Background Keegan Sugamoto
Patient History 36 YO M 75 Kg
Past Medical History: Type 1 Diabetes diagnosed one year ago
Allergies: No known drug allergies
Medications: 48 units of insulin daily: 12 units of regular insulin plus 20 units of NPH insulin beforebreakfast; 8 units of regular insulin before dinner; and 8 units of NPH insulin at bedtime.
Code Status: Full Code
Social/Family History: Married, lives in an apartment, spouse at bedside
Handoff Report
Situation: The patient is a 36-year-old male who was brought to the ED by paramedics after his wife found him confused and agitated in their apartment. According to his wife, he was diagnosed with Type 1 diabetes mellitus 12 months ago. She stated he has had “the flu” for five days with vomiting and anorexia and stopped taking his insulin two days ago when he was unable to eat. The paramedics started a saline lock in the right forearm and administered 250 mL of 0.9% NS en route to the hospital.
Background: Since his diagnosis, he has been taking 48 units of insulin daily: 12 units of regular insulin plus 20 units of NPH insulin before breakfast; 8 units of regular insulin before dinner; and 8 units of NPH insulin at bedtime. Prior to the “flu” his wife states that he had been doing well. He is currently confused and agitated. He has no known drug allergies.
Assessment:
Vital signs: HR 130, BP 82/46, RR 32 and deep, SpO 2 92% on RA, temperature 38.5 o C
General Appearance: Agitated, appears stated age
Cardiovascular: Sinus Tachycardia, S1&S2, Regular
Respiratory: Breath sounds are clear
GI: Bowel sounds normal, abdomen soft
GU: Voiding dark yellow, hazy urine. *NOTE Urine sample has been sent.
Extremities: Pink, warm and with poor turgor; MAEW
Skin: Flushed and dry
Neurological: Confused; Pupils equal, round, reactive to light and accommodation; unable to assess for neurological deficits
IVs: 20-gauge IV to saline lock in the right forearm, patent and non-reddened, 250 mL of 0.9% NS begun in route to hospital. * NOTE: Labe & blood culture have been sent.
Labs: Lab to be drawn STAT
Fall Risk: High-risk
Pain: Agitated and confused, unable to assess
Recommendations:
Initial Healthcare Provider’s Orders:
Capillary glucose STAT
ABG STAT
Portable Chest x-ray STAT
12-lead ECG STAT
Urinary catheter
Continuous SpO 2 monitoring
O2 per nasal cannula at 2 LPM
Maintain SpO 2 greater than 92%
Continuous cardiac monitoring
Vital signs and level of consciousness every one hour
Intake and Output every one hour
Electrolytes, BUN, Creatinine, Glucose and Anion Gap every one hour
IV #1 0.9% NS at rate of 1 L/hour
Ondansatron 4mg IV q 4hrs prn Nausea.
Lesson Objectives:
- Properly assess and treat a patient in DKA.
- Employ closed loop communications to increase PT safety.
- Assess the PT’s knowledge deficit regarding DM. Teach the PT and wife how to avoid DKA in the future.
Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar Syndrome (HHS)
1. Discuss the differences between type 1 diabetes mellitus and type 2 diabetes mellitus.
2. Describe the pathophysiologic changes that occur in DKA
3. Describe the management of the client in DKA and HHS.
4. What electrolytes are disturbed in the acute stage of DKA? Which one is most serious?