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DIABETIC KETOACIDOSIS

Diabetic Ketoacidosis Case Presentation

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Second year nursing student presentation. BSN-II

Text of Diabetic Ketoacidosis Case Presentation

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Nathan Vince Cruz Jameelah Tamayo Jan Abigaile Salisi Lyka Mae Retuya Charanjit Sangar Jaqui Villanueva

Cherry Rey Arvy Rebamonte Teresa Vinoya Hazel Ydeo Jeric Quinto Micka Rivera

Lyceum-Northwestern UniversityCollege Of NursingBS Nursing - II

IntroductionThis is the case of an 18 year old male that was diagnosed with Diabetic Ketoacidosis, (commonly termed DKA) with preexisting Chronic Kidney Disease. Diabetic ketoacidosis (DKA) can be an acute or major complication of diabetes that mainly occurs in patients with type 1 diabetes, such as our subject Bryan Mejia, but it is not uncommonly seen in patients with type 2 diabetes.

This condition deals with the imbalanced metabolism of the body, more specifically the shortage of insulin, causing the rejection of glucose into the body cells. In order to make up for the energy loss, fats are broken down for energy in the liver through a process called ketogenesis, resulting in the release of the acidic compounds called ketones as a byproduct. As ketones build up, this causes the body to become acidic (hence the term ketoacidosis) putting the body at risk for serious, if not fatal complications. In this study we will take you on an in depth tour of the manifestations, signs/symptoms, diagnosis, and treatments of DKA.

Significance of the StudyAs DKA effects 130,000 patients every year with a medical cost of 2.4 billion USD (105.6 billion), it is crucial that we understand this common complication and are competent in aiding our clients. The purpose of selecting Diabetic Ketoacidosis with preexisted Chronic Kidney Disease for our case presentation is so we can incorporate the knowledge gained from this study with our future case presentations. Doing this will increase our understanding of common diseases and will aid in determining the proper action and maintenance taken by us nurses in the field.

By selecting subjects with multiple complications, we have the privilege of exploring the relationship between two medical complications and the effect one has on the other. This will be useful to us seeming as many patients have preexisting and underlying conditions that may be difficult to dodge during treatment. In doing this, we transcend to a new level of understanding overall patient health.

General Objective

It is the aim of those who prepared this case study to acquire knowledge, experience and learn professional approach to Diabetic Ketoacidosis (DKA) that will be useful in the future as we move forward to become effective nurse both locally and internationally.

Specific objective

Define Diabetic Ketoacidosis (DKA)Raise awareness to local and international nurses so they can be better prepared Analysis of Physical Assessment and Laboratory results.Discuss the medication taken by the client, its action, side effect and nursing responsibilities.Explain the Anatomy and Physiology of the Endocrine System.Trace the Pathophysiology of Diabetic Ketoacidosis (DKA).Create effective and efficient nursing care plan required by a patient with the above mentioned disease process.Goals and Objectives

Patients name: B.D.M.Gender: MaleAddress: Bonuan Gueset, Dagupan City, PangasinanBirth date: February 2, 1996Age: 18 y/oFathers name: J.R.MMothers name: E.D.M.Nationality: FilipinoCivil Status: Single (child)Religion: Roman CatholicPatient type: PediatricAdmission date: December 23, 2014Admission time: 11 P.M.Attending physician: Dr. QAdmission diagnosis: Diabetic Ketoacidosis w/ Chronic Kidney disease (Stage V)Final diagnosis: Diabetic Ketoacidosis w/ Chronic Kidney disease (Stage V)PATIENTS PROFILE

Chief ComplaintDifficulty of breathing

History of past illnessPatient experienced numbness of feet and Sudden weight loss when he was 15 years old. History of present illness***Patient was confined 3x

1 week prior to admission- patient noted to have difficulty of breathing and numbness of feet. Consult done, Upon admission of the patient, he was diagnosed with Diabetic Ketoacidosis (DKA). Urinalysis and blood tests done, ultrasound done, FBS done, and was diagnosed with Chronic Kidney Disorder Stage V with the doctors order and a patients signed consent to started hemodialysis.PATIENT MEDICAL HISTORY

