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DIABETIC KETOACIDOSIS

Lyceum-Northwestern University
College Of Nursing
BS Nursing - II
Nathan Vince Cruz
Jameelah Tamayo
Jan Abigaile Salisi
Lyka Mae Retuya
Charanjit Sangar
Jaqui Villanueva

Introduction
This is the case of an 18 year old male that was diagnosed with Diabetic
Ketoacidosis, (commonly termed DKA) with preexisting Chronic Kidney
Disease. Diabetic ketoacidosis (DKA) can be an acute or major
complication of diabetes that mainly occurs in patients with type 1
diabetes, such as our subject Bryan Mejia, but it is not uncommonly
seen in patients with type 2 diabetes.
This condition deals with the imbalanced metabolism of the body, more
specifically the shortage of insulin, causing the rejection of glucose into
the body cells. In order to make up for the energy loss, fats are broken
down for energy in the liver through a process called ketogenesis,
resulting in the release of the acidic compounds called ketones as a
byproduct. As ketones build up, this causes the body to become acidic
(hence the term ketoacidosis) putting the body at risk for serious, if not
fatal complications. In this study we will take you on an in depth tour of
the manifestations, signs/symptoms, diagnosis, and treatments of DKA.

Significance of the Study


As DKA effects 130,000 patients every year with a medical cost of 2.4
billion USD (105.6 billion), it is crucial that we understand this common
complication and are competent in aiding our clients. The purpose of
selecting Diabetic Ketoacidosis with preexisted Chronic Kidney Disease
for our case presentation is so we can incorporate the knowledge gained
from this study with our future case presentations. Doing this will
increase our understanding of common diseases and will aid in
determining the proper action and maintenance taken by us nurses in
the field.
By selecting subjects with multiple complications, we have the privilege
of exploring the relationship between two medical complications and the
effect one has on the other. This will be useful to us seeming as many
patients have preexisting and underlying conditions that may be difficult

Goals and Objectives


General Objective
It is the aim of those who prepared this case study to acquire knowledge,
experience and learn professional approach to Diabetic Ketoacidosis (DKA)
that will be useful in the future as we move forward to become effective nurse
both locally and internationally.
Specific objective
Define Diabetic Ketoacidosis (DKA)
Raise awareness to local and international nurses so they can be better
prepared
Analysis of Physical Assessment and Laboratory results.
Discuss the medication taken by the client, its action, side effect and nursing
responsibilities.
Explain the Anatomy and Physiology of the Endocrine System.
Trace the Pathophysiology of Diabetic Ketoacidosis (DKA).
Create effective and efficient nursing care plan required by a patient with the
above mentioned disease process.

PATIENTS PROFILE
Patients name: B.D.M.
Gender: Male

Patient type: Pediatric

Address: Bonuan Gueset, Dagupan City,

Admission date: December 23, 2014

Pangasinan

Admission time: 11 P.M.

Birth date: February 2, 1996

Attending physician: Dr. Q

Age: 18 y/o

Admission diagnosis: Diabetic

Fathers name: J.R.M

Ketoacidosis w/ Chronic Kidney disease

Mothers name: E.D.M.


Nationality: Filipino
Civil Status: Single (child)
Religion: Roman Catholic

(Stage V)
Final diagnosis: Diabetic Ketoacidosis
w/ Chronic Kidney disease (Stage V)

PATIENT MEDICAL
HISTORY
Chief Complaint
Difficulty of breathing
History of past illness
Patient experienced numbness of feet and
Sudden weight loss when he was 15 years old.
History of present illness
***Patient was confined 3x

1 week prior to admission- patient noted to have difficulty of breathing and numbness of feet.
Consult done, Upon admission of the patient, he was diagnosed with Diabetic Ketoacidosis (DKA).
Urinalysis and blood tests done, ultrasound done, FBS done, and was diagnosed with Chronic Kidney
Disorder Stage V with the doctors order and a patients signed consent to started hemodialysis.


PERSONAL MEDICAL HISTORY

A. Nutritional History
Patient is severely underweight and presents positive signs of malnutrition. He has an
imbalanced diet consisting of salty junk food, as well as soda and fatty substances and is not
eating any vegetables as stated by the mother. He also smokes and normally consumes one
pack/day.

