Scenario:
Peter Parker is an 18-year-old male with insulin dependent diabetes. Peter
presented to the emergency department complaining of dizziness, with
vomiting and diarrhea. He was admitted to your unit with a tentative diagnosis
of diabetic ketoacidosis (DKA).
His partner informs that he has been feeling ‘unwell’ and has had flu-like
symptoms for the past three days. Explaining that Peter has been studying for
final exams and is feeling very stressed with school, work and family issues.
He is currently in a nursing program and finds the transition from high school,
live at home is challenging. His partner explains that he has been eating more
take-out food and not exercising as he once did.
Medical History:
Peter was first diagnosed with Type 1 DM at the age of 12. He has managed his
blood sugars well but lately his friends and family are concerned because he
has voiced frustration with the burden of diabetes. His mother has noticed he
does not always check his blood sugar telling her ‘He has this under control,
and she should not be concerned”.
You are the nurse assigned to care for Peter.
You perform your initial physical examination which reveals a pale Caucasian
male with extremely dry skin and very dry mucous membranes, abdominal
tenderness on palpation. Bowel sounds are present in all 4 quadrants, and
you note a fruity odor to his breath. Lungs are clear to auscultation. Peripheral
pulses are bilaterally equal but rapid and weak. He is drowsy – difficult to
rouse.
Vital signs are as follows:
Temp. 38
Pulse 118
RR 25
B/P 114/78 (supine); 90/68 (sitting); 80/50 (standing)
O2s at 96% on RA.
Laboratory studies revealed the following results:
• Plasma glucose = 35.5 mmol/l (640 mg/dl)
• Urine =positive for glucose and ketones
• Blood ketones=positive
• Blood gases: pH = 7.1; pCO2: = 28; HCO3 = 14 Na+ = 130 mEq/L
[ANION GAP = (Na + K) - (Cl+HCO3) ]
= 27.2meq/L > elevated AG indicates metabolic acidosis
• Cl–=94mEq/L
• Serum K + = 5.2 mEq/L
• BUN = 50 mg/dl
The physician wrote the following orders for Peter:
• 3 L NS (normal saline) @ 500 ml/hr first 2 L then 1 L @ 250 ml/hr
• Switch to D5/0.45 NS at 125 ml/hr when glucose falls below 16 mmol/l
• Ask pharmacy to add 20 mEq KCl to each liter IV fluid when serum K+
falls below 4.5 mEq/L
• Serum K + q1h (call report when < 4.5 mEq/L)
• Loading dose of regular insulin 20 U IV after first liter of NS has run in,
then give regular insulin 10U/hr IV
• Stop insulin when blood glucose falls below 16 mmol/l (call report)
• Check blood glucose q15min; then q30min; then q1h
• Observe for signs and symptoms of cerebral edema
• Keep patient NPO & R/A q24hrs4
Assignment:
Answer the following questions in complete sentences.
All work needs to be cited using scholarly sources. The articles from this
course and your Patho text are good examples and may be used. You may
research your own articles from the library but be sure they are scholarly.
Class slides and the internet are not scholarly sources – you may cite my
slides but as additional support, but they are not scholarly.
Consider the following 5 questions and answer fully:
1. Cluster the relevant cues (data). Identify what the cluster is inferring
(suggesting is a
problem or potential problem). (3 clusters 3 clusters 3 clusters&3inferences)
2. Identify one data gap for each cluster. Explain (using scholarly sources)
how/why this data cue would further support your inference.
3. State the 3 Problems from the inferences, and from those identify what
one is the Priority Problem. Briefly explain why this is the priority for
Peter (using scholarly sources).
4. Apply the four metaparadigms to this case study. Describe how you
would consider
Peter in relation to the 4 metaparadigms.
5. Choose 1 Pattern of Knowing (Except Empirical) and concisely explain:
a. How you anticipate this Way of Knowing will guide your care.
b. What will be included in your nursing management that
demonstrates/supports this Way of Knowing.
CLUSTER I CLUSTER II CLUSTER III
★ Elevated glucose ★ Orthostatic hypotension ★ Flu-like symptoms for 3 days
35.5mmol/L ★ extremely dry skin and very dry ★ Temperature = 38C
★ Presence of ketones in the mucous membranes ★ Tachycardia = 118b pm
urine and blood ★ Pallor
★ Diagnosed with DMI at the
★ Na+ 130 and Cl- 94
age of 12 y/o.
★ take-out food and not ★ Presenting with N&V upon
exercising as he once did. admission
★ Reported diarrhea
★ Currently NPO
Hyperglycemia d/t Risk for dehydration At risk for infection
mismanagement routine
GAP: Urine output & osmo GAP: no sepsis/PAN Cxr work-up was
GAP: awareness of DMI skin turgor. initiated. Possibly RSV panel, urine,and
management? Lifestyle ? blood cxr; sputum if he has
motivation? Is he on productive-cough.
insulin? What kind of
insulin? Last dose? And
how much and often? Or
did he missed it?
CLUSTER IV CLUSTER V CLUSTER VI
★ “feeling very stressed with school, ★ Blood gases: pH = 7.1; pCO2: = ★ pH = 7.1- severely acidotic
work and family issues.” 28; HCO3 = 14 ★ “Difficult to rouse”
★ Reported unhealthy diet and ★ RR=25 ★ HCO3 = 14
sedentary lifestyle. ★ Lethargy
★ voiced frustration with the burden ★ Spo2 95% on ra
of diabetes
Risk for impaired gas exchange
★ 18-years-old
Powerlessness d/t lack of control over Acid-base imbalance GAP: exact GCS unknown, any
current situation stimulation to pain? He could be gcs < 8
Consider sodium bicarbonate infusion?
Severely acidotic - requires immediate
medical attention, within unknown GCS
and difficulty to rouse - possibly prepare
for intubation for airway protection if low
GCS despite normal O2 saturation
Cluster 1: Cluster 2: Cluster 3:
Extremely dry skin
Dry mucous membranes
Rapid and weak pulses
Orthostatic hypotension
Drowsy - difficult to arouse
Inference: dehydration or
hypovolemia
- Dry skin and mucous
membranes, weak and
rapid pulses - fluid
deficit = hyperglycemia
for DM pts
HHS
- Hyperglycemia
- Serum osmolality high
Dehydration or hypovolemia - UO
Metabolic acidosis - elyte imbalance
K+
Poor diabetes management?