PERSONAL MEDICAL HISTORYNutritional HistoryPatient is severely underweight and presents positive signs of malnutrition. He has an imbalanced diet consisting of salty junk food, as well as soda and fatty substances and is not eating any vegetables as stated by the mother. He also smokes and normally consumes one pack/day.B. Family medical historyGrandfather - Hypertension and Asthma (Medications not specified)Grandmother Hypertension and Diabetic (Medications not specified)Father Asthma (Meds: Oregano and water)Mother Asthma (Meds: Oregano and water)ENVIRONMENTAL HISTORYPatient lives with 5 household members in a congested neighborhood near sea water with no electricity. Source of drinking water and water used for the household is deepwell, garbage is thrown in the bodies of water, toilet is flush type but it is shared between 3-5 families.

FINDINGSNORMAL VALUES ( based on avg. of an 18 year old male)ANALYSIS/INTERPRETATIONHeightWeightBMI153 cm32.9 kg32.9 / (1.53m)2 = 14.0669.267.1BMI:40-The patient is underweight and suffering from severe malnutrition.Vital SignsBP- 60/30 mmHgTemp- 36.9PR- 63RR- 20BP- 100-145 mmHg (systolic) 50-90 mmHg (diastolic)

Temp- 36.1-37.1 (axillary)PR- 60-100RR- 12-20Due to abnormal circulation of bloodNORMALNORMALNORMAL

A. GENERAL APPEARANCE/ SURVEYThe client is conscious, coherent, and cognitive.

B. MEASUREMENTSPHYSICAL ASSESSMENT

AssessmentIPPEAResultSignificanceIndicationNeurological*Responsive GCS score 15/15(+)conscious (+)coherent (+)cognitiveNORMALSkin*(-) lesionsNORMAL*(-)rashes (-)scars(-)flushing, warm and moist

(+)poor skin turgorNORMALNORMALABNORMAL

ABNORMAL

Skin is dry due to dehydrationDue to dehydrationHead*SymmetricalNORMAL*SmoothNORMAL*(-)masses and depressionsNORMALFace***(-)tenderness round face (-)no presence of nodules an infestation symmetrical(-) Facial edemaNORMAL

NORMALNORMALHair*Evenly distributedNORMAL*Fine Black in colorNORMALNORMAL**Coarse/dryNORMAL*(-)lice and nitsNORMALScalp*(-)dandruff NORMAL*(-)scarsNORMAL*(-)tendernessNORMALEyes*(-)wearing eyeglassesNORMAL*SymmetricalNORMAL*(-)periorbital edema(-)redness in both eyesNORMALNORMALNose*Proper olfactory functionNORMAL*SymmetricalNORMAL*With sense of smellNORMAL(-)tonsilo pharyngeal congestionNORMALEars*(-)tinnitusNORMAL*(-)dischargesNORMAL*Gross hearing intactNORMALLips*(-)moist and smooth (-)lesionABNORMALNORMALDue to dehydrationMouth*(-)painNORMAL

AssessmentIPPEAResultSignificanceIndication*(-)lumps/masses NORMAL*(-)stomatitisNORMALTongue*(+)moist (+)pink in colorNORMALNORMAL*(-)massesNORMAL* (-)tenderness (-)deviation to the side of the mouthNORMALNORMALChest* *(-)mass noted (-)dull soundNORMALNORMAL*Brown colored nipplesNORMAL*(-)sagging of breastNORMAL*(-) Inversion of nipples (-)nipple discharges (-)lesion (-)massNORMALNORMALNORMALNORMAL*Symmetrical chest expansionNORMALCardiovascular*Heart soundsNORMALUpper extremities**(-)lesion NORMAL*(-)masses (-)numbness at right arm (+)nail bedsNORMALNORMALNORMALAbdomen****(-)large abdomen (-)peristalsis (-)mass (-)scars (+)tympanic sound (-)abdominal painNORMALNORMALNORMALNORMALNORMALNORMALAssessmentIPPEAResultsSignificanceIndication Genitourinary*(+)polyuriaABNORMALDue to excretion of important minerals along with the urine*(-)pain in the suprapubic urinalysis resultNORMAL*(-)burning sensationNORMAL*(-)involuntary movementsNORMALLower extremities**(-)bipedal edema(-)wounds (-)pain in the lower extremities (+)ROM(+)numbness of the legsNORMALNORMALNORMALNORMALABNORMALDue to abnormal circulation of blood*

