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NURS 4613 Case Study Diabetes/DKA DIABETES MELLITUS (DM) AND DIABETIC KETOACIDOSIS (DKA) Pathophysiology Diabetes mellitus (DM) is a complex disease. DM results from insulin deficiency (complete or partial). Type I DM ? islets cells of the pancreas cannot produce insulin ? cells can’t access glucose for energy ? cellular starvation ? cells begin to compensate: 1) fat catabolism (breakdown) 2) protein catabolism. Fat breakdown ? fatty acids released and produce acetone and ketone bodies. Acetone excreted in lungs. Ketones not oxidized by the liver ? ketones accumulate in the blood ? can lead to ketoacidosis. Type II DM ? insulin present but not in sufficient quantities or it ma be available in sufficient quantities but the body is resistant to the action of insulin. A cessation or deficit of insulin secretion _________decreases______ the body’s ability to utilize glucose. (decreases or increases) Diabetic ketoacidosis (DKA) is more likely to occur with which type of diabetes? ___Type 1_______. Failure to metabolize glucose leads to a(n) ___increase________ (increase or decrease)in fat catabolism. Ketosis occurs, which results in a(n) ____excess________ (excess or deficit) of ketone bodies in the blood. With an increase in bicarbonate ions excreted by the kidneys due to osmotic diuresis, more hydrogen ions are reabsorbed into the circulation. Cellular breakdown causes lactic acidosis to be released from the cells. The increase in ketone bodies, hydrogen ions, and lactic acid serves to decrease the pH in the body causing an ____acidic______________ state of the body. (acidic or alkaline) Lack of insulin interrupts glucose metabolism and can cause which of the following: ________ Glucose utilization for energy ___X_____ Fat catabolism, which releases excessive amounts of ketone bodies An excessive number of ketone bodies in the body is known as ____ketosis_____________. (ketosis, exocytosis) Ketosis leads to ____ketoacidosis______________. (keto-alkalosis, ketoacidosis) An elevation of the blood glucose level > 180 mg/dL increases the glucose concentration in the glomeruli if the kidneys. When the concentration of glucose in the glomeruli exceeds the renal threshold for tubular reabsorption, glycosuria results. Increased glucose concentration acts as an osmotic diuretic, which causes diuresis. What does glycosuria mean? ___Glucose in urine __________________________________ What does diuresis mean? ____Excessive urine production________________________________ An elevated blood sugar also increases the hyperosmolarity of the extracellular fluid (ECF). The hyperosmolarity of the ECF leads to a withdrawal of fluid from the cells (ICF). Thus, the ECF space is increased (movement of fluid for in the cell to outside the cell). Increased blood sugar alters the osmolality of the body fluids. The body fluids become ____hyper_ - osmolar thus, osmotic diuresis results. (hyper, hypo) The migration of ICF into the ECF results in which of the following: ____X____ Cellular dehydration ________ Cellular hydration In renal excretion, the ketones (strong acids) combine with the cation sodium, causing sodium depletion. Ketone bodies (ketones) are excreted as ketonuria. The additional solute load of ketones in the glomeruli results in which of the following: ________ A decreased loss of water in the formation of ketonuria ___X_____ An increased loss of water in the formation of ketonuria Polyuria can result from which of the following? (Select all that apply) ___X_____ Glycosuria ________ Anuria ____X____ Ketonuria With the loss of water, the solute concentration of the blood ____increases_________ (increases or decreases) and the blood volume ______decreases ________ (increases or decreases). In DKA, the body attempts to compensate for the acidosis through nausea and vomiting. By ridding the body of stomach acids, the system attempts to normalize the pH. This may lead to severe fluid and electrolyte imbalances. There is an increase in water loss by way of the lungs due to Kussmaul breathing (rapid vigorous breathing). Dehydration occurs from which of the following? (Select all that apply) _____X___ Nausea and vomiting ________ Kussmaul respirations ________ Oliguria ____X____ Polyuria Potassium is lost as the result of vomiting and renal excretion but the failure of cellular utilization of glucose causes potassium to leave the cells. As a result of these shifts in potassium, the serum potassium level may measure ___high__________ (normal, high. Low) or ______low______ (normal, high, low). DKA occurs due to insulin deficiency leading to profound hyperglycemia. Which of the following are specific causes of DKA? (Select all that apply) ___X_____Undiagnosed Type I diabetes ____X____Omission of order insulin ________Skipping meals ___X_____Pancreatitis ________Vigorous exercise ____X____Trauma ___X_____Surgery ________Undiagnosed Type II diabetes Clinical Manifestations Which of the following vital signs are related to DKA? (Select all that apply) ____X (if infection)____ Elevated temperature ____X____ Tachycardia ________ Bradycardia ____X____ Decreased BP of 10 – 15 mmHg ________ High BP ____X____ Vigorous, rapid breathing ________ Apnea Identify the changes that result in: Skin: Cardiovascular System: Sensorium: When cells breakdown which electrolyte is lost from the cells? ____potassium_________. When the acidic state that develops from DKA is corrected, potassium re-enters the cell, which can cause which electrolyte disturbance? _________hypokalemia__________ . As fluid is lost ____________________ causes the hemoglobin and hematocrit to be elevated. If the WBC is elevated, it is most likely due to _______infection_________. A decrease in the pH and the arterial bicarbonate (HCO3) indicates metabolic _______acidosis_______ resulting from DKA. Why is the PaCO2 (arterial partial pressure carbon dioxide) decreased in DKA? It’s decreased because of the compensatory reaction to the low pH, resulting in Kussmaul’s respirations. Clinical Application Dehydration is one of the major symptoms and concerns for persons with DKA. Which of the following occurs with dehydration? (Select all that apply) ________ Decreased hemoconcentration ____X____ Increased hemoconcentration ____X____ Decreased blood volume ________ Increased blood volume While the client is receiving IV fluids and insulin, observe for symptoms of hypoglycemia, also known as an insulin reaction, or a hypoglycemic reaction. How can the insulin reaction be corrected quickly? Conscious Patient: 15 by 15 rule; give 15 grams of a simple carbohydrate, wait 15 minutes and recheck blood sugar, and repeat if necessary Unconscious Patient: glucagon injection or IV dextrose What are symptoms of too much insulin? ___sweating, tremors, headache, irritability, anxiousness, nervousness, hunger, and nausea_______________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Clients with diabetes who are ill are encouraged to rest to reduce their metabolic rate. This decreases fat and protein catabolism. These persons should also be protected from overheating and chilling. If they are in a state of vascular collapse, extra heat should not be applied since it can increase vasodilatation and intensify the failure of the circulation. Jake Hampton arrived in the emergency room in a semicomatose state. Prior to admission, he had been vomiting and had complained of “feeling weak.” His friends stated he had a severe cold with a fever for weeks. They felt the vomiting was due to a viral infection. The mucosa in his mouth was dry. Vomiting and dry mucosa would indicate __hyperglycemia______. His respirations were rapid and deep, this can be an indication of which of the following: ___X____ Kussmaul breathing ________ Dyspnea His heart rhythm was sinus tachycardia (pulse rate 120). His breath had a very sweet smell. The friends stated they did not think he had diabetes mellitus, but there was a familial history of it. In the emergency room, stat blood chemistry was done. The blood sugar was 476 mg/dL, the normal range being 70-110 mg/dL. A blood sugar of 476 mg/dL represents a __hyperglycemic____________ state. Laboratory Tests Normal Value Admission Day 1 Day 2 Day 3 Hemoglobin 12.9 – 17.0 g 17.2 Hematocrit 40 – 60% BUN 10 -25 mg/dL 18.9 Random BS < 150 mg/dL 464 200 50 144 Serum Chloride 95 – 108 mEq/L 99 130/132 133 110 Serum Sodium 135 – 145 mEq/L 136.7 151/159 164 145 Serum Potassium 3.5 – 5.0 mEq/L 5.5 3.0/3.2 4.2 4.5 Jake’s urinalysis was repeated on day 2 showing: Color: dark yellow Specific gravity: 1.024 Albumin: +3 Sugar: +4 WBC: many Jake’s specific gravity shows which of the following? (Select all that apply) ________A very high range ________A high average range ________A low range ____X____An indication of an increased amount of solute in the urine The +4 sugar in the urine indicates ___glycosuria_________. The +3 albumin in the urine indicates which of the following? ________Normal range ___X___Pathological involvement Jake’s hemoglobin and hematocrit counts were which of the following? (Select all that apply) ________ Normal ________ Below normal ___X_____ Above normal ________ An indication of mild edema ____X____ An indication of mild dehydration The random blood sugars on admission and the first day were which of the following? (Select all that apply) ________ Normal ________ Below normal ____X____ Above normal ___X_____ An indication of hyperglycemia ________ An indication of hypoglycemia The second day his blood sugar was 50 mg/dL, which indicates __hypoglycemia_________. Indicate if each of the following are low, normal or high on admission __normal_______ serum chloride __normal________ serum sodium __high________ serum potassium. Jake was treated with IV normal saline and an insulin drip. On admission, the laboratory studies indicated which of the following? (Select all that apply) ________ Hyperchloremia ________ Hypochloremia ________ Hypernatremia ________ Hyponatremia ____X____ Hyperkalemia ________ Hypokalemia Explain the reason for the changes in these lab values. His potassium levels decreased on day 1 because of the insulin he was receiving. The insulin took the potassium out of the blood and took it into the cell along with the glucose. In DKA there is frequently a serum sodium decrease before treatment due to which of the following? (Select all that apply) ________ Fluid intake ___X_____ Vomiting ____X____ Urine excretion Clinical Management Treatment for DKA includes: 1) vigorous fluid replacement, 2) insulin replacement, and 3) electrolyte correction. Osmotic diuresis can cause a fluid volume deficit of 4 – 8 liters of body fluid. In such a case immediate restoration of fluid loss is essential. In the first 24 hours, 80% of the total water and salt deficit should be replaced. Potassium must also be replaced but carefully since elevated potassium can also be toxic. Renal function must also be confirmed before administration of potassium. In the first hour, 1 – 2 liter(s) of normal saline may be rapidly infused to reestablish the fluid volume balance. This may be followed by 1 liter every hour for the next 2 hours as indicated. Cellular replacement of electrolytes occurs faster or slower ____slower__________ than extracellular replacement. Alternating normal saline solution with lactated Ringer’s solution may be rapidly infused to reestablish the fluid balance, renal perfusion, and blood pressure, ECF is restored directly form IV therapy. ICF replacement occurs in approximately 2 days. When reestablishing fluid balance in the ECF space, the suggested amount of IV fluid for the first hour is ____normal saline_______. The purpose of the rapid infusion of IV fluids is to improve _____blood volume________, __________________, and __________________. Restoration of ICF balance is somewhat slower or faster ___slower_______ than restoration of the ECF balance. Indicate which solutions are used initially to correct the fluid imbalance (select all that apply): ________ Dextrose in water (D5W) ___X_____ Normal saline solution A fluid overload in the ECF should be avoided. The nurse should assess for signs of fluid overload. Overhydration or hypervolemia occurs from over-replacement of fluids and is noted by specific symptoms. Four of the symptoms of overhydration or hypervolemia are: __weight gain__________. _________edema________, ________high blood pressure__________, and _____shortness of breath_____________. Overhydration of the brain cells can result from over-replacement. This is known as _______cerebral___________ ______edema____________. The preferred route of insulin administration for correction of DKA is: ____X____ Intravenous ________ Subcutaneous ________ Intramuscular The blood sugar must be closely monitored during insulin replacement. When the blood sugar reaches 250 mg/dL the IV fluids are usually switched to 5% dextrose and water. The IV fluid is changed to 5% dextrose and water to help prevent the possible occurrence of a ______hypoglycemic_______ reaction. Which of the following types of insulin can be administered intravenously? (Select all that apply) ________NPH ____X____Regular ________Protamine zinc insulin Potassium replacement should start approximately 6 to 8 hours after the first dose of insulin has been administered and as the acidotic state is being corrected. Potassium replacement is dependent on adequate renal function. The patient must be voiding in order to begin replacement potassium. Serum potassium levels should be taken frequently. Potassium moves back into the cells as fluid balance and the acidic state begin to correct. If potassium is not corrected as acidosis is corrected, the serum potassium level may be __high_______. Why does the potassium level drop with treatment? Because insulin takes potassium from the blood into the cells. While fluid and insulin replacements are occurring, the serum potassium levels should be constantly monitored. Does the serum potassium level increases or decreases ____decreases_______ as fluids and insulin are being administered? As acidosis is corrected, insulin is utilized more rapidly by the body for metabolizing glucose. Is hypoglycemia or hyperglycemia most likely to result? ___________________ Why? Kee, JL, Paulanka, BJ, Purnell, LD (2004). Fluids and Electrolytes with Clinical Applications A Programmed Approach. 7th edition. Thomson Delmar Learning, Clifton Park, New York. Created Fall 2009 sek Revised Spring 2010 sek, Revised 5/31/202 sek