B. Family medical history


. Grandfather - Hypertension and Asthma (Medications not specified)
. Grandmother Hypertension and Diabetic (Medications not specified)
. Father Asthma (Meds: Oregano and water)
. Mother Asthma (Meds: Oregano and water)

ENVIRONMENTAL HISTORY
Patient lives with 5 household members in a congested neighborhood near sea water with no
electricity. Source of drinking water and water used for the household is deepwell, garbage is
thrown in the bodies of water, toilet is flush type but it is shared between 3-5 families.

PHYSICAL ASSESSMENT
A. GENERAL APPEARANCE/ SURVEY
The client is conscious, coherent, and
cognitive.
B. MEASUREMENTS

FINDINGS

Height
Weight

BMI

153 cm
32.9 kg

32.9 / (1.53m)2
= 14.06

Vital
Signs

BP- 60/30 mmHg


Temp- 36.9
PR- 63
RR- 20

NORMAL VALUES ( based on avg. of an 18


year old male)
69.2
67.1
BMI:
<18.5
18.5-24.9
25-29.9
30-34.9
35-39.9
>40
BP- 100-145 mmHg (systolic) 50-90 mmHg
(diastolic)
Temp- 36.1-37.1 (axillary)
PR- 60-100
RR- 12-20

ANALYSIS/INTERPRETATIO
N
-The patient is underweight
and suffering from severe
malnutrition.

Due to abnormal circulation


of blood
NORMAL
NORMAL
NORMAL

Assessment
Neurological

Skin

I P P A
E
*

*
*

Result
Responsive
GCS score 15/15
(+)conscious (+)coherent (+)cognitive
(-) lesions
(-)rashes
(-)scars
(-)flushing, warm and moist
(+)poor skin turgor

Head

P PE A
*

Result
(-)lumps/masses

Significan
ce
NORMAL

NORMAL
NORMAL
NORMAL
ABNORMA Skin is dry
L
due to
dehydratio
n
ABNORMA Due to
L
dehydratio
n

Tongue

(-)stomatitis

NORMAL

(+)moist
(+)pink in color

NORMAL
NORMAL

(-)masses

NORMAL

(-)tenderness
(-)deviation to the side of the
mouth
(-)mass noted
(-)dull sound

NORMAL
NORMAL

Chest

*
*

NORMAL
NORMAL

Brown colored nipples

NORMAL

Smooth

NORMAL

(-)sagging of breast

NORMAL

(-)masses and depressions

NORMAL

(-)tenderness
round face
(-)no presence of nodules an infestation
symmetrical
(-) Facial edema
Evenly distributed

NORMAL

(-) Inversion of nipples


(-)nipple discharges
(-)lesion
(-)mass
Symmetrical chest expansion

NORMAL
NORMAL
NORMAL
NORMAL

Heart sounds

NORMAL

(-)lesion

NORMAL

Fine
Black in color

NORMAL
NORMAL

Coarse/dry

NORMAL

(-)masses
(-)numbness at right arm
(+)nail beds

NORMAL
NORMAL
NORMAL

(-)lice and nits

NORMAL

(-)dandruff

NORMAL

(-)scars

NORMAL

(-)tenderness

NORMAL

Assessment I

(-)wearing eyeglasses

NORMAL

Genitourina

Hair

*
*
* *

Indication

NORMAL

NORMAL

*
* *

Eyes

Assessment I

Symmetrical

Face

Scalp

Significanc Indication
e

NORMAL
NORMAL
NORMAL

Cardiovasc
ular

Upper
* *
extremities
*

Abdomen

* * *

P PE A

(-)large abdomen
(-)peristalsis
(-)mass
(-)scars
(+)tympanic sound
(-)abdominal pain
Results
(+)polyuria

NORMAL

NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
Significan Indication
ce
ABNORMA Due to excretion of
L
important minerals along

Anatomy of the cell


Mitochondr
ia

KC - kreb cycle
AcA - Acetyl coenzyme A or
Co-A
ATP Adenesine
triphosphate
Fatty acid

AT
P

Glucos
e

HO

AcA

K
C

Cell wall

AcA

Glycolysis
Pyruv
ate

insulin

Pathophysiology

Insulin
Deficiency

Stage V Chronic Kidney Disease

counter-regulatory hormones
Proteolysis
Gluconeogenic Substrates
Hepatic gluconeogenesis