MitochondriaCell wall

insulinGlucoseKCKC - kreb cycleAcA - Acetyl coenzyme A or Co-AATP Adenesine triphosphate

Glycolysis

HOFatty acidAcAAcAATPPyruvate

Anatomy of the cell

PathophysiologyInsulin Deficiency Osmotic diuresisGlycogenolysisLoss of electrolytes Hepatic gluconeogenesis counter-regulatory hormonesHyperglycemiaKetogenesisKetoacidosis lipolysisDehydration Gluconeogenic Substrates ProteolysisKetonuria Bicarbonate serum levels Blood Pressure Blood glucose Urine outputGlucosuria Beta-HydroxybutyrateNausea & Vomiting FFAAcetone BreathKassmauls RespirationsImpaired kidney functionEnd Stage Renal FailureStage V Chronic Kidney Disease

Management:Medication Dec. 23, 2014 Pen G IM per soluset q4 ANST Diazepam 5mg TID for restlessness Dec. 24, 2014 Give 30 meqs of sodium hydrochloride with equal diluent to run for 1hr Hydralazin 7mg q6 Paracetamol 200mg suppository/ 2 suppository q6 PRN Furosemide 20mg mid and post Dec. 25 2014 Pen G 500,000 via soluset q6 Omeprazole Furosemide 20mg Dec. 26 2014 Continue meds: pen G & omeprazole Dec. 27 2014 D/c omeprazole Hydralazine PRN Racemic epinephrine q15 x 3 doses then q4 x 6 doses Dec. 28 2014 Continue meds: pen G Hydralazine Paracetamol PRN Dec. 30, 2014 Continue meds: Pen G Hydralazine

Dec. 31, 2014 Continue meds: Pen G Hydralazine Jan. 2, 2015 Continue meds: Pen G Hydralazine Start kalium durule + durule 2x a day for 6 doses NaCl tablet, 1 tablet 2x a dayJan. 3, 2015 D/C Pen G Kalium durule to complete 6 doses NaCl tabletJan. 4, 2015 D/c kalium durule D/c NaCl tab Hydralazine PRNJan. 7 2015 Paracetamol 500mg 1 tab for temp. 37.8 CJan 8 2015 Ceforoxine 250mg PO q12 Paracetamol 500mg PO q4 PRN for temp 37.8 C Cetirizine 10mg PO OD Start dopamine premix at 24-25cc/hrJan 10 2015 Cefroxine ParacetamolJan 11 2015 Cont. cefuroxine Start kalium durule, 1 durule BID PO x 6 doses NaCl tablet, 1tablet BID

IV FLUIDSDec 23 2014 Line 1: PNSS 650cc to run for 1hr then 350cc to run for 1hr then refer Line 2: insert heplock Start insulin drip PNSS 99cc + regular insulin 1cc =100cc to run for 3.3cc/hrDec. 24, 2014 D/c insulin drip Shift IVF to PNSS 1 liter to run at 30cc/hr (7 to 8 gtts/min)Dec. 25, 2014 PNSS 1LDec. 29, 2014 Consume IVF & insert heplockDec. 31 2014 Consume IVF & insert heplock Jan. 2 to 7, 2015 Maintain heplock Jan. 8, 2015 Give PNSS 300cc IV bolus then re check BPJan. 10, 2015 PNSS 350cc IV bolus then repeat BP (90/50) Line 1: PNSS 1 liter 350cc FD then KVO Line 2: Dopamine premix at 24 to 25cc/hrJan. 11, 2015 Continue IV line PNSS 350cc once with BP less than 90/60 if not, at KVO

