Case Study #2

DKA 

Mrs. S is a 28-year-old patient, with a 12-year history of type I diabetes mellitus. Her husband states that she has had a “bad cold” for several days. Yesterday she stayed in bed and slept all day. She was “too ill” to check her blood sugar, and since she was not really eating, she did not take her insulin. This morning, she was not able to stand up and vomited twice. A Gram stain of Mrs. S’s blood contains gram-positive cocci in clusters. Her admission vital signs are: BP = 90/60; HR = 118 bpm (sinus tachycardia); RR = 32/min; T = 102.3° F; O2 sat via pulse oximetry = 96%. Her serum glucose is 398 mg/dl, and she is positive for serum ketones. She is admitted with a diagnosis of DKA.

Her baseline ABGs on 2 L of oxygen are: pH = 7.25; PCO2 = 28; HCO3 = 14; PaO2 = 92; O2 sat = 96%. Her respirations are deep, rapid, and labored. She has bronchial breath sounds in the right axillary area. There is bilateral chest expansion and no evidence of cyanosis.

A regular insulin bolus is given, and a regular insulin drip is initiated. Mrs. S’s IV fluids are infusing at 800 ml/hr. Her vital signs after 2 hours in the unit are: BP = 120/70; HR = 78 bpm (normal sinus rhythm); RR = 22/min; O2 sat = 100%. Her serum glucose is 250 mg/dl and serum potassium is 4.0 mEq/L. She is more alert and is feeling hungry.

1. What is insulin’s function in the body? What is the most significant basic defect in the development of DKA?
2. What is the cause of Ms. S experiencing DKA?  Describe the pathophysiologic rationale for your answer.
3. List the classic signs and symptoms of DKA. Which signs and symptoms did Ms. S experience? What are the pathophysiologic causes of these signs and symptoms?
4. What is an anion gap? Why is the anion gap important to follow in the treatment of DKA?
5. What acid base disturbance is Ms. S experiencing? What compensatory mechanisms are in effect at this time?
6. What is the primary nursing diagnosis for Ms. S.? What are the goals for treatment (both independent and collaborative)? What interventions are imperative to initiate immediately? What interventions are important within the next 12-24 hours?
7. What are potential lab abnormalities for a patient in DKA?
8. What nursing considerations are important in planning Ms. S’s discharge?
9. Discuss the American Association of Critical Care Nurses (AACN) Synergy Model and how this concept would be important in this patient’s care.

please use the attached book. 

Making judgement as to whether a theory could be adapted for use in research is very important.  Describe the internal and external criticism that is used to evaluate middle range theories.

 Last week you provided an overview of each nurse theorist/and or nursing theory that you have chosen.
This week, please expand upon your initial post by describing a situation from your experiences in nursing in which you would apply your particular nursing theories.
To be clear, you will describe a situation in detail and then apply each of your nursing theory(ies) to that situation separately.
Be sure to pick and example that clearly illustrates the strength of each nursing theory in application to either nursing practice, nursing research, nursing education, or nursing administration.
Describe why the classification of each theory is appropriate for the situation you have described.
Compare and contrast the the usefulness of each of your theories to this particular situation.

Be sure to use appropriate APA citation and when responding to your peers, begin with addressing them personally and end your response posting with your name.
Guidelines for Weekly Discussion Postings/ Discussion Participation: The online discussions will provide opportunities to explore different topics, share what you are learning with your classmates, and gain clarity about the course content. Your discussion responses should demonstrate critical thinking skills and your responses should be thoughtful and promote respectful discourse with the other students in the class. The rules of common courtesy are to be followed (e.g., one voice speaks at a time, polite debate occurs, and all opinions are honored). In order for an online discussion assignment to be considered complete, the student must effectively and adequately cover the assigned topic, reference the course text and other sources with appropriate APA citations, meet the 400 word minimum, the responses to classmates must be developed in a manner that furthers the conversation and learning, the spelling, grammar, and writing must be appropriate, and the online discussion assignment must be submitted on time. Interactions should be thorough, thoughtful and facilitate the learning community’s growth. Discussions will be reviewed on a weekly basis. Contribution toward the course grade total will be based on the pattern of demonstrating these characteristics. Please remember, initial posts should be submitted by deadline. 

 Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition Adolescent With Diabetes Mellitus (DM) Case Studies The patient, a 16-year-old high-school football player, was brought to the emergency room in a coma. His mother said that during the past month he had lost 12 pounds and experienced excessive thirst associated with voluminous urination that often required voiding several times during the night. There was a strong family history of diabetes mellitus (DM). The results of physical examination were essentially negative except for sinus tachycardia and Kussmaul respirations. Studies Results Serum glucose test (on admission), p. 227 1100 mg/dL (normal: 60–120 mg/dL) Arterial blood gases (ABGs) test (on admission), p. 98 pH 7.23 (normal: 7.35–7.45) PCO2 30 mm Hg (normal: 35–45 mm Hg) HCO2 12 mEq/L (normal: 22–26 mEq/L) Serum osmolality test, p. 339 440 mOsm/kg (normal: 275–300 mOsm/kg) Serum glucose test, p. 227 250 mg/dL (normal: 70–115 mg/dL) 2-hour postprandial glucose test (2-hour PPG), p. 230 500 mg/dL (normal: <140 mg/dL) Glucose tolerance test (GTT), p. 234 Fasting blood glucose 150 mg/dL (normal: 70–115 mg/dL) 30 minutes 300 mg/dL (normal: <200 mg/dL) 1 hour 325 mg/dL (normal: <200 mg/dL) 2 hours 390 mg/dL (normal: <140 mg/dL) 3 hours 300 mg/dL (normal: 70–115 mg/dL) 4 hours 260 mg/dL (normal: 70–115 mg/dL) Glycosylated hemoglobin, p. 238 9% (normal: <7%) Diabetes mellitus autoantibody panel, p. 186 insulin autoantibody Positive titer >1/80 islet cell antibody Positive titer >1/120 glutamic acid decarboxylase antibody Positive titer >1/60 Microalbumin, p. 872 <20 mg/L Diagnostic Analysis The patient’s symptoms and diagnostic studies were classic for hyperglycemic ketoacidosis associated with DM. The glycosylated hemoglobin showed that he had been hyperglycemic over the last several months. The results of his arterial blood gases (ABGs) test on admission indicated metabolic acidosis with some respiratory compensation. He was treated in the Case Studies Copyright © 2018 by Elsevier Inc. All rights reserved. 2 emergency room with IV regular insulin and IV fluids; however, before he received any insulin levels, insulin antibodies were obtained and were positive, indicating a degree of insulin resistance. His microalbumin was normal, indicating no evidence of diabetic renal disease, often a late complication of diabetes. During the first 72 hours of hospitalization, the patient was monitored with frequent serum glucose determinations. Insulin was administered according to the results of these studies. His condition was eventually stabilized on 40 units of Humulin N insulin daily. He was converted to an insulin pump and did very well with that. Comprehensive patient instruction regarding selfblood glucose monitoring, insulin administration, diet, exercise, foot care, and recognition of the signs and symptoms of hyperglycemia and hypoglycemia was given. Critical Thinking Questions 1. Why was this patient in metabolic acidosis? 2. Do you think the patient will eventually be switched to an oral hypoglycemic agent? 3. How would you anticipate this life changing diagnosis is going to affect your patient according to his age and sex? 4. The parents of your patient seem to be confused and not knowing what to do with this diagnoses. What would you recommend to them?