Glycogenol
ysis
Blood
glucose
Acetone
Breath

Hyperglycemia

Beta-Hydroxybutyrate

Glucosur
ia
Loss of
electrolytes
Osmotic
diuresis
Urine output

Nausea &
Vomiting

Dehydrati

Ketonuri
a

lipolysis
FFA

End Stage Renal Failure

Ketogenesis
Ketoacidosis Impaired kidney function

Bicarbonate serum
levels
Kassmauls
Respirations

Management:
Medication
Dec. 23, 2014
Pen G IM per soluset q4 ANST

Dec. 27 2014

Diazepam 5mg TID for restlessness

D/c omeprazole

Dec. 24, 2014


Give 30 meqs of sodium hydrochloride
with equal diluent to run for 1hr

Hydralazine PRN
Racemic epinephrine q15 x 3
doses then q4 x 6
doses

Hydralazin 7mg q6

Dec. 28 2014

Paracetamol 200mg suppository/ 2


suppository q6 PRN

Continue meds: pen G


Hydralazine

Furosemide 20mg mid and post


Dec. 25 2014

Paracetamol
PRN

Pen G 500,000 via soluset q6

Dec. 30, 2014

Omeprazole

Continue meds: Pen G

Furosemide 20mg

Hydralazine

Dec. 26 2014
Continue meds: pen G & omeprazole

Dec. 31, 2014

Jan. 7 2015

Continue meds: Pen G


Hydralazine

Paracetamol 500mg 1 tab for temp.


37.8 C
Jan 8 2015

Jan. 2, 2015

Ceforoxine 250mg PO q12

Continue meds: Pen G


Hydralazine
Start kalium durule + durule
2x a day for
6 doses
NaCl tablet, 1 tablet 2x a day
Jan. 3, 2015
D/C Pen G
Kalium durule to complete 6
doses

Paracetamol 500mg PO q4 PRN for


temp 37.8 C
Cetirizine 10mg PO OD
Start dopamine premix at 24-25cc/hr
Jan 10 2015

Cefroxine
Jan 11 2015 Paracetamol

NaCl tablet
Jan. 4, 2015
D/c kalium durule
D/c NaCl tab

Cont. cefuroxine

Start kalium durule, 1 durule BID


PO x 6 doses
NaCl tablet, 1tablet BID

IV FLUIDS
Dec 23 2014
Line 1: PNSS 650cc to run for 1hr then 350cc to
run for 1hr then refer
Line 2: insert heplock
Start insulin drip PNSS 99cc + regular insulin 1cc
=100cc to run for 3.3cc/hr
Dec. 24, 2014
D/c insulin drip
Shift IVF to PNSS 1 liter to run at 30cc/hr (7 to 8
gtts/min)
Dec. 25, 2014
PNSS 1L
Dec. 29, 2014
Consume IVF & insert heplock
Dec. 31 2014
Consume IVF & insert heplock
Jan. 2 to 7, 2015

Jan. 8, 2015
300cc IV
check BP

Give PNSS
bolus then re

Jan. 10, 2015


bolus
(90/50)

PNSS 350cc IV
then repeat BP

Line 1: PNSS 1 liter


350cc FD then KVO
Line 2: Dopamine
premix at 24 to
25cc/hr
Jan. 11, 2015
Continue IV
line PNSS
350cc once
with BP less
than
90/60 if not, at
KVO

DIET

Dec.23 to 26, 2014: NPO


Dec. 27, 2014
Start NGT feeding at 30cc q4 (6AM)
NPO temporarily (11:50 AM)
Dec. 28, 2015
Resume NGT feeding (6:40PM)
May try oral/ feeding (9AM)
Remove NGT once feeding well
Dec.29, 2014
Low salt low fat diet
Dec. 30, 2014
Diet as Tolerated (DAT)
Dec. 31, 2014
Low salt, low fat diet

Jan. 1, 2015
Diet as Tolerated (DAT)
Increase oral fluid intake
Jan. 2, 2015
Diet as Tolerated (DAT)
Jan.3, 2015
Diet as tolerated (DAT)
Jan. 8, 2015
Low salt, low fat diet
Jan. 11, 2015
NPO

LABORATORY EXAMINATION

Jan. 1, 2015

Dec. 23, 2014

Repeat CBC, Creatinine

Complete blood count


Blood typing

Leptospira test
Jan. 2, 2015

ABG (arterial blood gas)