DIETDec.23 to 26, 2014: NPODec. 27, 2014 Start NGT feeding at 30cc q4 (6AM) NPO temporarily (11:50 AM)Dec. 28, 2015 Resume NGT feeding (6:40PM) May try oral/ feeding (9AM) Remove NGT once feeding wellDec.29, 2014 Low salt low fat dietDec. 30, 2014 Diet as Tolerated (DAT)Dec. 31, 2014 Low salt, low fat dietJan. 1, 2015 Diet as Tolerated (DAT) Increase oral fluid intakeJan. 2, 2015 Diet as Tolerated (DAT)Jan.3, 2015 Diet as tolerated (DAT)Jan. 8, 2015 Low salt, low fat dietJan. 11, 2015 NPO

LABORATORY EXAMINATIONDec. 23, 2014 Complete blood count Blood typing ABG (arterial blood gas) Urinalysis Serum electrolytes RBS q6Dec. 24, 2014 Repeat CBC 6 hours post BT (blood transfusion) D/c q6 of CBC, serum electrolytes, RBS D/c q1 of HGTDec. 29, 2014 Repeat Creatinine

Jan. 1, 2015 Repeat CBC, Creatinine Leptospira testJan. 2, 2015 Repeat serum electrolyte after 24 hrs. Jan. 3, 2015 Repeat serum electrolyte (10PM)Jan. 10, 2015 Serum electrolytes, BUN, Creatinine, CBC, CKMB (7:15 AM) Repeat CBC w/ PTT, serum electrolytes, BUN, creatinine, HGTJan. 11, 2015 Repeat serum electrolytes after 24 hrs.

DIAGNOSTIC EXAMINATIONDec. 23, 2014 Chest Xray APLDec.24, 2014 BUN, Creatinine q6, repeat serum electrolytes KUB (Kidney Ureter Bladder) UltrasoundTREATMENTInsert IJ Catheter Hemodialysis 3x a week

patients name: b.d.m.gender: male age: 18y/omedical diagnosis: diabetic ketoacidosis w/ STAGE V chronic kidney DISEASETESTNORMAL VALIESACTUAL RESULTINTERPREATTIONHEMOGLOBIN140-180g/L103 g/LBelow normal. This indicates less oxygen in the blood and possibility of iron deficiency in the body which leads to anemia.HEMATOCRIT0.400-0.5400.30Decrease hematocrit level indicates anemia which can be result of hemolysis.RED BLOOD CELLS4.3-5.6x10^12/L3.58Decrease in RBCs may indicate anemia.WHITE BLOOD CELLS4.00 10.00 x 10^9/L9.19NormalPLATELET COUNT150,000 450,000 x 10^9/L111Low platelet level indicates thrombocytopenia

LABORATORY EXAM RESULT

LABORATORY EXAM RESULT

DIFFERENTIAL COUNTNEUTROPHILS50.0-70.094.1Above normal. May indicate acute bacterial infection.LYMPHOCYTES20.0-40.02.9Below normal indicates leukopenia.MONOCYTES3.0-12.02.5Below normal indicates leukopenia.

EOSINOPHILS0.5-5.00.4Below normal indicates leukopenia.

Laboratory exam resultFULL NAMERESULTUNITSREMARKREFERENCE VALUEINTERPRETATIONPOTASSIUM2.69 mmol/LLow3.5-5.3Below normal. Indicates hypokalemia which can be cause by low intake protracted vomiting, renal loss, cirrhosis and others.

CHLORIDE93.7 mmol/LLow98-107Below normal which indicates hypochloremia. Chloride is normally loss in the urine, sweat and stomach secretions. Excessive loss can occur from heavy sweating, vomiting and adrenal and kidney disease.SODIUM125.1 mmol/LLow135-148Below normal. Indicates hyponatremia which may be cause by vomiting, diarrhea, gastric suction, excessive perspiration, continuous IV 5% dextrose/water: low sodium diet, burns inflammatory reactions, tissue injury.

