Type 1 Diabetes Mellitus Type I/DKA UNFOLDING Reasoning

Type 1 Diabetes Mellitus Type I/DKA UNFOLDING Reasoning Jack Anderson, 9 years old Primary Concept Glucose Regulation Interrelated Concepts (In order of emphasis) ● Fluid and Electrolyte Balance ● Acid-Base Balance ● Clinical Judgment ● Patient Education ● Communication ● Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment Management of Care 17-23% Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity Basic Care and Comfort 6-12% Pharmacological and Parenteral Therapies 12-18% Reduction of Risk Potential 9-15% Physiological Adaptation 11-17% History of Present Problem: Jack Anderson is a 9-year-old boy who presents to the emergency department because he has been more sleepy and his breathing is “not normal;” it is deeper and faster, according to his parents. Jack was sick with a respiratory virus two weeks ago but has since recovered. Jack began feeling more tired a few days ago when he started to complain of abdominal pain, headache, muscle aches, and consistently being hungry and thirsty. He is urinating more frequently during the day and at night. His mother reports a normal full-term pregnancy and Jack has been healthy with no known medical conditions. Personal/Social History: Jack lives with both parents and two siblings; a younger sister four years old and a 12-year-old brother. Both parents work as middle school teachers in the community. Jack is in the 4th grade and earns above-average marks. He is physically active and plays soccer on the school team. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: He's more sleepy His breathing is "not normal" it's deeper and faster Was sick with a respiratory virus 2 weeks ago Always hungry and thirsty Fatigue is a common symptom and can result from high blood sugar levels Kussmaul breathing is rapid or labored breathing, a symptom of DKA Lack of insulin or insulin resistance helping convert food to energy causes increased hunger and thirst RELEVANT Data from Social History: Clinical Significance: Has a support system from family Physically active, plays soccer Shows he will get the care he needs with his support system Being active can lead to hypoglycemia once he manages his diabetes Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 100.4 F/38.0 C (oral) Provoking/Palliative: Made worse with solid food. P: 136 (regular) Quality: Dull and aching R: 44 (deep/rapid) Region/Radiation: Confined to abdomen, generalized within abdominal region BP: 80/48 Severity: He states his pain is a 4/10 on the numeric scale. O2 sat: 98% on RA Timing: States, “All the time” Weight: 64.0 lbs/29.1 kg What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: T: 100.4 F (oral) High temperature could be a sign of infection P: 136 (regular) Tachycardia is present R: 44 (deep/rapid) Kussmaul respirations is present BP: 80/48 Very low blood pressure, could be a sign of dehydration with the excessive urination Pain: Made worse with solid food, dull and aching, generalized within abdominal region, states pain is all the time Abdominal pain could be a side effect of not getting enough insulin Current Assessment: GENERAL SURVEY: Lying on the bed with eyes closed, whimpers with touch, recognizes mom and dad. Fruity odor to the breath. NEUROLOGICAL: Lethargic, responding to parents with one-word phrases. Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Eyes appear “sunken,” mucus membranes dry, tacky mucosa, chapped lips. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, respirations are deep and rapid CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses slightly weak/thready, equal with palpation at radial/pedal/post-tibial landmarks, cap refill 2 seconds. Heart tones audible and regular, S1 and S2, noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. ABDOMEN: Abdomen round, soft, and tender to light palpation. BS active in all four quadrants, feeling nauseated GU: Voiding large amounts of clear light yellow urine INTEGUMENTARY: Skin warm, dry, itchy, flushed, intact, normal color for ethnicity. No clubbing of nails, cap refill 3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor nonelastic, tenting present. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: General Survey – whimpers with touch,fruity odor to the breath Neurological – lethargic HEENT – eyes appear sunken, mucus membranes dry, tacky mucosa, chapped lips Respiratory – respirations are deep and rapid Abdomen – tender to light palpation, feeling nauseated GU – voiding large amounts of clear light yellow urine Integumentary – warm, dry, itchy, flushed, turgor nonelastic, tenting present Fruity odor to breath is when ketones rise to unsafe levels Lethargic is caused by dehydration Sunken eyes, mucus membranes dry, tacky mucosa, and chapped lips are caused by dehydration Weak/thready pulse and possibly cap refill being slow is caused by dehydration Being tender is a sign of insulin deficiency Urinating a lot is a sign of diabetes All of these are an indication of dehydration Based on the clinical cues collected so far by the nurse, what additional data is needed ASAP to determine the most likely problem and identify the nursing priority? What orders should the nurse anticipate? Additional Clinical Data Needed: Orders to Anticipate: Blood glucose IV fluids and insulin Lab Results: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 6.2 16.1 252 58 0 Most Recent: 7.2 14.2 210 52 0