Urinalysis
Serum electrolytes

Repeat serum electrolyte after


24 hrs.
Jan. 3, 2015
Repeat serum electrolyte

RBS q6
Dec. 24, 2014
Repeat CBC 6 hours post BT
(blood transfusion)
D/c q6 of CBC, serum electrolytes,
RBS
D/c q1 of HGT
Dec. 29, 2014
Repeat Creatinine

(10PM)
Jan. 10, 2015
Serum electrolytes, BUN,
Creatinine, CBC, CKMB (7:15 AM)
Repeat CBC w/ PTT,
serum electrolytes, BUN, creatinine,
HGT
Jan. 11, 2015
Repeat serum

DIAGNOSTIC EXAMINATION

Dec. 23, 2014


Chest Xray APL
Dec.24, 2014
BUN, Creatinine q6, repeat serum electrolytes
KUB (Kidney Ureter Bladder)
Ultrasound

TREATMENT
Insert IJ Catheter
Hemodialysis 3x a week

LABORATORY EXAM RESULT


PATIENTS NAME: B.D.M.
GENDER: MALE
AGE: 18Y/O
MEDICAL DIAGNOSIS: DIABETIC KETOACIDOSIS
W/ STAGE V CHRONIC KIDNEY DISEASE

TEST

NORMAL VALIES

ACTUAL
RESULT

INTERPREATTION

HEMOGLOBIN

140-180g/L

103 g/L

Below normal. This indicates


less oxygen in the blood and
possibility of iron deficiency in
the body which leads to
anemia.

HEMATOCRIT

0.400-0.540

0.30

Decrease hematocrit level


indicates anemia which can be
result of hemolysis.

RED BLOOD
CELLS

4.3-5.6x10^12/L

3.58

Decrease in RBCs may


indicate anemia.

WHITE BLOOD
CELLS

4.00 10.00 x 10^9/L

9.19

Normal

LABORATORY EXAM RESULT


DIFFERENTIAL COUNT

NEUTROPHIL
S

50.0-70.0

94.1

Above normal. May indicate acute


bacterial infection.

LYMPHOCYT
ES

20.0-40.0

2.9

Below normal indicates


leukopenia.

MONOCYTES

3.0-12.0

2.5

Below normal indicates


leukopenia.

EOSINOPHIL
S

0.5-5.0

0.4

Below normal indicates


leukopenia.

LABORATORY EXAM RESULT


FULL
NAME

RESULT

UNITS

REMARK

REFERE
NCE
VALUE

INTERPRETATION

POTASSIU
M

2.69

mmol/L

Low

3.5-5.3

Below normal. Indicates hypokalemia


which can be cause by low intake
protracted vomiting, renal loss,
cirrhosis and others.

CHLORID
E

93.7

mmol/L

Low

98-107

Below normal which indicates


hypochloremia. Chloride is normally
loss in the urine, sweat and stomach
secretions. Excessive loss can occur
from heavy sweating, vomiting and
adrenal and kidney disease.

SODIUM

125.1

mmol/L

Low

135-148 Below normal. Indicates hyponatremia


which may be cause by vomiting,
diarrhea, gastric suction, excessive
perspiration, continuous IV 5%
dextrose/water: low sodium diet, burns

BLOOD
UREA
NITROGEN

44.6

mmol/L

High

3.2-7.4

CREATANIN
E

1032.3

umol/l

HIgh

63.6110.5

Above normal. Test results may


indicate liver or urinary tract issues.
Elevated BUN can be caused by the
following health conditions: heart
disease, heart failure, heart attack,
bleeding in the digestive tract,
dehydration, kidney failure, stress,
urinary tract problems such as
obstruction and shock. Further test
maybe needed.
Above normal. The test is issued to
assess renal glomerular filtration and
screen for renal damage because renal
impairment is virtually the only cause
of creatinine elevation.
Elevated levels usually indicate
diminished renal function.
Too high creatinine level indicates that
the patient has renal disease that has
seriously damaged nephrons of the
kidney.

