sounds, lungs are clear, and he is alert and playful. Vitals and labs
are within normal limits with some traces of ketones. The diabetes educator
came in this morning and discussed nutrition, insulin administration and sites
with the family. The patient is taking Lantus 7 units SC q morning and
Humilin-R (sliding) SC at this time.”
“However, I’m concerned that because Ryan is afraid of needles at his age
that it is going to be hard to manage his diabetes. Therefore, In order to
reduce needle exposure I want to request getting him a insulin pump or
consider changing his current insulin regimen to a mixture of rapid acting
and a intermediate-acting insulin. That way it will cover Ryan throughout the
day and reduce getting needle stick to only twice a day.”
Physician: “Ok when I make my rounds, I will discuss the changes of insulin
with the family and determine whether the patient should use the insulin
pump. I want you to make sure the family understands this new medication
change and for you to monitor the patient’s blood glucose closely to see how
he tolerates the change. Notify me if there are any signs of
hypo/hyperglycemia to which we will reevaluate the medication order.”
*
*What orders might you expect or request from the
physician if applicable?
*Ryan is afraid of needles so request a insulin mixture to
reduce needle exposure and cover the pt throughout
the day. Or consider a insulin pump.
*
*Continuous reassessment and monitoring
*Reduce the amount of needle sticks
*Teach patient to cope with finger
sticks/needles
*Daily weight
*Food/beverage log (intake and output)
*BS check ac (TID) and at bedtime
*Contact social worker because Ryan’s house
was burned down and he and his family are
homeless
*Offer the mom a break
Highest priority is BS check ac (TID) and at
bedtime to monitor pt condition, because the
physician changed the patient's insulin order.
*
* Hypoglycemia
* Chills, shakiness, sweating, headaches, and confusion
* DKA
* Hyperglycemia, ketones in the urine
* Polyuria, polydipsia, polyphagia,
* Hypokalemia
* Blood pressure - Usually normal until terminal stages of illness
* Tachycardia - May be present
* Capillary refill - Initially maintained, but a combination of increasing acidosis and
dehydration cause poor tissue perfusion
* Kussmaul breathing
may be mistaken for status asthmaticus, pneumonia, and even
hysterical hyperventilation,
* Fruity odor on breath - patient may have a smell of ketones on the breath, although
many people cannot detect this smell
* Weakness and fatigue.
* Impaired consciousness- occurs in approximately 20% of patients
* Coma - may be present in 10% of patients
* Abdominal tenderness - tenderness is usually nonspecific or epigastric in location; bowel
sounds may be reduced or absent in severe cases, nausea/vomiting
* Cerebral edema
*
* Hypoglycemia
* Treated by giving 15 grams of fast acting carbohydrates (OJ or candy). Make sure patient,
family
members, and teachers are aware of the signs/symptoms of hypoglycemia and have something
containing sugar with them at all times. Check BS afterwards.
* DKA
* Primary prevention involves
making sure pt, family members, and teachers know how to identify DKA
early signs /symptoms , check BS routinely, and to call 911/bring to the ED if symptoms occur
* ABCs [airway, breathing, circulation]).
* Give oxygen, Diagnose by clinical history, physical signs, and elevated blood glucose.
* Restore fluid. child should be weighed and height .Once a line is established, an isotonic solution is
infused. Normal saline (0.9% sodium chloride) is the fluid of choice. After initial 0.9% NaCl bolus,
rehydration/maintenance should be continued with 0.45% NaCl.
* Continuous intravenous insulin infusion is usually commenced one to two hours after starting fluid
replacement. With insulin infusion the rate of glucose decline should be 50–150 mg/dL (2.8–8.3
mmol/L/hour), but not >200 mg/dL (11 mmol/L/hour).
* Specifically designed recording charts (measurements of clinical and biochemical status, fluid balance,
and insulin prescription.
* Patients with diabetic ketoacidosis using an insulin pump, need it removed during treatment
* Cerebral Edema
* Frequent review of neurologic status—at least hourly (or any time a change in the level of
consciousness is suspected)—is essential during the first 12 hours of diabetic ketoacidosis treatment.
* Promptly treat any suspected cerebral edema with osmotic diuretic, CT scan and referral to a
neurosurgeon.
*
* Record blood pressure, temperature, pulse and respiration.
* Record blood glucose levels
* Obtain height and weight.
* Administer and monitor intravenous fluids.
* Cerebral edema- Mannitol 0.5-1 g/kg infused over 30 minutes, which
can be repeated after 1 hour. The usual dose of hypertonic saline is 510 mL/kg, again infused over 30 minutes, which can be repeated after
1 hour. (preferred)
* Strictly measure input and output.
* Provide catheter care if necessary.
* Carefully monitor labs such as potassium to prevent problems from
hypokalemia.
* Record capillary refill time.
* Assist in administration and monitoring of insulin therapy.
