Hyperglycemia or Dehydration what to treat first

[hazzadis]

I am doing an assignment and I am a little stuck on the question.

I have a case study and Mr. Smith has five clinical problems:

1. Dehydration
2. Tachycardia
3. Decreased Level of consciousness
4. Hyperglycaemia
5. Hyperkalemia

Our question is out of the five problems Mr. Smith has which one do you believe requires the highest priority and why.

I Defined them all as follows...

Definitions of the five clinical problems Mr. Smith has:

• Dehydration is the loss of water and salts essential for normal body function.
• Tachycardia is abnormally rapid heart rate
• Decreased level of consciousness
• Hyperglycaemia: High levels of free sugar in the blood.
• Hyperkalemia: High levels of potassium in the blood

Now I know this isn't much info as we are not given much ourselves.

They are all interrelated and all of them can cause most of the same Five symptoms he has.

I was thinking that the first one to do was hyperglycemia, due to the fact that he has altered consciousness and that insulin is required to move glucose in and out of cells.

I read a journal article that stated hyperglycemia can cause hyperkalemia.

Then I asked some friends at University and they told me they where doing dehydration first. So I am a little lost any help or just pointing me to a journal article would be great thanks guys.

[littlebear23]

I would say hyperkalemia. A high potassium level can kill your patient a lot faster than any other one of those others listed. I would say that you REALLY need to review this because it is apparent that you are weak in this area.

[David.Nelson]

Correct me if I'm wrong, but hyperglycemia could be a result of dehydration. It's about the concentration of sugar in the blood. Less water in the blood would essentially increase the sugar concentration. So in my opinion you should treat the dehydration first.

[littlebear23]

Also, research WHY hyperglycemia would be treated along with hyperkalemia. I'm really kicking myself for giving the answer. PLEASE review your material!

[hazzadis]

Hi littlebear23,

I know that high potassium levels can kill people. But i also now that Acute increase in osmolality, such as hyperglycemia, causes potassium to exit cells and then increases the level of potassium in the blood stream. So i was thinking along those lines that if you treat the hyperglycemia first it will reduce the levels of potassium being released from the cells. Also i guess i should of said that his potassium level is only 6mmol/l and i believe this is only a slight increase and thats why i thought that i would treat the hyperglycemia first. Thanks for your input and i will do some more research as i know i need to.

And thanks to david nelson as well for your input i will look into that as well.

[CodeteamB]

It sounds like you are looking at Mr. Smith as having 5 separate problems, I believe what little bear was suggesting is that if you look at these problems as a whole you will have an easier time prioritizing, unlikely these things are unrelated and taking place in a vacuum.

[kht124]

If you give insulin, that will control blood sugar and help drive potassium into the cells, which will temporarily decrease serum k...

Decreased LOC can d/t dehydration or hyperglycemia. Dehydration can be caused by hyperglycemia (hyperosmolar hyperglycemic state)....Dehydration can cause tachycardia. Hyperglycemia (lack of sufficient insulin and increased osmolality from dehydration r/t hyperglycemia) can cause hyperkalemia. There is not enough info, its hard to answer, but I would do with the hyperglycemia since I think it is causing everything else. Also, if you are treating hyperosmolar hyperglycemis state, you'll be giving a lot of fluid anyway...

[Esme12, ASN, BSN, RN]

Quote

Mr. Smith has five clinical problems:

1. Dehydration
2. Tachycardia
3. Decreased Level of consciousness
4. Hyperglycaemia
5. Hyperkalemia

So our question is out of the five problems Mr. Smith has which one do you believe requires the highest priority and why.

So I Defined them all as follows:

Definitions of the five clinical problems Mr. Smith has:

• Dehydration is the loss of water and salts essential for normal body function.
• Tachycardia is abnormally rapid heart rate
• Decreased level of consciousness
• Hyperglycemia: High levels of free sugar in the blood.
• Hyperkalemia: High levels of potassium in the blood

In it's purest form, with no other information (H&P, labs, meds)......You need to decide which will kill them first. You must consider ALL information available about that patient to make the best decisions. In nursing the devil is in the details, those subtle notes in between that impact your decisions and learning how to find them.

Technically....it is the Hyperkalemia. Then which will kill them next...dehydration. The first two are equally important and in the real world treated simultaneously

followed by hyperglycemia, followed by tachycardia and LOC (if you correct the others the last 2 will resolve).

Then you gave further information that could change this process....the K+ is only 6...do you have any other information (assessment) that afects this patient? Like I said it is the subtle notes that afect the entire picture that effects how any given patient is cared for....what each patient needs.

What are you studying in school? What condition will cause this sequelae of events? What makes this particular condition special/common to a certain population of patients? Think of the mechanisms involved in the disease process what does what to what.....Medscape: Medscape Access (medscape requires registration but it is free and is an EXCELLENT resource)

Now you need to look at the disease process involved. These are a particular set of symptoms/presentation that are WELL known to a particular disease process. What is that process/condition?

For this particular disease process and knowing the pathophysiology of this condition......these patients are very dehydrated and can be very hypotensive. They require enormous amounts of fluids and can easily require 3 liters in the first hour.......when subtle signs of dehydration are present approximately 3 liters of fluid are gone.

We also know that changes in osmolarity causes the potassium to shift so if we then treat the glucose as we hydrate...what may correct itself with the correction of the other two? Potassium...so the correction of the glucose would be the best choice. You will then evaluate if the K+ will need further treatment and act accordingly.

If all of the above are corrected the rest will resolve. Do you see how that information was analyzed? That is using critical thinking to formulate your plan on how to best care for this patient. I'll be curious to what your school thinks.

[classicdame, MSN, EdD]

I would expect to hang fluids containing K+ with rapid infusion rate, then give insulin depending on level of hyperglycemia, in that order. The lack of fluids can cause all of the other issues listed. Rehydration is primary to prevent seizures, arrhythmias, etc

[hodgieRN]

This might be cherry picking, but I would address the decreased LOC. Everything else is affecting the LOC, but I would go the ABC route and make sure this isn't about to lead to intubation. It would be better if the option said confusion or even altered LOC, but a decreased LOC is what activates a rapid response and what makes you run for oxygen. The hyperkalemia would be next in line.

[psu_213, BSN, RN]

How would you correct the hyperglycemia? How would this effect the K?

Why are they tachycardic? Is it related to another problem on your list? How would you treat those problems?

[justin.j]

What are you studying in school? What condition will cause this sequelae of events? What makes this particular condition special/common to a certain population of patients? Think of the mechanisms involved in the disease process what does what to what....

Now you need to look at the disease process involved. These are a particular set of symptoms/presentation that are WELL known to a particular disease process. What is that process/condition?

This is why you're so great Esme! When I originally read the OPs post, my mind went right to the hyperkalemia; perhaps because the threat of elevated K+ levels is so drilled into our skulls in school. (As my professor said, half jokingly... "If you see hyperkalemia on the NCLEX, it's probably the right answer. As long as 'assess' isn't an option." )

However...we're also taught that in the real world, you must look at all the symptoms and how they fit together into the bigger picture. I don't know if I'm correctly identifying the condition in question, but if I am the pt. would also have sweet fruity smelling breath, could possibly be hyperventilating, and might also be hypotensive.

Again, not sure if I'm right in my guess, but the point is that you reminded me that we have to always think about the bigger picture, and not miss the forest for the trees. In the real world, we wouldn't treat the hyperkalemia, or even the dehydration in and of itself. The correct action would be to treat the underlying cause of these symptoms. Now I just want to know what the "right" answer is.