BLOOD UREA NITROGEN44.6 mmol/LHigh3.2-7.4Above normal. Test results may indicate liver or urinary tract issues. Elevated BUN can be caused by the following health conditions: heart disease, heart failure, heart attack, bleeding in the digestive tract, dehydration, kidney failure, stress, urinary tract problems such as obstruction and shock. Further test maybe needed.CREATANINE1032.3 umol/lHIgh63.6-110.5Above normal. The test is issued to assess renal glomerular filtration and screen for renal damage because renal impairment is virtually the only cause of creatinine elevation.Elevated levels usually indicate diminished renal function.Too high creatinine level indicates that the patient has renal disease that has seriously damaged nephrons of the kidney.

LABORATORY EXAM RESULTRESULTNORMAL VALUEINTERPRETATIONSIGNIFICANCECOLORLight YellowPale to DarkYellow to AmberNormalTRANSPARENCYTurbidClearAbnormalIndicates the presence of crystals deposits, white cells, red cells, epithelial cells or fat globules.SPECIFICGRAVITY1.0101.010-1.020NormalPh6.0 Acidic5.0-6.0Normal SUGAR395 mg/dl120-160 mg/dlAbnormalIndicates renal glycosuria, hyperglycemia, and increased osmotic diuresis

URINALYSIS

TESTNORMAL VALUESACTUAL RESULTINTERPRETATIONSODIUM3.5-5.3125.1Above normal, indicates hypernatremia which can cause edemaPOTASSIUM98-1072.69Below normal. Indicates hypokalemia which can be cause by low intake protracted vomiting, renal loss, cirrhosis and others.CHLORIDE135-14893.7Below normal which indicates hypochloremia. Chloride is normally loss in the urine, sweat and stomach secretions. Excessive loss can occur from heavy sweating, vomiting and adrenal and kidney disease.

TESTNORMAL VALUESRESULTINTERPRETATIONBUN3.2-7.444.6Above normal. Test results may indicate liver or urinary tract issues. Elevated BUN can be caused by the following health conditions: heart disease, heart failure, heart attack, bleeding in the digestive tract, dehydration, kidney failure, stress, urinary tract problems such as obstruction and shock. Further test maybe needed.CREATININE63.6-110.51023.3Above normal. The test is issued to assess renal glomerular filtration and screen for renal damage because renal impairment is virtually the only cause of creatinine elevation.Elevated levels usually indicate diminished renal function.Too high creatinine level indicates that the patient has renal disease that has seriously damaged nephrons of the kidney.

Laboratory exam resultRESULTNORMAL VALUEINTERPRETATIONSIGNIFICANCELEUKOCYTES+++4.00-11.0 x 109/LNo resultLeukocytes in the urine is a sign of damaged kidneys, urethra or bladderRBC/uL 6/uL 0-11NormalSignifies lost blood in the lower urinary tractEPITHELIAL CELLS0 o/hpf0-1.8 epithelial cells/hpfNormalEpithelial cells in the urine may indicate a tumor

DRUG ORDERMECHANISM OF ACTIONINDICATIONSCONTRAINDICATIONSADVERSE EFFECTNURSING RESPONSIBILITYPRECAUTIONGENERIC NAME:Potassium ChlorideBRAND NAME:Kalium DuruleCLASSIFICATION:ElectrolytesDOSAGE:10 meqs/duruleFREQUENCY:1 durule 3x/dayROUTE:POMaintain acid-base balance,Isotonicity, and electrophysiologic balance of the cell. Activator in many enzymatic reactions; essential to transmission of nerve impulses; contraction of cardiac, skeletal, and smooth muscle; gastric secretion; renal function; tissue synthesis; and carbohydrate metabolism.Therapeutic effect: Replacement. Prevention of deficiency.Treatment/ Prevention of potassium depletion.Contraindicated in patient with oliguria, anuria,; patient with untreated Addisons disease or with acute dehydration, heat cramps,Use cautiously with patient with cardiac disease and renal impairment.Nausea and VomitingArrhythmiasHeart blockHypotensionCardiac arrestHyperkalemiaRespiratory paralysisNausea and vomitingAbdominal painMake sure the powder are completely dissolve before giving.Monitor renal function. After surgery, dont give drug until urine flow is established, tell patient to take drug with or after meals with full glass of water or fruit juice to lessen GI distress.

