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Diabetic Ketoacidosis (DKA)
Diana Humphries, 45 years old
Primary Concept
Fluid and Electrolyte Balance
Interrelated Concepts (In order of emphasis)
1. Acid-Base Balance
2. Glucose Regulation
3. Infection
4. Pain
5. Clinical Judgment
6. Patient Education
7. Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
, UNFOLDING Reasoning Case Study: STUDENT
Diabetic Ketoacidosis (DKA) History
of Present Problem:
Diana Humphries is a 45-year-old woman with chronic kidney disease stage III and diabetes mellitus type1 who checks
her blood sugar daily, or whenever she feels like it. She has been feeling increasingly nauseated the past 12 hours. She has
had a harsh, productive cough of yellow sputum the past three days. She checked her blood glucose before going to bed
last night and it was 382, but then she fell asleep early and missed her bedtime dose of glargine (Lantus) insulin. When she
awoke this morning, she had generalized abdominal pain and continued to feel nauseated and had a large emesis. Her
glucometer was unable to read her blood glucose because it was too high. She took 10 units of lispro (Humalog) insulin
this morning. Her nausea has increased all morning and she has been unable to eat or keep anything down despite having
an increased thirst and appetite. She also has had increased frequency of urination. When her lunchtime glucometer gave
no reading because it was too high and out of range, she called 9-1-1 to be evaluated in the emergency department (ED).
Personal/Social History:
Diana has been inconsistently compliant with her medical/diabetic regimen due to her struggles with anxiety and
depression that have worsened since her mother died three months ago. She considers 200 a good blood sugar reading.
She is divorced with no children and has been homeless and has lived in a shelter off and on the past month. She is on
Social Security disability because of complications related to diabetes. At one point during the intake interview, she
expressed to the nurse, “I’m going to die anyway, why does all this matter?”
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Decreased function of the kidneys and if patient is in DKA there is an
Chronic Kidney Disease increased load on kidneys due to polyuria
Type 1 Diabetes and checks blood sugar Puts her at risk for developing DKA especially since she doesn’t check
whenever she feels like it her blood sugar regularly
Blood Sugar 383 before bed and didn’t take Blood sugar already high before bed so we know it was high for a while
her bedtime Lantus before she called 911
Generalized abdominal pain, nausea, emesis Signs and symptoms of hyperglycemia
Increased thirst, appetite, urination Signs and symptoms of hyperglycemia
Lunchtime glucometer gave no reading Severe hyperglycemia
because too high
RELEVANT Data from Social History: Clinical Significance:
Inconsistently compliant with her
medical/diabetic regimen Inability to comply with medications increases risk for
complications.
Anxiety and Depression from her
mother’s death Doesn’t have emotional support
Divorced with no children Due to her current financial hardship, she is unable to comply
with her medications and her diabetes regimen.
Homeless
© 2016 Keith Rischer/www.KeithRN.com
, Receives social security disability
benefits
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
• Chronic Kidney disease 1. Aspirin 81mg PO daily
stage III (diabetic 2 .Lisinopril 10 mg PO daily Salicylates Aspirin will help with the pain
nephropathy) 3. Lorazepam 1mg PO bid caused by her neuropathy.
• Anemia prn ACE inhibitors
• Diabetes mellitus type 1 4. Citalopram 40 PO mg daily Lisinopril will help manage her
since age 12 5. Zolpidem 10 mg PO at HS hypertension and with her
Benzodiazepine kidney disease.
• Diabetic retinopathy prn
• Neuropathy in lower legs 6. Gabapentin 300 mg PO bid SSRI Lorazepam will help calm
• Hyperlipidemia 7. Labetalol 200 mg PO bid 8.
down the patient and make her
• Hypertension Omeprazole 20 mg PO daily Sedative less anxiety.
• Coronary artery disease 9 .Simvastatin 40 mg PO HS
• Gastroesophageal reflux 10. Glargine insulin 50 units Analgesic adjunct Zolpidem will allow the patient
disease (GERD) SQ at HS to sleep better.
• Anxiety 11. Lispro insulin SQ sliding Beta Blocker
• Depression scale AC and HS Gabapentin will help with
nerve pain caused by her
Antilipidemia neuropathy.
Pancreatics Labetalol will help with her
hypertension and decrease her
Pancreatics heart rate decreasing stress on
the heart.
Omeprazole will decrease the
stomach acid helping with her
GERD.
Simvastatin will help her
cholesterol and lipids which
will help with hyperlipidemia
and coronary artery disease.
Glargine is long acting insulin
used to manage diabetes
Lispro is rapid acting insulin
used to manage diabetes
What medications treat which conditions?
Draw a line to identify what illness is being managed by what medication?
Listed in the table
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her life?
