case study help!

[vague111]

i want somebody to give some advice.

I need to prioritize to make a care plan based on data.

Here are the data.

Family Members & Profiles

13 years old, Type I Diabetic

Introduction/ Background: An anxious-looking, just arrived without report or notification on a gurney from the ED

Situation: Chart data:

History reveals that pt is a 13-year-old student attending middle school who was diagnosed with type 1 diabetes a year ago. Last weekend, pt and several of his friends traveled with his family to a beautiful beach in Mexico for a weekend of sun, swimming, and fun. On the last day of the weekend, pt stubbed his right toe on a nearby rock during a volleyball game that resulted in a small, open cut. At the time, pt didn't pay much attention to it; he kept on playing. After the game, he put his sandals on and headed back to the motel room to pack for the drive home. When getting out of the car, pt noticed his right toe was swollen and reddened. The first thing he did when returning home was to rinse his toe with cool water before going to bed. pt awoke in the early hours of the next morning with vomiting, fever, and diarrhea. His flu-like symptoms and continued anorexia lasted about a week. Pt stopped taking his usual insulin regimen two days prior to admission to the ED because of his inability to eat.

Pt was admitted to the ED via ambulance and presented with the typical signs and symptoms of DKA. Pt experienced a drop in his BP to 88/50 mm Hg and was stabilized in the ED with an infusion of 0.9% NaCl, the same crystalloid solution that was infusing as he arrived on the medical unit.

Initial lab results from the ED include:

• blood glucose (540 mg/dL)
  
• serum sodium (129 mEq/L)
  
• serum potassium (5.0 mEq/L)
  
• serum chloride (94 mEq/L)
  
• BUN (70)
  
• serum osmolality (319 Osm/L)
  
• pH (7.23)
  
• partial pressure of carbon dioxide (pCO2) (22)
  
• HCO3 (8)
  

New orders included the establishment of a regular insulin intravenous (IV) drip along with serum glucose, electrolyte labs, and other blood studies per protocol; oxygen via nasal cannula; activity restrictions; and other ongoing monitoring orders necessary for managing quick changes in health status secondary to treatment modalities.

Unfolding data:

Client Assessment Data as documented by Nurse on admission:

VS: T99.0, P120, R28, 105/72

Assessment:

Neuro: Oriented to self, but confused to time and place. Unsteady gait.

CV: Regular rate and rhythm; diminished peripheral pulses; positive skin tenting, capillary refill >3 seconds.

Respiratory: Lung sounds clear but dyspnea with increased rate. Fruity breath.

GI: Nausea and vomiting with emesis of 50 mL of green bile fluid during admission process.

GU: Subjective: "I peed a cup full this morning."

Integumentary: Skin flushed, dry and warm. R great toe is swollen and inflamed with an open laceration midline above the nail of great toe-draining slight amount of yellow fluid.

Musculoskeletal: Generalized weakness.

This is what I did.

Three priorities

1. Acute confusion

2.Risk for electrolyte Imbalance (hyperkalemia/hypokalemia).

3. Deficient fluid volume related to hyperglycemia.

This is my care plan

1. Acute confusion

Evidenced by

↓pH (7.23).

Confused to time and place

Infuse IV fluid

Intervention

Give regular insulin by IV infusion.

Check CBG.

Measure pt's VS every

15 minutes.

Check pt's blood glucose level.

Check pt's intake & output.

Check urine ketones.

Assess neurological status.

Check ECG.

Speak slowly with a low voice pitch.

Refer to time of day and place.

Provide pt with a clock and calendar.

Use nightlights or dim light at night.

Offer simple explanations of tasks.

Do not argue with pt.

2. Risk for electrolyte Imbalance (hyperkalemia/hypokalemia).

Evidenced by

Hyperkalemia: anxious -looking, diarrhea, pH (7.23), insulin deficiency evidenced by blood glucose (540 mg/dL), severe hypovolemia (evidenced by

↑Blood glucose

(540 mg/dL),

↑Serum osmolarity (319 Osm/L),

↑BUN (70),

↑P (120), ↑RR (28),

↓BP (88/50 mmHg → 105/72 mmHg) vomiting, fever, and

diarrhea);

Risk for Hypokalemia:

confusion, hypotension,

Regular insulin IV drip (↓ potassium).

Intervention

Monitor ECG.

When give IV potassium, make sure pt produces at least 30mL/hr of urine.

Listen to the lung & heart.