DRUG ORDERMECHANISM OF ACTIONINDICATIONSCONTRAINDICATIONSADVERSE EFFECTNURSING RESPONSIBILITYPRECAUTIONGENERIC NAME:OmeprazoleBRAND NAME:OmepronCLASSIFICATION:Proton Pump InhibitorDOSAGE:1 CAPFREQUENCY:2x/day 0700-1900HROUTE:G-TUBEReduces Gastric Acid Secretion and increases Gastric mucus and bicarbonate production, creating protective coatingon gastric mucosa and easing discomfort from excess gastric acid.GERD, Erosive Esophagitis, Short term treatment Duodenal ulcer, Gastric ulcer, Pathologic hypersecretory condition, including Zollinger-Ellison Syndrome, frequent heart burnHypersensitivityHepatic DiseasePregnancyChildrenPosterior LaryngitisNausea and VomitingDizzinessHeadacheAstheniaNauseaVomitingDiarrheaConstipationAbdominal PainBack PainCoughUpper Respiratory InfectionRashAssess vital signsCheck for abdominal pain, emesis, diarrhea or other Constipation.Evaluate fluid and intakeWatch for elevated liver function test resultsTell patient to take 30-60 minutes before meal, preferably in morning.Instruct patient to swallow capsules or tablets whole and no to chew or crash themCaution patient to avoid driving and other hazardous activities until he know drug effects concentration and alertness.

DRUG ORDERMECHANISM OF ACTIONINDICATIONSCONTRAINDICATIONSADVERSE EFFECTsNURSING RESPONSIBILITYPRECAUTIONGeneric Name:Penicillin GTrade Name:PenadurClassification:Pharmacologic Classification PenicillinTherapeutic ClassAnti-ineffective, antibioticPregnancy Risk FactorBRoute:IntravenousMaximum Dose:2-4 million units IM weekly for 3 weeksMinimum Dose300,000 Units IMInterferes with bacterial cell wall synthesis during active multiplication, causing cell wall death and resultant bactericidal activity against susceptible bacteria.General Indications:Severe infections caused by sensitive organisms (streptococci)URTI caused by sensitive streptococciTreatment of syphilis, bejel, congenital syphilis, pinta, yawsProphylaxis or rheumatic fever and choreaContraindications Concentrations:Allergies to penicillins, cephalosporins, or other allergensPrecaution:Renal disorderPregnancyLactationDrug interaction drug to drug:Deceased effectiveness with tetracylinesInactivation of parenteral amino glycosides.lethargy, hallucinations, seizures, glossitis, stomatitis, gastritis, sore mouth, furry tongue, nausea, vomiting, diarrhea, abdominal pain, colitis, nonspecific hepatitis, nephritisThrombocytopenia, anemia, leukopenia, neutropenia, prolonged bleeding timeRash, fever, wheezing, anaphylaxisPain, phlebitis, thrombosis at injection siteSuperinfections, sodium overload leading to heart failureBefore:Observe 15 rights of administrationReduce dosage with hepatic or renal failureAssess for any contradictions to the drugEducate about side effects of drugDuring:Do not inject or mix with other IV solutionsGive IM injections in upper outer quadrant of the buttockAvoid contact with the needle Withdraw the needle as quickly as possible to avoid discomfortStay with the patient throughout whole duration of administrationAfter:Monitor client for at least 30 minutesArrange for regular follow-up, including blood tests, to evaluate effectsInstruct to report difficulty breathing, rashes, severe pain at injection site, mouth soresInstruct to take medications as directed for the full course of therapy, even if feeling betterDo proper documentation

AssessmentDiagnosisPlanninginterventionRationaleEvaluationUPON ADMISSIONSubjective:manutay anako insan agko nakatungtung ya masimpit as verbalized by the mother.

objective:-polyuria-weak-dry mouth-deep & rapid breathing

Blood glucose level:= 395 mg/dLBP: 80/30 mmHgPR: 48 BPMRR: 41 CPMT: 36.9 CFluid & electrolyte imbalance related todiabetes as evidence by glucose 395 mg/dl and K+ 2.69

Insufficient insulinLack of glucoseUtilization in muscle and adiposeHyperglycemiaShort term goal:-patients blood glucose will be 180 mg/dl within 24hours.

