DIABETES AND DIABETIC KETOACIDOSIS

DIABETES AND DIABETIC KETOACIDOSIS

            Diabetic ketoacidosis is a medical emergency that arises when there is insulin deficiency (Chang & Yang, 2016). Often, DKA is a complication of type I diabetes that results in the body breaking fat at a faster rate, hence, accumulation of acids in the blood, which eventually leads to coma or death. According to the Centers for Disease and Control (2017), approximately 100 million US adults have diabetes. In 2015, diabetes was the seventh leading cause of death in the United States, while 25% of the United States’ population have diabetes but are not aware of it. Diabetic ketoacidosis develops when a diabetic patient does not adhere to medications, have infections, have undiagnosed type I diabetes, or if the patient becomes ill. A systematic review by Stolpe on adherence to diabetes medications revealed that there was poor compliance with diabetic therapy among diabetic patients in the US (Stolpe et al. 2016). Also, according to the Centers for Disease Control and Prevention (2017), the rate of hospitalizations from DKA increased by 54.9% from 2009 to 2014, which was alarming.  Therefore, as a nurse, being prepared to manage patients who present with DKA using critical thinking skills and scientific knowledge is essential.

IMPORTANCE OF STANDARDIZED CARE MAP FOR NURSES

A standardized care map is a tool that integrates the pathophysiology of a given medical condition, data from history taking, signs and symptoms the patient presents with, objective data including laboratory findings, and imaging results that confirm the diagnosis. Based on these data, nursing, medical, and other healthcare providers’ care plans for the patient are discussed (Darley et al. 2017). Nursing care plans for patients utilize standardized languages, including NANDA, NOC, and NIC. Darley et al. (2017), argues that a care map is essential for nurses since it helps to develop critical thinking skills as one plans safe, efficient, and effective patient care. Besides, it helps the nurse to link the relationship between a patient’s problems, the cause of the problem, and the nurse’s clinical response.

NURSING DIAGNOSES FOR PATIENT WITH DKA

Deficient fluid volume related to osmotic diuresis resultant from hyperglycemia as evidenced by tachycardia, orthostatic hypotension, decreased skin turgor, sunken eyes, dry mucous membranes, and increased urinary output of 6.5 liters in 24 hours.

In diabetic ketoacidosis, excessive fluid and electrolyte loss is resulting from hyperglycemia. Usually, when there is sufficient insulin production, blood glucose levels are kept at normal ranges, and all glucose filtered in the kidneys is reabsorbed. However, in cases of hyperglycemia, the kidneys become overwhelmed by the excessive glucose levels. Therefore, glucose gets into the filtrate and pulls water along with it, thus, polyuria, which causes fluid and electrolyte loss. Often, a patient presenting with DKA will have symptoms of dehydration such as sunken eyes, dry mucous membranes, tachycardia, and hypotension.

Fatigue related to hyperglycemia and altered body chemistry as evidenced by patient complaining of tiredness on performing ordinary activities, lack of sleep, and listlessness.

Hyperglycemia, which is a common sign of DKA causes blood to be sludgy, thus, slows blood circulation. The result for this is cells will not receive enough oxygen and nutrients they require. Therefore the patient feels fatigued. Besides, according to Chang & Yang (2016), high blood glucose causes blood vessel inflammation. Thus, monocytes accumulate in the brain, causing fatigue. Also, when insulin is deficient in the body, the cells of the body cannot take up glucose and use it to produce energy. Instead, the body begins to breakdown non-carbohydrate substances such as fats and proteins.  (Chang & Yang, 2016) postulates that this alteration of body chemistry results in fatigue.

Risk for infection related to decreased leukocyte function, changes in circulation, and hyperglycemia.

According to Rahmadi et al. (2016), when a patient has DKA, he/she is predisposed to infections such as yeast, urinary tract infections, and surgical site infections. Besides, with hyperglycemia, which is a characteristic of DKA, the patient is predisposed to diabetic neuropathy, which predisposes the patient to foot injuries, and the patient may not recognize them because of lack of sensation.