LABORATORY EXAM RESULT


URINALYSIS
RESULT

NORMAL
VALUE

INTERPRETATI
ON

COLOR

Light Yellow

Pale to Dark
Yellow to
Amber

Normal

TRANSPARENCY

Turbid

Clear

Abnormal

SPECIFIC
GRAVITY

1.010

1.010-1.020

Normal

Ph

6.0 Acidic

5.0-6.0

Normal

SUGAR

395 mg/dl

120-160 mg/dl

Abnormal

SIGNIFICANCE

Indicates the presence of


crystals deposits, white
cells, red cells, epithelial
cells or fat globules.

Indicates renal glycosuria,


hyperglycemia, and
increased osmotic diuresis

TEST

NORMAL
VALUES

ACTUAL
RESULT

INTERPRETATION

SODIUM

3.5-5.3

125.1

Above normal, indicates hypernatremia


which can cause edema

POTASSIUM

98-107

2.69

Below normal. Indicates hypokalemia


which can be cause by low intake
protracted vomiting, renal loss,
cirrhosis and others.

135-148

93.7

Below normal which indicates


hypochloremia. Chloride is normally
loss in the urine, sweat and stomach
secretions. Excessive loss can occur
from heavy sweating, vomiting and
adrenal and kidney disease.

CHLORIDE

TEST
BUN

CREATINI
NE

NORMAL
VALUES

RESUL
T

INTERPRETATION

3.2-7.4

44.6

Above normal. Test results may indicate liver or


urinary tract issues. Elevated BUN can be
caused by the following health conditions: heart
disease, heart failure, heart attack, bleeding in
the digestive tract, dehydration, kidney failure,
stress, urinary tract problems such as
obstruction and shock. Further test maybe
needed.

63.6-110.5

1023.
3

Above normal. The test is issued to assess renal


glomerular filtration and screen for renal
damage because renal impairment is virtually
the only cause of creatinine elevation.
Elevated levels usually indicate diminished renal
function.
Too high creatinine level indicates that the
patient has renal disease that has seriously
damaged nephrons of the kidney.

LABORATORY EXAM RESULT


RESULT

NORMAL VALUE

INTERPRETATIO
N

SIGNIFICANCE

LEUKOCYTES

+++

4.00-11.0 x
109/L

No result

Leukocytes in
the urine is a
sign of
damaged
kidneys, urethra
or bladder

RBC

/uL 6

/uL 0-11

Normal

Signifies lost
blood in the
lower urinary
tract

EPITHELIAL
CELLS

0 o/hpf

0-1.8 epithelial
cells/hpf

Normal

Epithelial cells
in the urine may
indicate a
tumor

DRUG ORDER

GENERIC NAME:
Potassium
Chloride

BRAND NAME:
Kalium Durule

CLASSIFICATION:
Electrolytes

DOSAGE:
10 meqs/durule

FREQUENCY:
1 durule 3x/day

ROUTE:
PO

MECHANISM OF
ACTION

INDICATION CONTRAINDICATIO
S
NS

Maintain acid-base
Treatment/
balance,
Prevention of
Isotonicity, and
potassium
electrophysiologic
depletion.
balance of the cell.
Activator in many
enzymatic reactions;
essential to transmission
of nerve impulses;
contraction of cardiac,
skeletal, and smooth
muscle; gastric
secretion; renal function;
tissue synthesis; and
carbohydrate
metabolism.
Therapeutic effect:
Replacement. Prevention
of deficiency.

Contraindicated
in patient with

oliguria, anuria,;
patient with

untreated

Addisons

disease or with
acute

dehydration,

heat cramps,

Use cautiously
with patient with
cardiac disease
and renal
impairment.

Nausea and
Vomiting

ADVERSE
EFFECT

Arrhythmias

NURSING
RESPONSIBILITY
PRECAUTION

Heart block
Hypotension

Cardiac arrest
Hyperkalemia
Respiratory
paralysis
Nausea and
vomiting
Abdominal
pain

Make sure the


powder are
completely
dissolve before
giving.
Monitor renal
function. After
surgery, dont
give drug until
urine flow is
established, tell
patient to take
drug with or
after meals with
full glass of
water or fruit
juice to lessen
GI distress.

DRUG ORDER

MECHANISM OF
ACTION

GENERIC NAME:
Omeprazole

BRAND NAME:
Omepron

CLASSIFICATION:
Proton Pump
Inhibitor

DOSAGE:
1 CAP

FREQUENCY:
2x/day 07001900H

ROUTE:
G-TUBE

Reduces Gastric Acid


Secretion and
increases Gastric
mucus and
bicarbonate
production, creating
protective coating
on gastric mucosa and
easing discomfort
from excess gastric
acid.

