Question

Med Surge 50

5. Describe the treatment of a patient experiencing acute hypoglycemia or diabetic ketoacidosis.
6. Identify nursing interventions for a patient diagnosed with diabetes mellitus or hypoglycemia.

Answer 1

Diabetic ketoacidosis

Diabetic ketoacidosis is serious diabetes complication where the body produces excess blood acids called ketones .this condition occurs when there is not enough insulin in the body .It can be triggered by infection or other illness.

5.Treatment

*fluid replacement

* electrolyte replacement

* Insulin therapy

Fluid replacement

Patienti will receive Fluids by mouth or through a vein until the patient is rehydrated.T he Fluids will replace the amount of urine that lost through excessive urinationation as well as help to dilute the excess sugar in the blood.

- restore perfusion of the tissues

• lowers counterregulatory hormones

• increase insulin sensitivity

- average fluid deficit 3 to 5 litres

Initial fluid resuscitation

• 15 to 20 ml / kg lean body weight per hour

• maximum of <50 ml per kg in the first four hours

• 1- 2 litres of normal saline over the first two hours

• slower rates of 500cc/ hr × 4 hrs or 250 cc / hr × 4 hours when fluid overload is concern.

• if hypernatremia develops 1/2 NS can be used.

Electrolyte replacement

Electrolytes are minerals in the blood that carry an electric charge Sodium ,Potassium and chloride. The absence of insulin can lower the level of several electrolytes in the body. Patient will receive electrolytes through a vein to help keep your heart muscles and nerve c ells functioning normally.

* hyperkalemia initially present

- Resolves quickly with insulin drip

- Once urine output is present and K<5.0,add lit less 20 - 40 meq KCL per litre.

• phosphate deficit

- may want to use Kphos

• Bicarbonate not given unless pH <7 or bicarbonate <5 mmol/L.

Insulin therapy

Insulin reverses the process that cause diabetic ketoacidosis. In addition to Fluids and electrolytes, patient should receive insulin therapy usually through a vein .when the blood sugar levels falls to about 200 milligrams per decilitre and the blood is no longer acidic patient may be able to stop intravenous insulin therapy and resume the normal subcutaneous insulin therapy.

• Iv bolus of 0 . 1 - 0.2 units/ kg ( 10 units) regular insulin

• follow with hourly regular insulin infusion

• glucose levels

- decrease 4 to 5.5 mmol/ L per hr

- minimize rapid fluid shifts

* treatment of HHHS

• Hydration

Even more important than in DKA

• find underlying cause and treat

• Insulin drip

- should be started only once aggressive hydration taken place

- switch to subcutaneous regimen once glucose <11mmol / L and patient eating

• serial electrolytes

- pottasium replacement

-If the initial K is below 3.3 mmol/L, IV pottasium chloride 20 to 40 mmol/ hr, before insulin therapy till raise the serum pottasium concentration in to the normal range of 4 to 5 mmol/L

- 3.3 to 5.3 given IV K with insulin infusion

- If above 5.3 not to given IV K till level less .

6. Nursing interventions

The management of patients presenting with DkA includes a full clinical assessment ,while regular monitoring of vital signs and consciousness level using the Glasgow Coma Scale is essential.

• Fluid resuscitation with 0.9 % sodium chloride

• insulin infusion ( fixed rate intravenous insulin infusion) at 0.1 unit / kg / hr

• close monitoring of vital signs, blood glucose ,keatones, electrolytes and blood gases.

• continue FRIII until DKA has resolved before converting to subcutaneous insulin

• correcting metabolic acidosis and electrolyte imbalance

• identify and treating precipitating factors

*Restoring circulatory volume

Fluid replacement is one of the most important initial therapeutic interventions in the management of DKA. Patients are usually dehydrated and correcting these deficit will result in significant metabolic improvement.

NS is recommended for fluid resuscitation replacement.rapid fluid replacement is usually required in the first few hours of treatment .most patients required between 500 ml to 1 litre to be given rapidly. however the rate of fluid replacement must be tailored to patients clinical situation .special attention must be paid to fluid balance in patients at high risk of complications. This include older people, pregnant women ,children and young people and those with heart and kidney failure.

*Insulin therapy - this should be administered as prescribed.

* Regular monitoring of capillary blood glucose and ketones .It is required at least hourly during the acute phase. nurses should liaise with the medical team for appropriate adjustment to insulin doses as required.

* Accurate monitoring of fluid balance this includes accurate intake and output charts .prescribed fluids should be administered and patients monitored for signs of complications related to fluid overload , ,dehydration and electrolyte imbalance.

* support early referral to the diabetes team . this involves liaising with the medical team to ensure the diabetes team is contacted as soon as possible after admission.

* Provide psychological support for patient. this includes keeping the patient and relatives fully informed about the patient's clinical condition and the care given.