NURSING INTERVENTIONS FOR NURSING DIAGNOSES ACCORDING TO NIC

To restore fluid volume:

1. Maintain a large bore cannula and initiate fluid resuscitation therapy with 0.9% normal saline at a rate of one liter per hour until blood pressure and pulse are within normal ranges. Fluid replacement is essential because the patient loses a significant amount of fluids through polyuria, vomiting, and hyperventilation.
2. Monitor blood pressure when the patient is standing, sitting, or lying to note orthostatic hypotension. Taking blood pressures on different positions of the patient provides baseline data that the nurse can use to monitor the effectiveness of interventions him /she implements to restore fluid volume in the patient.
3. Evaluate peripheral pulses, skin turgor over the thighs and sternum, and capillary refill time. Assessing these indicators will help in evaluating the outcomes of nursing interventions.

To restore the patient’s energy reserves:

1. Plan diary with the patient to identify activities that easily make the patient feel fatigued, and after identifying those activities, assist the patient in having rest by setting the room comfortable.
2. Assist where necessary in the performance of activities of daily living.
3. Administer oxygen as prescribed and monitor respiratory rate, pulse, and blood pressure after every activity.

To prevent infections:

1. Observe for signs of infection such as fever, inflammation, dysuria, or discharge from wounds to ensure that the patient is free from infections
2. Practice infection prevention control measures such as hand washing by staff and significant others to prevent gross infections.
3. Use aseptic technique when performing invasive procedures such as intravenous line insertion to prevent infections.

DESIRED OUTCOMES ACCORDING TO NOC

Fluid volume

After implementing nursing interventions, the patient will:

1. Be normovolemic, as evidenced by a systolic blood pressure of 90 -120mmHg, there will be no orthostatic, and the patient’s pulse will be 60-100 beats per minute.
2. Be aware that insulin non-compliance causes fluid volume deficit; thus, will comply with medications.
3. Have palpable peripheral pulses, and blood sugar levels will be 70-200mg/dl.

Fatigue

By the end of nursing interventions, the patient will:

1. Share their feelings about how they feel about fatigue
2. The patient identifies what worsens fatigue, and what offsets it.
3. Demonstrate techniques to reduce fatigue that will enable her/him to perform activities of daily living.

Infection

1. The patient will demonstrate ways of reducing risk of infection
2. The patient will identify techniques and lifestyle changes to prevent the development of an infection such as footwear.

CARE MAP

REFERENCES

Centers for Disease Control and Prevention. (2017). New CDC report: More than 100 million Americans have diabetes or prediabetes. Retrieved from Centers for Disease Control and Prevention: https://www. CDC. gov/media/releases/2017/p0718-diabetes report. HTML.

Chang, S. C., & Yang, W. C. V. (2016). Hyperglycemia, tumorigenesis, and chronic inflammation. Critical reviews in oncology/hematology, 108, 146-153.

Daley, B. J., Beman, S. B., Morgan, S., Kennedy, L., & Sheriff, M. (2017). Concept maps: A tool to prepare for high fidelity simulation in nursing. Journal of the Scholarship of Teaching and Learning, 17(4), 17-30.

Rahmadi, A., Decroli, E., & Kam, A. (2019). Sepsis in Latent Autoimmune Diabetes in Adults with Diabetic Ketoacidosis: A Case Report. Open Access Macedonian Journal of Medical Sciences, 7(20).

Stolpe, S., Kroes, M. A., Webb, N., & Wisniewski, T. (2016). A systematic review of insulin adherence measures in patients with diabetes. Journal of managed care & specialty pharmacy, 22(11), 1224-1246.

Swearingen, P. L., & Wright, J. (2019). All-in-One Nursing Care Planning Resource-E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health. Elsevier Health Sciences.