INDICATIONS CONTRAINDICAT
IONS

GERD, Erosive
Esophagitis,
Short term

treatment
Duodenal

ulcer, Gastric

ulcer,
Pathologic

hypersecretor
y condition,

including
ZollingerEllison
Syndrome,
frequent heart
burn

ADVERSE
EFFECT

Hypersensitivit
y

Hepatic

Disease

Pregnancy

Children

Posterior
Laryngitis

Nausea and
Vomiting

NURSING
RESPONSIBILITY
PRECAUTION

Dizziness
Headache
Asthenia

Nausea
Vomiting
Diarrhea

Constipati

on
Abdominal
Pain

Back Pain

Cough

Upper

Respirator
y Infection

Rash

Assess vital signs


Check for abdominal
pain, emesis, diarrhea
or other
Constipation.
Evaluate fluid and
intake
Watch for elevated
liver function test
results
Tell patient to take 3060 minutes before
meal, preferably in
morning.
Instruct patient to
swallow capsules or
tablets whole and no
to chew or crash them
Caution patient to
avoid driving and
other hazardous

DRUG ORDER

MECHANISM
OF ACTION

Generic Name:
Penicillin G
Trade Name:
Penadur
Classification:
Pharmacologic
Classification
Penicillin
Therapeutic
Class
Anti-ineffective,
antibiotic
Pregnancy Risk
Factor
B
Route:
Intravenous
Maximum Dose:
2-4 million units
IM weekly for 3
weeks
Minimum Dose
300,000 Units IM

Interferes with
bacterial cell
wall synthesis
during active
multiplication,
causing cell
wall death and
resultant
bactericidal
activity
against
susceptible
bacteria.

INDICATIONS

CONTRAINDICATIO
NS

ADVERSE EFFECTs

General
Contraindications
Concentrations:
Indications:
Allergies to
Severe
penicillins,
infections
cephalosporins
caused by
, or other
sensitive
allergens
organisms
(streptococci) Precaution:
URTI caused Renal disorder
by sensitive Pregnancy
streptococci Lactation
Treatment of Drug interaction
syphilis, bejel, drug to drug:
Deceased
congenital
effectiveness
syphilis,
with
pinta, yaws
tetracylines
Prophylaxis or
Inactivation of
rheumatic
parenteral
fever and
amino
chorea
glycosides.

lethargy,
hallucinations,
seizures, glossitis,
stomatitis, gastritis,
sore mouth, furry
tongue, nausea,
vomiting, diarrhea,
abdominal pain,
colitis, nonspecific
hepatitis, nephritis
Thrombocytopenia,
anemia, leukopenia,
neutropenia,
prolonged bleeding
time
Rash, fever,
wheezing,
anaphylaxis
Pain, phlebitis,
thrombosis at
injection site
Superinfections,
sodium overload
leading to heart
failure

NURSING RESPONSIBILITY
PRECAUTION
Before:
Observe 15 rights of administration
Reduce dosage with hepatic or renal
failure
Assess for any contradictions to the
drug
Educate about side effects of drug
During:
Do not inject or mix with other IV
solutions
Give IM injections in upper outer
quadrant of the buttock
Avoid contact with the needle
Withdraw the needle as quickly as
possible to avoid discomfort
Stay with the patient throughout
whole duration of administration
After:
Monitor client for at least 30 minutes
Arrange for regular follow-up,
including blood tests, to evaluate
effects
Instruct to report difficulty breathing,
rashes, severe pain at injection site,
mouth sores
Instruct to take medications as
directed for the full course of
therapy, even if feeling better
Do proper documentation

Assessment
UPON
ADMISSION
Subjective:
manutay anako
insan agko
nakatungtung ya
masimpit
as verbalized by
the mother.
objective:
-polyuria
-weak
-dry mouth
-deep & rapid
breathing
Blood glucose
level:
= 395 mg/dL

BP: 80/30 mmHg


PR: 48 BPM
RR: 41 CPM

Diagnosis
Fluid & electrolyte
imbalance related
to
diabetes as
evidence by
glucose 395 mg/dl
and K+ 2.69

Planning
intervention
Short term
Independent:
goal:
1. The nurse will
-patients
verbalize & provide
blood glucose
printed material to pt.
will be 180
on the side effects of
mg/dl within
an managed diabetes.
24hours.

