Four Days of Nausea, Vomiting and Fever

What is most important in this case study in which an older Vietnamese woman presents to the ER with fever, nausea and vomiting? Nurses General Nursing Case Study


You are reading page 2 of Four Days of Nausea, Vomiting and Fever

Patient Safety Columnist / Educator

SafetyNurse1968, ADN, BSN, MSN, PhD

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Specializes in Oncology, Home Health, Patient Safety.


This patient has Diabetic Ketoacidosis (DKA) likely brought on by a urinary tract infection. DKA develops when your body doesn’t have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body.

DKA is characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Hyperglycemia causes an osmotic diuresis with significant fluid and electrolyte loss. DKA occurs mostly in type 1 diabetes mellitus. It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia.

According to the American Diabetes Association, symptoms of DKA include:

  • a “fruity” or acetone smell on the breath
  • frequent urination
  • thirst
  • dry or flushed skin
  • difficulty breathing
  • confusion
  • abdominal pain
  • nausea and vomiting
  • high blood sugar levels
  • In severe cases, a person may experience:
  • a loss of consciousness
  • a coma

Causes of DKA

Very high blood sugar and low insulin levels lead to DKA. The two most common causes are:

  • Illness. When you get sick, you may not be able to eat or drink as much as usual, which can make blood sugar levels hard to manage.
  • Missing insulin shots, a clogged insulin pump, or the wrong insulin dose.

Other causes of DKA include:

  • Heart attack or stroke.
  • Physical injury, such as from a car accident.
  • Alcohol or drug use.

Some drugs implicated in causing DKA include

  • Corticosteroids
  • Thiazide diuretics
  • Sympathomimetics
  • Sodium-glucose co-transporter 2 (SGLT-2) inhibitors

Overall mortality rates for diabetic ketoacidosis are < 1%; however, mortality is higher in older patients and in patients with other life-threatening illnesses. Shock or coma on admission indicates a worse prognosis. Main causes of death are circulatory collapse, hypokalemia, and infection.


Urinary excretion of ketones causes additional losses of sodium and potassium. Serum sodium may rise due to excretion of large volumes of urine. Potassium may also be lost in large quantities. Despite a significant total body deficit of potassium, initial serum potassium is typically normal or elevated because of the extracellular migration of potassium in response to acidosis. Potassium levels generally fall further during treatment as insulin therapy drives potassium into cells. If serum potassium is not monitored and replaced as needed, life-threatening hypokalemia may develop.

  • IV 0.9% saline
  • Correction of hypokalemia
  • IV insulin (as long as serum potassium is ≥ 3.3 mEq/L [3.3 mmol/L])
  • Rarely IV sodium bicarbonate (if pH < 7 after 1 hour of treatment)

The most urgent goals for treating diabetic ketoacidosis are rapid intravascular volume repletion, correction of hyperglycemia and acidosis, and prevention of hypokalemia. Identification of precipitating factors is also important. Treatment should occur in intensive care settings because clinical and laboratory assessments are initially needed every hour or every other hour with appropriate adjustments in treatment.

What about those red circles?

The round red circles are signs of Cupping (Giác hơi). This traditional Vietnamese practice involves the use of partially vacuumed glass cups or large bamboo tubes on the skin to “suck out” bad wind. A vacuum is created inside the cup by waving flaming alcohol-laden cotton balls inside them or, with bamboo tubes (5 cm long and 1.5 cm in diameter) by boiling them in water before applying them. To relieve illness, cupping is done frequently on the back and chest or, much less frequently, on joints. The cup or tube is left in place for 5–10 minutes before being snapped off, creating a popping sound. Sometimes, the cup is dragged along the back or arms and then snapped off the skin. Cupping leaves circles of dark red marks caused by broken capillaries that remain for weeks. Blisters, burns, and thrombocytopenia have been reported to be associated with cupping. Many medical traditions, including Western, have used cupping but the Vietnamese consider this a Vietnamese practice.

Japanese honeysuckle (lonicera japonica), or day nhan long, is a leafy vine. The leaves are steamed or boiled and it is drunk as a tea to help lower fevers by inducing sweat. It's antibiotic elements are also said to kill bacteria while others use it as a mild laxative or for insomnia.


After fluid and insulin therapy for dehydration and hyperglycemia, as well as antibiotic therapy for the UTI, the patient’s lab values and vital signs normalized. She became A&Ox3 and ambulated without assistance. After three days in the hospital the patient was discharged with a new prescription for NPH 8 units (HS) and Regular insulin sliding scale with meals and HS and orders to check her blood sugars 3x daily.

Culturally competent care

In an ethnographic study of 40 Vietnamese patients being treated for diabetes, a strong aversion to insulin therapy was reported. Ideas about cause and proper treatment were strongly related to culture. Almost 2/3 had used traditional home remedies for diabetes. This points to a need for culturally appropriate education about TII diabetes and modern therapy for the disease.


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The following are the guesses/diagnoses/rationales from members who came to the Help Desk during the Four Days of Nausea, Vomiting and Fever Case StudyCase Study.

Thank you, @SafetyNurse1968, for this interesting Case Study.




I'm guessing that the patient has diabetic ketoacidosis. 




Diabetic keto acidosis. Fluids, med reconciliation, endocrine referral and cultural sensitive teaching on diabetes and diet. Teach family. Get nutrition, renal and optha consult.





I’m thinking DKA and UTI/Sepsis vs End of life/palliative work up (end of life fever spike and not eating/seeing deceased relatives).  Assess her reasons for non-compliance with insulin. 

Obviously she's cupping and into non-western remedies and not taking insulin. Social work consult yo determine needs and long term care planning as a start but she made need an insulin drip.






This woman appears to be in DKA, as evidenced by metabolic acidosis, the presence of ketones and hyperglycemia. 

It's not clear to me what may have pushed her into ketosis, but she obviously needs hydration, IV insulin, tight glucose and electrolyte management. If she continues with fever would look for a more occult source of infection. Once she is more alert, she may be able to give more history. 

There are many non-insulin therapies now for Type 2 DM that she may be open to. She may be willing to use those one of the newer longer acting insulins like Tresiba.  








Great job everyone! 

Stay tuned for the next Case Study by @SafetyNurse1968

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