-Patients K+ level will be 3.5 -5.0 within 12 hours.

Long term goal: -patients will demonstrated to the nurse in-charge how to take his blood sugar & how to get himself insulin injections by discharge.Independent:The nurse will verbalize & provide printed material to pt. on the side effects of an managed diabetes.The nurse will demonstrate to the pt how to check blood sugars and give insulin injection properly and will ask the patient to reciprocatedependent:Patient will be started on an insulin drip and blood sugars will be checked every hour per md order Patient will be given potassium supplementation per physicians order.- To give knowledge to the client for the side effects that may occur.

- To give the patient enough knowledge on how to check blood sugars and give insulin injection independently by discharge.- To determine if blood glucose is stable or not.

- Potassium works to maintain proper fluid balance between cells & body fluids.After 12 hours of nursing intervention, the patients K+ level is 3.6 and blood glucose of 104 mg/dl. The patient was able to take his own blood sugar and insulin injections by himself.

AssessmentDiagnosisPlanningInterventionRationaleEvaluationUPON ADMISSIONSubjective:manutay anako insan agko nakatungtong ya masimpit as verbalized by the mother.

objective:-3x vomiting-weakness-increased urination (+) decreased fluid intake (+) dry lips

Blood glucose level:= 395 mg/dL

BP: 80/30 mmHgPR: 48 BPMRR: 41 CPMT: 36.9 CDeficient fluid volume as evidenced by increased urine output, vomiting, poor skin turgor and dry mucous membranes.

High blood glucoseLevelIncrease in urinationdehydrationShort term goal: After 12 hrs. of nursing interventions, no signs of dehydration will be noted.

long term goal: During the patients stay in the hospital, the patient will have appropriate knowledge regarding dehydration.Independent: assess patient conditionincrease fluid intake & encourage to eat foods w/ high fluid

ensure accurate intake and output monitoring

dependent:Administer 0.9% sodium chloride as ordered.- To monitor for other signs and symptoms - Content to promote hydration.

- Accurate records are critical in assessing the patients fluid

- To rehydrated the patient.

After 12 hours of nursing interventions, no signs of dehydration were noted and the mucosa of patient was moist.

ASSESSMENTDIAGNOSISPLANNINGINTERVENTIONRATIONALEEVALUATIONUPON ADMISSIONSUBJECTIVE:hindi ako makahinga as verbalized by the patientOBJECTIVE:-dyspnea-difficulty speaking-restlessness-productive cough-pale in appearanceHemoglobin level:= 103 g/L(normal range: 120-160)

BP: 80/30 mmHgPR: 48 BPMRR: 41 CPMT: 36.9 CAbnormal breathing pattern due to low hemoglobin level

Low hemoglobin levelInsufficient O circulating in the bodyDifficulty of breathingShort term Goal:-The patient will have a normal respiratory rate of 12 20 breathes per minute and signs of dyspnea will regress after 2 hours of nursing interventionsLong term Goal:-During the patients stay in the hospital, he will be able to maintain patent airway as manifested by:-independence from O2 and ventilator support-Normal breathing pattern of 12 20 CPMIndependentAuscultate breath sounds

Monitor respiratory patternsPosition client to optimize respirationDependentAdminister O inhalation as ordered.- Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. Presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction.- Normal RR of an adult is 12 20 CPM. With secretions in the airway, the respiratory rate will increase.An upright position allows for maximal air exchange and lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe.

- To correct the patients breathing pattern- After 2 hours of nursing intervention, airway patency maintainedand signs of dyspnea disappeared.-Clients respiratory rateis within normal range:RR- 12 20 CPM-Remained calm: allay restlessness.