2. The nurse will


Insufficient
demonstrate to the pt
insulin
-Patients K+
how to check blood

level will be
sugars and give
Lack of glucose 3.5 -5.0 within
insulin injection
Utilization in
12 hours.
properly and will ask
muscle and
the patient to
adipose
Long term
reciprocate

goal:

Hyperglycemia -patients will dependent:


demonstrated 3. Patient will be started
to the nurse
on an insulin drip and
in-charge how
blood sugars will be
to take his
checked every hour
blood sugar
per md order
& how to get
himself insulin 4. Patient will be given

Rationale

Evaluation
After 12 hours
- To give knowledge of nursing
to the client for the intervention,
side effects that
the patients
may occur.
K+ level is 3.6
and blood

glucose of 104

mg/dl. The
- To give the patient patient was
enough knowledge able to take his
on how to check
own blood
blood sugars and
sugar and
give insulin injection insulin
independently by
injections by
discharge.
himself.

- To determine if
blood glucose is
stable or not.

- Potassium works to
maintain proper
fluid balance

Assessment
UPON
ADMISSION
Subjective:
manutay anako
insan agko
nakatungtong
ya masimpit as
verbalized by
the mother.
objective:
-3x vomiting
-weakness
-increased
urination
(+) decreased
fluid intake
(+) dry lips
Blood glucose
level:
= 395 mg/dL
BP: 80/30 mmHg

Diagnosis
Deficient fluid
volume as
evidenced by
increased urine
output, vomiting,
poor skin turgor
and dry mucous
membranes.
High blood
glucose
Level

Increase in
urination

dehydration

Planning
Short term goal:
After 12 hrs. of
nursing
interventions, no
signs of
dehydration will
be noted.
long term goal:
During the
patients stay in
the hospital, the
patient will have
appropriate
knowledge
regarding
dehydration.

Intervention
Independent:
1. assess patient
condition

2. increase fluid
intake &
encourage to
eat foods w/
high fluid

3. ensure
accurate intake
and output
monitoring

dependent:
4. Administer
0.9% sodium
chloride as
ordered.

Rationale

- To monitor for
other signs and
symptoms

- Content to
promote
hydration.

- Accurate records
are critical in
assessing the
patients fluid

- To rehydrated
the patient.

Evaluation
After 12 hours of
nursing
interventions, no
signs of
dehydration were
noted and the
mucosa of patient
was moist.

ASSESSMENT
UPON
ADMISSION
SUBJECTIVE:
hindi ako
makahinga as
verbalized by
the patient

OBJECTIVE:
-dyspnea
-difficulty
speaking
-restlessness
-productive
cough
-pale in
appearance

Hemoglobin
level:
= 103 g/L
(normal range:
120-160)

DIAGNOSIS
Abnormal
breathing
pattern due to
low
hemoglobin
level
Low
hemoglobin
level

Insufficient
O
circulating
in the body

Difficulty of
breathing

PLANNING

INTERVENTI
ON
Short term Goal:
Independent
-The patient will
1. Auscultate
have a normal
breath
respiratory rate of
sounds
12 20 breathes per
minute and signs of
dyspnea will regress
after 2 hours of
2. Monitor
nursing interventions
respiratory

patterns

3. Position
Long term Goal:
client to
-During the patients
optimize
stay in the hospital,
respiration
he will be able to

maintain patent
Dependent
airway as

manifested by:
4. Administer
-independence from
O
O2 and ventilator
inhalation
support
as

ordered.

RATIONALE

EVALUATION

- Breath sounds are


normally clear or
scattered fine crackles at
bases, which clear with
deep breathing. Presence
of coarse crackles during
late inspiration indicates
fluid in the airway;
wheezing indicates an
airway obstruction.

- Normal RR of an adult is
12 20 CPM. With
secretions in the airway,
the respiratory rate will
increase.
- An upright position
allows for maximal air
exchange and lung
expansion; lying flat
causes abdominal
organs to shift toward
the chest, which crowds

- After 2 hours of
nursing
intervention,
airway patency
maintained
and signs of
dyspnea
disappeared.

