What’s the relationship between the medical history and current concerns for the client?
Shannon’s history of being a DM1 since she was three years old directly relates to her current medical condition. Illnesses interfere with the management of diabetes because blood glucose levels are not regulated when intake of food and fluids is altered as well as the administration of insulin (Centers for Disease Control and Prevention , 2014). In addition, being ill usually causes stress on the body which increases the blood glucose levels (Robbins et al., 2010). Lastly, diabetes affects the immune system by disturbing humoral immunity, damaging neutrophil function, and depressing the antioxidant system. As a result the individual will be more susceptible to illness or have a reduced ability to fight microbes. Certain organisms thrive in hyperglycemic environments which make it harder for a diabetic clients immune system to control (Casqueiro, Casqueiro, & Alves, 2012). Since Shannon has not been eating and not taking insulin she has not been managing her diabetes during their illness appropriately. This means her body has not been able to process glucose for energy and has been forced to metabolize fat instead leading to the development of DKA (Robbins et al., 2010).
What else would you like to know about Shannon’s recent history and events leading to her hospitalization.
When Shannon received her last flu shot – is her current condition a result of a reaction to the immunization or does she have a different strain of influenza.
Diabetes management – her diet, activity level, and average blood glucose levels.
When/what was her last meal was and when/how much was her last dose of insulin.
Are there any other symptoms other than loss of appetite, vomiting, and fatigue.
What information is missing from the initial assessment and state the significance of performing this assessment
Pain assessment – assess for abdominal pain which is common in DKA patients due to the acidic environment and decreased perfusion to the gastrointestinal tract (Robbins et al., 2010).
Abdominal assessment – assess functioning and affect of the metabolic acidosis on the gastrointestinal tract, look for presence of bowel sounds, and ask when their last bowel movement was and if they are currently passing gas (Robbins et al., 2010).
Smell breath – a fruity or acetone breath is a hallmark sign of DKA (Pollock & Funk, 2013).
Neurovital signs for a baseline – get an idea of level of consciousness upon admission and pupil assessment to assess for any other potential issues/complications that need to be addressed (Wolfsdorf et al., 2014).
Baseline CBS level – look for a directive or call the doctor to get an order for CBS along
with sliding scale to treat abnormal results.
Relate the assessment findings to the pathophysiology of DKA.
Shannon is displaying Kussmaul’s respirations because she is breathing rapid at 28 breaths
per minute and they are deep. This is the respiratory system’s way of compensating for metabolic acidosis (Bopp, 2010; Marieb, & Hoehn, 2010). Shannon is displaying signs of dehydration through the presence of hypotension (BP of 82//50), tachycardia (heart rate of 144), and has poor skin turgor with dry mucus membranes. Dehydration occurs due to fluid loss and osmotic diuresis (Fowler, 2009).
Provide rationale for the physicians orders and therefore, subsequent collaborative care.
The following are the rationals for the physician’s orders:
Neurovital signs are to assess the clients level of consciousness to quickly determine whether their overall status is improving or deteriorating. Cardiac monitoring is a way for continuous assessment for hyper or hypokalemia through evaluating the T waves (Wolfsdorf et al., 2014). Lab work is done to assess imbalances, create and adjust treatment as needed, as well as, provide information about the clients response to treatment (Robbins et al., 2010).
NPO so serum blood sugar levels are not increased and for accurate measurement of client fluid and caloric intake (Pollock & Funk, 2013). NPO status also maintains the airway by preventing choking/aspiration if they were to loose consciousness with something in their mouth (Robbins et al., 2010).
Bed rest is for harm reduction. DKA patients are typically lethargic and if they are up and walking they can easily become fatigued and fall (Robbins et al., 2010). Patients can become hypokalemic which can cause dangerous cardiac rhythms (Bopp, 2010).
IV regular insulin is given to restore glucose metabolism. IV is the best route to fix moderate to severe DKA and regular insulin is the only insulin that can be given through an IV at a rate of 0.1units/kg/hr (Pollock & Funk, 2013). CBS hourly is required to continually assess the clients blood glucose levels, response to treatment, as well as, provide a reference for titrating the insulin infusion rates, if needed (Pollock & Funk, 2013).
IV Normal Saline (NS) is used initially to restore the clients fluid volume in their intravascular,
interstitial, and intercellular spaces. It is also used to restore renal perfusion (Pollock & Funk,
2013). Foley catheter assists in documenting the clients hourly output and assists in maintaining
the bed rest order. An accurate hourly intake along with the hourly output helps determine
kidney function, as well as, hydration status (Pollock & Funk, 2013).
The doctor has ordered a oxygen via non-rebreather. Oxygen is essential in maintaining adequate oxygenation within the bodies cell (Robbins et al., 2010).
The following is the subsequent collaborative care Shannon should receive:
Ongoing monitoring of vital signs and mental status, cardiac rhythms, respiratory status for fluid overload, serum glucose, pH, intake and output, and serum potassium. This is done to measure the clients response to treatment and to evaluate their overall status and prevent hypoglycemia (Pollock & Funk, 2013; Robbins et al., 2010).
Potassium is heavily monitored and a switch from NS to NS with potassium chloride may be needed to maintain potassium levels and prevent hypokalemia (Pollock & Funk, 2013).