AssessmentDiagnosisPlanningInterventionRationaleEvaluationSubjective: agto gabay so pising mapilid sira balet agto met papaulyanan ya manpaerasas verbalized by the mother .Objective:-the patient doesnt look like his age (18)-impaired mobility-the pt is thin, has dry skin-patient frequently experiences numbness of feet

weight: 32.9 kgHeight: 153 cm BP: 80/30 mmHgPR: 60 BPMRR: 23 CPMT: 36.9 CImbalanced nutrition related to imbalance of insulin ,food and physical activity.

Nutritional imbalanceInability of the body to absorb nutrientsWeight lossShort term goal:after 4 hours of nursing intervention, the patient will be able to eat food given by him

long term goal:during the patients stay to the hospital , there will be a reversal of weight loss.

Independent:take into consideration about the patients lifestyle, cultural background, activity level and food preferenceencourage the patient to to eat full meals and snacks as prescribed in the diet prescriptioncontrol the glucose levelprovide an appropriate caloric intake.Dependent:implement meal planning

provide for an extra snacks before increased physical activity as ordered by the dietitian.- To have a background about the patient and how to manage him- It is the first step towards the desired body weight

- To determine if blood glucose is stable or not.- It allows the patient to achieve and maintain the desired body weight.

- To monitor the food intake the patient is about to receive each day.- To keep blood glucose on safe range.After nursing interventions, the patient achieves metabolic balance as manifested by:-the patient is able to eat his full meals and snacks given to him each day.-the patient exhibits glucose levels within target range-avoids further weight loss and begins to approach desired weight.

MEDICATION

Penicillin G- to prevent recurrence of streptococcal infectionOmeprazole- used for treating acid-inducedinflammation and block the production of acidPotassium Chloride- to prevent or to treat low blood levels of potassium (hypokalemia).DISCHARGE PLAN

HEALTH TEACHING/HYGIENE

Describe to the client the sign and symptoms to be reported immediately. High glucose level, dry mouth, weakness/fatigue, shortness of breath, nausea and vomiting, and abdominal pain. ( Chronic Kidney Failure- blood in urine, dark urine, swelling of feet and ankle, persistent itching, and chest pain.)

Clearly and specifically explain the nature of disease, its coarse and eventual prognosis of the condition to the child (if old enough to understand), parents or caregivers. They need to understand that, while complete resolution is expected, a small possibility exists for a persistent disease and an even smaller possibility exists that it will progress. The information is necessary for some patient to ensure the compliance with the follow up program.

Remind the patient or the family members to have check up or to consult the physician once a while to monitor the patients condition.DISCHARGE PLAN

TREATMENT

Ensure follow up and self-careAdvise the client to take the prescribed medicinesEnsure dietary restriction to carbohydrates, salts and proteinsTell the patient or family member to monitor for signs of developing diabetes and kidney failureMaintain a steady, normal patient blood glucose/sugar under control

SPIRITUAL

COUNSELLING: Tell the patient that neither she/he nor GOD will not given you a problem that you cant handle.Advice relatives, friends or significant others to provide moral support and widen their understanding.Tell them to pray for the client faster recovery.DISCHARGE PLAN

http://emedicine.medscape.com/http://www.ncbi.nlm.nih.gov/http://www.drugs.com/http://www.diabetesselfmanagement.com/http://www.bd.comhttp://www.wisegeek.com/the adrenal glands secreteepinephrine, which signals the liver and kidneys to produce more glucosethe alpha cells of the pancreas secrete the counter regulatory hormoneglucagon, which signals the liver to release more glucose.when glucagon and epinephrine fail to adequately raise blood glucose levels, the body releases cortisol and growth hormone, which can also increase blood glucose levels.Ketonesin particular, beta-hydroxybutyrateinduce nausea and vomiting that consequently aggravate fluid and electrolyte loss already existing in DKA.When blood sugar levels are so high, some sugar "overflows" into the urine. As sugar is carried away in the urine, water, salt andpotassiumare drawn into the urine with each sugar molecule, and your body loses large quantities of your fluid and electrolytes, which are minerals that play a crucial role in cell function. As this happens, you produce much more urine than normal. Eventually it may become impossible for you to drink enough fluids to keep up with amounts that you urinate. Vomiting caused by the blood's acidity also contributes to fluid losses and dehydration.Reference Page