* Provide supportive care to family
* Inquire about culture and health beliefs and how that can be included
in the plan of care
* Provide relief for them to care for themselves
* Keep them informed regarding any changes in patients status and
orders
* Connect them to the right team member
*
* Dietary regarding dietary guidelines while admitted and after
admission
* Neurosurgeon if cerebral edema is expected
* Social work/case manager to discuss current case of patient,
insurance coverage, resources needed to pay for insulin pump
if needed,
* Resources for temporary housing. How to go through the
insurance process of obtaining new housing
* Reaching out to family members and friends for support
* Asking about spiritual support within the community
*
*V/S every 4 hours
*Monitor the patient Q1 for
signs of
hypo/hyperglycemia/DKA/LOC
*Observe child after he eats
*Notify physician immediately
if a change occurs
*
* Do not to skip insulin doses
* In the case of hypoglycemic shock rapid replacement of glucose with 15 grams of rapid
carbohydrate such as 4 oz. of fruit juice (orange juice) or tablespoon of honey or syrup. Lowfat cheese sandwich Ham, roast beef, or turkey sandwich
* Know when to test for ketones, such as when you are sick or BS >240mg/dl
* If you use an insulin pump, check often to see that insulin is flowing through the tubing. Make
sure the tube is not blocked, kinked or disconnected from the pump.
* Do not skip meals or snacks and always carry a quick source of sugar especially when
exercising.
* Staying hydrated by drinking plenty of fluids
* Check blood sugar before each meal and at bed time and to take medications at the same
time everyday
* Teach medication interactions, talk to pharmacist before taking other medications
* Seek immediate medical attention if you recognize:
* Ketones in urine
* Polyuria, polydipsia, and polyphagia
* Trouble breathing
* Decreased LOC
* High blood glucose
* Fruity breath
* Nausea/vomiting
* Complains of abdominal pain
*
* Hx of symptoms upon admission
* Admission v/s, subjective and objective data
* Vitals
* Lab values
* Changes in blood glucose
* Trend of ketones
* Time and date of insulin initiation and
administration
* Changes in diet and intake/output
* Changes in physical abilities
* Changes in LOC
* Complains of pain and steps taken to relieve pain
* All interventions time, date, and outcome
* Note time and date physician was contacted and
any new orders given
* Document consultations and the outcome of those
consultations
* Documenting that discharge teaching was provided
along with resources for patient and family to take
home.
*
* Patient was d/c home on day 3 with diabetic teaching
information, medication administration, when to check blood
pressure and glucose, diet and when to contact the
physician/hospital.
* Patient stated that he was starting to get use to the finger sticks
and that he is happy to be going home.
* The family will be staying with the father’s brother who lives 10
miles away, close to Ryan’s school. They hope to find a new home
in the next month or so. They also plan to find a new family pet
with Ryan as soon as his health is back to being stable.
*
* 1) Clinical manifestations associated with a diagnosis of type 1 DM
include all of the following except:
* a. Hypoglycemia
* b. Hyponatremia
* c. Ketonuria
* d. Polyphagia
* 2) A nurse is caring for a client admitted to the emergency
department with diabetic ketoacidosis (DKA). In the acute phase,
the priority nursing action is to prepare to:
* A. Correct the acidosis
* B. Administer 5% dextrose intravenously
* C. Administer regular insulin intravenously
* D. Apply a monitor for an electrocardiogram
*
*
*
*
*
*
Bangstad, H., Danne, T., Deeb, L., Jarosz-Chobot, P., Urakami, T., &
Hanas, R. (2009). Insulin treatment in children and adolescents with
diabetes. Pediatric Diabetes, 10, 82-99. Retrieved from
http://www.ispad.org/sites/default/files/resources/files/ispad_guidelin
es_2009_-_insulin_treatment.pdf
Fröhlich-Reiterer, E. E., Ong, K. K., Regan, F. F., Salzano, G. G., Acerini,
C. L., & Dunger, D. B. (2007). A randomized cross-over trial to identify
the optimal use of insulin glargine in prepubertal children using a threetimes daily insulin regimen. Diabetic Medicine, 24(12), 1406-1411.
Retrieved from
https://webmail.health.usf.edu/owa/attachment.ashx?attach=1&id=RgA
AAADdNv2wg0cGTLgOLCy3Ie%2blBwD6p5nXpbIXTYnodiiC%2bDfnAAAAT3i9
AAD6p5nXpbIXTYnodiiC%2bDfnAAAVfTeXAAAJ&attid0=BAAAAAAA&attcnt=
1
Lamb, W., Corden T., Cantell, P., Barry, E., Windle, M. (2013). Pediatric
Diabetic Ketoacidosis Treatment & Management. Retrieved from
http://emedicine.medscape.com/article/907111-treatment
Mcfarlane, K. (2011). An overview of diabetic ketoacidosis in children.
Pediatric Care, 23(1), 14-19.
Silverstein, J., Holzmeister, L. A., Clark, N., Anderson, B., Grey, M.,
Deeb, L., et al. (2005). Care of children and adolescents with type 1
diabetes: A statement of the american diabetes association. Diabetes
Care, 28(1), 186-212. Retrieved from
http://care.diabetesjournals.org/content/28/1/186.full.pdf+html