Assess for S/S of

Hyperkalemia: irritability, anxiety, abdominal cramping, diarrhea, weakness of lower extremities, paresthesia, irregular pulse, cardiac standstill;

Assess for S/S of hypokalemia: fatigue, malaise, confusion, muscular weakness, cramping or pain, and shallow respirations.

3.Deficient fluid volume related to hyperglycemia

Evidenced by

Vomiting, fever, and diarrhea.

Nausea and vomiting with emesis of 50 mL of green bile fluid during admission process.

↑ Blood glucose (540 mg/dL)

↑Serum osmolarity (319 Osm/L).

↑BUN (70).

↑P (120), ↑RR (28),

↓BP (88/50 mmHg → 105/72 mmHg).

↑Serum potassium (5.0 mEq/L).

Diminished peripheral pulse,

Positive skin tenting, Capillary refill >3 seconds.

Intervention

Infuse IV fluid.

Give regular insulin by IV infusion.

Check CBG.

Measure pt's VS every 15min.

Check pt's blood glucose level.

Check pt's intake & output.

Check hematocrit/hemoglobin.

Check urine specific gravity.

Weigh pt daily.

Assess skin turgor, dry mucous membranes, or complaints of thrist.

Assess VS every 15 minutes until stable.

I am not sure about my 3 priorities.

Also, I want somebody to point out if there are any missing info?

[Clovery]

I think a big priority would be teaching to prevent recurrence of DKA since it's life-threatening. Sorry don't really have time to post more or thoroughly read your post over. I might take another look later tonight.

[vague111]

I think pt is in life-threatening situation, so pt care is more important than teaching.

[xtxrn, ASN, RN]

This is a little disjointed, as I'm using the quick reply so I can bounce back up and read what you have written :)

If this is a regular medical floor, are you going to do vitals every 15 minutes? What are your parameters for "stable"? Or is this ICU?

Fall risk/call light- assess ability to use, or need for bed alarm (confusion issue)

I'd add another I & O in the electrolyte/dehydration section (this is HUGE with DKA) and when you will notify the MD if the volumes aren't what's expected (he will probably not put out a whole lot while he's regaining the fluid he's lost- it might look VERY unbalanced until his hydration stabilizes ). I know you've got it in the other sections, but you could get dinged for not having it w/the electrolytes. More of a CYA thing.

His K+ isn't catastrophically high- and fluid replacement will more than likely take care of it by morning... but what are you watching for that may indicate a need for increased monitoring (tele, auto BP, etc).

While the DKA is more likely to kill the kid faster, the infection is the source of the illness... what are you doing about the toe wound? I'd add a 4th (even if you only need 3, in this case I think the 4th is valid- and I can't see losing any of the other 3).

Do you want MD orders in with the nursing interventions as if they're you're idea, or "as ordered"? I didn't see serum ketones.... or are those in the protocol?

And when will you use the O2? It says he's got dyspnea. O2 sats? (could add to the confusion)

I think that the 3 you have are good- but I'd have dehydration first, infection or K+ second & third, and the confusion 4th- rationale- the confusion won't kill him (at least not directly :)).

I hope this helps some :)

[vague111]

Thank you for your comment.

Pt's confusion is from metabolic acidosis. When blood pH is low, neurons don't function well. Is dyspnea related to confusion, and can O2 sat be under confusion?

By the way, this case study is a kind of senario from my theory class.

[xtxrn, ASN, RN]

Thank you for your comment.

Pt's confusion is from metabolic acidosis. When blood pH is low, neurons don't function well. Is dyspnea related to confusion, and can O2 sat be under confusion?

By the way, this case study is a kind of senario from my theory class.

Hyperglycemia can also contribute significantly to mental status-- when you've got motor oil instead of water going through the vessels, stuff gets sticky and slow... (I get extremely tired- to the point of feeling like I'm going to sleep no matter what I do to avoid it- around 250-275....> 500 could knock someone out...

Look at the cause of the acidosis- not using acidosis as the actual problem; to get rid of the acidosis, the blood sugar, ketones, and hydration have to be fixed).

Also, hypoxia is going to add to the lethargy, so yes, you could put it there :) Dehydration will cause fluid volume deficit- as you've noted- so less blood going to the brain (with less O2 as a result- in addition to the dyspnea being a potential for decreased sats).

26 years ago, I didn't have an official theory class (more of a 'nursing lecture'....) - LOL.... I just see the labs/objective data

Get through the theory class, and learn what you need to- but objective data will always trump theory in actual practice. :)