• Circle what PMH problem started FIRST Diabetes
© 2016 Keith Rischer/www.KeithRN.com
Diabetic Ketoacidosis (DKA)
Diana Humphries, 45 years old
Primary Concept
Fluid and Electrolyte Balance
Interrelated Concepts (In order of emphasis)
1. Acid-Base Balance
2. Glucose Regulation
3. Infection
4. Pain
5. Clinical Judgment
6. Patient Education
7. Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
, UNFOLDING Reasoning Case Study: STUDENT
Diabetic Ketoacidosis (DKA) History
of Present Problem:
Diana Humphries is a 45-year-old woman with chronic kidney disease stage III and diabetes mellitus type1 who checks
her blood sugar daily, or whenever she feels like it. She has been feeling increasingly nauseated the past 12 hours. She has
had a harsh, productive cough of yellow sputum the past three days. She checked her blood glucose before going to bed
last night and it was 382, but then she fell asleep early and missed her bedtime dose of glargine (Lantus) insulin. When she
awoke this morning, she had generalized abdominal pain and continued to feel nauseated and had a large emesis. Her
glucometer was unable to read her blood glucose because it was too high. She took 10 units of lispro (Humalog) insulin
this morning. Her nausea has increased all morning and she has been unable to eat or keep anything down despite having
an increased thirst and appetite. She also has had increased frequency of urination. When her lunchtime glucometer gave
no reading because it was too high and out of range, she called 9-1-1 to be evaluated in the emergency department (ED).
Personal/Social History:
Diana has been inconsistently compliant with her medical/diabetic regimen due to her struggles with anxiety and
depression that have worsened since her mother died three months ago. She considers 200 a good blood sugar reading.
She is divorced with no children and has been homeless and has lived in a shelter off and on the past month. She is on
Social Security disability because of complications related to diabetes. At one point during the intake interview, she
expressed to the nurse, “I’m going to die anyway, why does all this matter?”
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Decreased function of the kidneys and if patient is in DKA there is an
Chronic Kidney Disease increased load on kidneys due to polyuria
Type 1 Diabetes and checks blood sugar Puts her at risk for developing DKA especially since she doesn’t check
whenever she feels like it her blood sugar regularly
Blood Sugar 383 before bed and didn’t take Blood sugar already high before bed so we know it was high for a while
her bedtime Lantus before she called 911
Generalized abdominal pain, nausea, emesis Signs and symptoms of hyperglycemia
Increased thirst, appetite, urination Signs and symptoms of hyperglycemia
Lunchtime glucometer gave no reading Severe hyperglycemia
because too high
RELEVANT Data from Social History: Clinical Significance:
Inconsistently compliant with her
medical/diabetic regimen Inability to comply with medications increases risk for
complications.
Anxiety and Depression from her
mother’s death Doesn’t have emotional support
Divorced with no children Due to her current financial hardship, she is unable to comply
with her medications and her diabetes regimen.
Homeless
© 2016 Keith Rischer/www.KeithRN.com
, Receives social security disability
benefits
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
• Chronic Kidney disease 1. Aspirin 81mg PO daily
stage III (diabetic 2 .Lisinopril 10 mg PO daily Salicylates Aspirin will help with the pain
nephropathy) 3. Lorazepam 1mg PO bid caused by her neuropathy.
• Anemia prn ACE inhibitors
• Diabetes mellitus type 1 4. Citalopram 40 PO mg daily Lisinopril will help manage her
since age 12 5. Zolpidem 10 mg PO at HS hypertension and with her
Benzodiazepine kidney disease.
• Diabetic retinopathy prn
• Neuropathy in lower legs 6. Gabapentin 300 mg PO bid SSRI Lorazepam will help calm
• Hyperlipidemia 7. Labetalol 200 mg PO bid 8.
down the patient and make her
• Hypertension Omeprazole 20 mg PO daily Sedative less anxiety.
• Coronary artery disease 9 .Simvastatin 40 mg PO HS
• Gastroesophageal reflux 10. Glargine insulin 50 units Analgesic adjunct Zolpidem will allow the patient
disease (GERD) SQ at HS to sleep better.
• Anxiety 11. Lispro insulin SQ sliding Beta Blocker
• Depression scale AC and HS Gabapentin will help with
nerve pain caused by her
Antilipidemia neuropathy.
Pancreatics Labetalol will help with her
hypertension and decrease her
Pancreatics heart rate decreasing stress on
the heart.
Omeprazole will decrease the
stomach acid helping with her
GERD.
Simvastatin will help her
cholesterol and lipids which
will help with hyperlipidemia
and coronary artery disease.
Glargine is long acting insulin
used to manage diabetes
Lispro is rapid acting insulin
used to manage diabetes
What medications treat which conditions?
Draw a line to identify what illness is being managed by what medication?
Listed in the table
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her life?
• Circle what PMH problem started FIRST Diabetes
© 2016 Keith Rischer/www.KeithRN.com
