DKA nursing care plan

[olaureno]

Family Name: *****

Family Members & Profiles

********, 13 years old, from Texas, 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 ****** is a 13-year-old student attending middle school in Texas who was diagnosed with type 1 diabetes a year ago. Last weekend, ***** 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, ***** stubbed his right toe on a nearby rock during a volleyball game that resulted in a small, open cut. At the time, ***** 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, ***** 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. ***** 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. ***** stopped taking his usual insulin regimen two days prior to admission to the ED because of his inability to eat.

*****was admitted to the ED via ambulance and presented with the typical signs and symptoms of DKA. ***** 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.

Priority issues:

- Alterned fluid and electrolyte balance r/t vomiting, diarrhea and osmotic diuresis

- Altered nutrition r/t impaired utilization of nutrients

- Dyspnea r/t respiratory compensation for metabolic alkalosis

- Anxiety r/t dyspnea, disorientation, fear of bodily injury, fear of medical procedures, fear of separation from family/friends, fear of violation of body autonomy

- Alteration in comfort r/t nausa, vomiting, painful toe, shortness of breath, fatigue

- Risk for fall/injury to self r/t acute disorientation, unsteady gait, generalized weakness

- Risk for sepsis? Something to do with the infected toe

[Double-Helix, BSN, RN]

Do you have a specific question or something we can clarify for you? What are you thinking regarding this care plan and where do you need assistance?

[olaureno]

I just wanted some feedback on my priority issues- my identified nursing diagnoses. These are listed at the bottom of the case study in italics. Do they seem appropriate? Do they seem tailored to this particular placement? We are supposed to put them in order of immediate importance. This is what I'm having the most trouble with. What order would you put them in? What is your thought process behind it so I can compare it to mine?

[Banana nut, BSN, RN, EMT-B]

I think you did a really great job with your dx. Some thoughts I had that might be high priority were fluid volume deficit and risk for infection, also you mentioned a dx of metabolic alkalosis but I think it should be acidosis. PH 7.28 hco3 was8

I'm a student so this is just food for thought best of luck to you!

[Kuriin, BSN, RN]

Weird...didn't we just see this exact same care plan question a week ago? This looks very familiar.