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:
Dehydration
Tachycardia
Decreased Level of consciousness
Hyperglycaemia
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.
What's the serum glucose? I think that's am important piece of information. If the glucose is 150 it's technically hyperglycemia, but since it's only slightly elevated above normal it's more likely to be a symptom of dehydration (less fluid volume = higher concentration of sugar and electrolytes) than a cause. If that's the case then all of his issues could probably be fixed with a couple of liters of NS. But if the glucose is 500 we're probably dealing with diabetic ketoacidosis causing dehydration (which causes tachycardia), hyperkalemia and decreased LOC.
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
I think many of us are thinking of DKA, in which it is possible to see a serum hyperkalemia even though the total body potassium levels are low. You want to get the serum K+ to return to intracellular K+ and stabilize (insulin will help with that). I would not expect to replace K+ immediately with a serum level of 6.0, I would however be on the lookout for dropping potassium levels, and anyone with a "normal" potassium on the chem panel I would expect to be running at least a maintenance of K+. For this patient I would expect to treat the dehydration first (not uncommon to pour 5-6 liters into a patient just in the ER, and then the hyperglycemia/ hyperkalemia (again, the insulin is going to help with both). With a K+ of 6 I would not expect to be giving any other treatments for the hyperkalemia and I would expect that at some point the patient may require potassium replacement. This is why we keep the patient on monitor and check the chem panel/ chemstrip so frequently. Anyhow, OP I'm curious, is this what your assignment was driving at?? Inquiring minds wish to know!
I think many of us are thinking of DKA, in which it is possible to see a serum hyperkalemia even though the total body potassium levels are low. You want to get the serum K+ to return to intracellular K+ and stabilize (insulin will help with that). I would not expect to replace K+ immediately with a serum level of 6.0, I would however be on the lookout for dropping potassium levels, and anyone with a "normal" potassium on the chem panel I would expect to be running at least a maintenance of K+. For this patient I would expect to treat the dehydration first (not uncommon to pour 5-6 liters into a patient just in the ER, and then the hyperglycemia/ hyperkalemia (again, the insulin is going to help with both). With a K+ of 6 I would not expect to be giving any other treatments for the hyperkalemia and I would expect that at some point the patient may require potassium replacement. This is why we keep the patient on monitor and check the chem panel/ chemstrip so frequently. Anyhow, OP I'm curious, is this what your assignment was driving at?? Inquiring minds wish to know!
I know the patho phys behind it and I agree with you, however I would not be replacing fluid with K+ at a "rapid rate". This is why I asked.
Actually a very hard question to answer without knowing specifics. If it was prioritized to you as listed with out objective data,
i would be tempted to handle the dehydration first.
Without knowing any more than what's already listed, I'd also be tempted to treat the dehydration first as fluid therapy will dilute the hyperglycemia, the hyperkalemia, and so on. I'd then be tempted to treat the hyper-K next. Albuterol could be given to drive K back into the cells, but treating the hyperglycemia with insulin would also drive K back into the cells. This patient would be on monitor and I'd be wanting to see serial labs to determine if the therapies are working and to keep an eye on the serum K level. I don't want it to fall to a critical level.
If I knew the labs to go along with the presentation, I'd possibly change my prioritization of therapies based on that.
The reality is that we'd probably end up treating all those things nearly simultaneously and just be VERY paranoid about the K level.
If you have lab values for K+, do you have the other lab values as well. The glucous has us all thinking this is a diabetic, but we don't know what type of diabetic the pt is. Anyway, whether it is DKA or HHS the first step in a hospital setting is NS. However, in a nclex setting what you do in nclex and real life are not always the same. The use of insulin is more warranted in DKA, but less so in HHS. The high potassium will usually correct its self after fluids are restored and can change to a hypo state.
2. Tachycardia
3. Decreased Level of consciousness
These throw up a red flag, decreases in LOC is really, really bad, and I have to ask is this pt. about go into shock or diabetic coma. So for me either the priority is the LOC or dehydration.
I'd say treat the dehydration first. By replenishing the fluid, glucose and potassium levels will drop slightly. 6 is barely hyperkalemic although it does need treatment. When fluid is back in circulation the tachycardia should resolve. I'm not sure what would be causing the decreased LOC. A better clinical picture would be helpful.
Of course the LOC could trump all if assessment revealed something stroke like or something that needed prompt treatment.
~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~
The question is what is the priority... The answer is hyperkalemia.... Yes solving the dehydration may help the hyperkalemia however the priority is to get the k levels down... The k range is 3.5-5 that window is very narrow and a level of 6 is more significant than you would think.
And I had patient who was a newly diagnosed diabetic. She had a glucose in the 400s and the K was 5.8 (so both hyperglycemia and hyperkalemia). She was given IV insulin and started on an insulin drip. This treats both the high blood sugar and the high K...so, in the NCLEX world, what are you going to treat "first" (i.e., top priority) I would say the K. However you are going to treat both at once in the real world.
Also, in the real world, you will first know that they are dehydrated. Unless the sugar or K is super high (say 600 and 6.4, just to pick numbers) you are not going to really know that they are hyperglycemic and hyperkalemic. You are likely going to look at them and see that they are dehydrated--this is probably what is causing the tachycardia. So the dehydration will likely be treated first before you even have a K level.
This is my first post but have used the site for a while. I am doing an assignment and i am a little stuck on the question.
So 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
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
Hyperglycaemia: High levels of free sugar in the blood.
Hyperkalemia: High levels of potassium in the blood
Now I know this aint much info as we are not given much our selfs.
So 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 conciseness 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.
I beliebe dehydration gets the highest priority. The tachy and LOC are results of hyperglycemia and dehydratiom. Being a diabetic I also know that when I go into the hospital for hyperglycemia they always push fluids first and treat the dehydratiom because the the insulin wont work while severly dehydrated. Once the insulin can be administered it will also cause the potassim to decrease naturally so if you were to treat the hyperkalemia first they might end up going too low after the insulin is administered.
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Double-Helix, BSN, RN
3,377 Posts
What's the serum glucose? I think that's am important piece of information. If the glucose is 150 it's technically hyperglycemia, but since it's only slightly elevated above normal it's more likely to be a symptom of dehydration (less fluid volume = higher concentration of sugar and electrolytes) than a cause. If that's the case then all of his issues could probably be fixed with a couple of liters of NS. But if the glucose is 500 we're probably dealing with diabetic ketoacidosis causing dehydration (which causes tachycardia), hyperkalemia and decreased LOC.