-Clients
respiratory rateis
within normal
range:RR- 12 20
CPM

-Remained calm:
allay restlessness.

Assessment
Subjective:
agto gabay so
pising mapilid sira
balet agto met
papaulyanan ya
manpaeras
as verbalized by
the mother .
Objective:
-the patient
doesnt look like
his age (18)
-impaired mobility
-the pt is thin, has
dry skin
-patient frequently
experiences
numbness of feet
weight: 32.9 kg
Height: 153 cm
BP: 80/30 mmHg
PR: 60 BPM
RR: 23 CPM

Diagnosis
Imbalanced
nutrition related to
imbalance of
insulin ,food and
physical activity.
Nutritional
imbalance

Inability of the
body to absorb
nutrients

Weight loss

Planning
Intervention
Short term
Independent:
goal:
1. take into
after 4 hours
consideration about
of nursing
the patients
intervention,
lifestyle, cultural
the patient
background, activity
will be able to
level and food
eat food
preference
given by him 2. encourage the
patient to to eat full
long term
meals and snacks as
goal:
prescribed in the
during the
diet prescription
patients stay 3. control the glucose
to the
level
hospital ,
4. provide an
there will be a
appropriate caloric
reversal of
intake.
weight loss.
Dependent:
5. implement meal
planning

Rationale

Evaluation

After nursing
- To have a
interventions,
background about the the patient
patient and how to
achieves
manage him
metabolic

balance as

manifested by:

-the patient is
- It is the first step
able to eat his
towards the desired
full meals and
body weight
snacks given to
him each day.

-the patient
- To determine if blood exhibits
glucose is stable or
glucose levels
not.
within target
- It allows the patient range
to achieve and

maintain the desired -avoids further


body weight.
weight loss and
begins to
6. provide for an extra - To monitor the food approach
snacks before
intake the patient is
desired weight.

DISCHARGE
PLAN
MEDICATION

Penicillin G- to prevent recurrence of streptococcal


infection
Omeprazole- used for treating acidinducedinflammation and block the production of acid
Potassium Chloride- to prevent or to treat low blood
levels of potassium (hypokalemia).

DISCHARGE
PLAN
HEALTH TEACHING/HYGIENE
Describe to the client the sign and symptoms to be reported
immediately. High glucose level, dry mouth, weakness/fatigue,
shortness of breath, nausea and vomiting, and abdominal pain.
( Chronic Kidney Failure- blood in urine, dark urine, swelling of feet and
ankle, persistent itching, and chest pain.)
Clearly and specifically explain the nature of disease, its coarse and
eventual prognosis of the condition to the child (if old enough to
understand), parents or caregivers. They need to understand that, while
complete resolution is expected, a small possibility exists for a
persistent disease and an even smaller possibility exists that it will
progress. The information is necessary for some patient to ensure the
compliance with the follow up program.
Remind the patient or the family members to have check up or to
consult the physician once a while to monitor the patients condition.

DISCHARGE
PLAN
SPIRITUAL

COUNSELLING: Tell the patient that


neither she/he nor GOD will not given
you a problem that you cant handle.
Advice relatives, friends or significant
others to provide moral support and
widen their understanding.
Tell them to pray for the client faster
recovery.

TREATMENT

Ensure follow up and self-care


Advise the client to take the
prescribed medicines
Ensure dietary restriction to
carbohydrates, salts and proteins
Tell the patient or family member to
monitor for signs of developing
diabetes and kidney failure
Maintain a steady, normal patient
blood glucose/sugar under control

Reference Page
http://www.drugs.com/
http://www.diabetesselfmanagement.com/
http://emedicine.medscape.
com/

Ketonesin particular, beta-hydroxybutyrateinduce


nausea and vomiting that consequently aggravate fluid
and electrolyte loss already existing in DKA.

http://www.bd.com
http://www.wisegeek.com/
http://www.ncbi.nlm.nih.gov/

When blood sugar levels are so high, some sugar "overflows" into the ur
sugar is carried away in the urine, water, salt andpotassiumare drawn in
urine with each sugar molecule, and your body loses large quantities of
and electrolytes, which are minerals that play a crucial role in cell functio
happens, you produce much more urine than normal. Eventually it may b
impossible for you to drink enough fluids to keep up with amounts that yo
urinate. Vomiting caused by the blood's acidity also contributes to fluid lo
dehydration.