Keegan Sugamoto
Age: 36
Location: Medical-Surgical Unit
Today’s Objectives
● Formulates a nursing plan of care based on the pathophysiology of diabetic ketoacidosis
● Designs an individualized plan of care for the nursing management of a patient in DKA
● Prioritizes the implementation and approach to the nursing care of a patient in DKA • Evaluates
the patient’s response to interventions and modifies the nursing care as appropriate for the patient in
DKA
SBAR Report
Situation:
The patient is a 36-year-old male directly admitted to the Medical-Surgical Unit after his wife found him confused and agitated in their
apartment. Prior to being admitted, he was seen in the healthcare provider’s office where he was hypotensive and tachycardic. An
intermittent peripheral lock was inserted in the right arm. A 250 mL bolus of normal saline was administered. Capillary glucose testing
indicated results greater than 450 mg/dL. Orders were written to admit the patient directly to the Medical-Surgical Unit with an
admitting diagnosis of diabetic ketoacidosis.
Background:
The patient was diagnosed with type 1 diabetes mellitus 12 months ago. According to his wife, he has had “the flu” for 5 days, with
nausea, vomiting, and anorexia. He stopped taking his insulin 2 days ago when he was unable to eat. This morning, his wife found
him confused and agitated in their apartment and took him to see his primary healthcare provider.
Past Medical History: The patient was diagnosed with type 1 diabetes mellitus 12 months ago and suffered a broken collarbone at
age 17 due to a sports-related accident
Allergies: No known allergies
, Medications: NPH insulin 20 units plus regular insulin 12 units SUBCUT every morning before breakfast. Regular insulin 8 units
SUBCUT every evening before dinner. NPH insulin 8 units subcutaneous every night at bedtime
Code Status: Full code
Social/Family History: He is a lawyer with a private law firm and is married with 2 school-age children. He denies tobacco or drug use
and reports drinking 1 to 2 drinks a week
Assessment:
Vital signs: HR 133, BP 80/50, RR 26 and deep, SpO2 93% on room air, Temperature 38.5C
General Appearance: Agitated. Appears stated age
Cardiovascular: Sinus tachycardia
Respiratory: Respirations deep. Breath sounds clear bilaterally
GI: Abdomen soft. Bowel sounds normal
GU: Incontinent of strong-smelling urine
Extremities:. Moves all extremities with generalized weakness
Skin: Flushed and dry
Neurological: Confused and restless. Oriented to person. Pupils equal, round, reactive to light and accommodation
IVs: 20-gauge saline lock in the right arm, patent and non-reddened
Labs:STAT labs (complete blood count, basic metabolic panel, phosphate, magnesium, arterial blood gases, urinalysis, urine culture
and sensitivity, blood cultures X 2), chest x-ray and ECG were completed in the lab before arrival to the unit. Results should be
available now.
Fall Risk: High-risk
Age: 36
Location: Medical-Surgical Unit
Today’s Objectives
● Formulates a nursing plan of care based on the pathophysiology of diabetic ketoacidosis
● Designs an individualized plan of care for the nursing management of a patient in DKA
● Prioritizes the implementation and approach to the nursing care of a patient in DKA • Evaluates
the patient’s response to interventions and modifies the nursing care as appropriate for the patient in
DKA
SBAR Report
Situation:
The patient is a 36-year-old male directly admitted to the Medical-Surgical Unit after his wife found him confused and agitated in their
apartment. Prior to being admitted, he was seen in the healthcare provider’s office where he was hypotensive and tachycardic. An
intermittent peripheral lock was inserted in the right arm. A 250 mL bolus of normal saline was administered. Capillary glucose testing
indicated results greater than 450 mg/dL. Orders were written to admit the patient directly to the Medical-Surgical Unit with an
admitting diagnosis of diabetic ketoacidosis.
Background:
The patient was diagnosed with type 1 diabetes mellitus 12 months ago. According to his wife, he has had “the flu” for 5 days, with
nausea, vomiting, and anorexia. He stopped taking his insulin 2 days ago when he was unable to eat. This morning, his wife found
him confused and agitated in their apartment and took him to see his primary healthcare provider.
Past Medical History: The patient was diagnosed with type 1 diabetes mellitus 12 months ago and suffered a broken collarbone at
age 17 due to a sports-related accident
Allergies: No known allergies
, Medications: NPH insulin 20 units plus regular insulin 12 units SUBCUT every morning before breakfast. Regular insulin 8 units
SUBCUT every evening before dinner. NPH insulin 8 units subcutaneous every night at bedtime
Code Status: Full code
Social/Family History: He is a lawyer with a private law firm and is married with 2 school-age children. He denies tobacco or drug use
and reports drinking 1 to 2 drinks a week
Assessment:
Vital signs: HR 133, BP 80/50, RR 26 and deep, SpO2 93% on room air, Temperature 38.5C
General Appearance: Agitated. Appears stated age
Cardiovascular: Sinus tachycardia
Respiratory: Respirations deep. Breath sounds clear bilaterally
GI: Abdomen soft. Bowel sounds normal
GU: Incontinent of strong-smelling urine
Extremities:. Moves all extremities with generalized weakness
Skin: Flushed and dry
Neurological: Confused and restless. Oriented to person. Pupils equal, round, reactive to light and accommodation
IVs: 20-gauge saline lock in the right arm, patent and non-reddened
Labs:STAT labs (complete blood count, basic metabolic panel, phosphate, magnesium, arterial blood gases, urinalysis, urine culture
and sensitivity, blood cultures X 2), chest x-ray and ECG were completed in the lab before arrival to the unit. Results should be
available now.
Fall Risk: High-risk
