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Diabetic Ketoacidosis

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  1. 1. Presented By: MARIE JUNE BARGO BEBING BSN,RN IRISH KRISTIAN REYES TAMBANGAN BSN,RN
  2. 2. This presentation aims to study the case of a particular patient in ICU that concerns the topic DKA (Diabetic Ketoacidosis). The aspects looked into were the overview of the disease mentioned above, personal data of patient and all the important matters that concerns nursing care, nursing management and nursing tasks. The observations and all the data that will be mentioned in this study will be treated confidential and for educational purpose only. In this regard, the research done in this course of study will be treated with high ethical consideration.
  3. 3. Diabetic ketoacidosis is a acute, major, life threatening complication of Diabetes that mainly occurs in patient with Type 1 diabetes, but it is not uncommon in some patients with Type 2 DM. This condition is a complex disordered metabolic state characterized by hyperglycemia, ketoacidosis and ketonuria.
  4. 4. ACIDOSIS KETOSIS HYPERGLYC EMIA DK A
  5. 5. The most common scenarios for DKA are underlying or concomitant infection (40%), missed insulin treatment (25%) and newly diagnosed, previously unknown diabetis (15%). Other associated causes make up roughly 20% in the various scenarios.
  6. 6. 61 y.o. Male, born on January 1, 1954, Syrian by nationality, married, stands 173 cm tall and weighs 91 kilograms. Known case of Type I Diabetes Mellitus, He has no known allergies.
  7. 7. Mr. X had Type I Diabetes Mellitus for about 10 years, as he could remember. He was only taking oral medication for his DM. He is also hypertensive. He has no impairment or disabilities and He has not undergone any surgical procedures in the past.
  8. 8. Mr. X presented to the emergency department with severe constipation for about 5 days. Prior to the day of presentation to the Emergency Room, Mr. X claimed that he visited four doctors and they gave him four different prescriptions and all failed to help him to relieve his constipation. He didnt remember any of the medication names. With a known DM and HPN, Mr. X was worried that this caused him severe constipation.
  9. 9. EATING PATTERN Before illness During illness Analysis -Eats 4-5 times a day with two heavy meals. -Three days prior to admission, ate less than 3 times a day. -On liquid diet/diabetic low salt diet as per Doctors order, eats without assistance. -Mr.X lost his appetite a little bit due to no bowel movement. Never the less, he was seen eating well on a liquid diet with full compliance and improved day by day.
  10. 10. DRINKING PATTERN Before illness During illness Analysis -Drinks 3-5 bottles of 500ml mineral water/day -Drinks tea and can tolerate at least 4-6 cups/day -approximately two 500 ml bottled water /day -Mr.X feels thirsty most of the day because of the weather as he claimed but clinically may be connected to his DM. Drank less water on admission because he claimed he was not feeling thirsty most of the time.
  11. 11. ELIMINATION PATTERN VOIDING Before illness During illness analysis 8-10 times/day Color: yellow amber Characteristics: Clear Amount: 1000-1500ml/day On Foley catheter Output: 1500-2500ml Urine output increased since some furosemide was given as part of his moderate regimen.
  12. 12. BOWEL Before illness During illness Analysis Usually after breakfast Amount: Moderate Characteristics: formed, soft, brownish On colostomy drainage Characteristics: coffee brown,soft to liquid form Mr. X undergone surgery to relieve his severe constipation.
  13. 13. PHYSICAL Before illness During illness Analysis Did Activities of Daily Living independently. Slightly dependent on his wife or domestic helper especially upon wearing his slippers or washing prior to prayer time. Moves freely on bed but needs assistance on going up and down the bed or in sitting. Mr.X felt slightly uncomfortable of his condition prior to admission. He has the difficulty to bend down and move.
  14. 14. HYGIENE Before illness During illness Analysis Takes a bath everyday. Needs assistance from the nurse especially upon change of gown. Mr.X said he was still uncomfortable with his colostomy, his movements are limited but he is well aware that maybe without the colostomy nor the IV lines, he could do this tasks alone.
  15. 15. SLEEPING PATTERN Before illness During illness Analysis Sleeps 6-9 hours/day Sleeps whenever he wants, anytime he wants. Sometimes, he claimed that he is not aware of the time. Mr.Xs sleeping pattern was only changed because he is not used to people coming in and out of his room.
  16. 16. INFECTION STRESS EXCESS SECRETION OF GLYCOGEN AND OTHER COUNTER REGULATORY HORMONES ACIDOSIS DEHYDRATION VOMITING GLYCOGENENOLYSIS AND GLUCONEOGENESIS POTASSIUM LOSS OSMOTIC DIURESIS HYPERGLYCEMIA DECREASE GLUCOSE UPTAKE INADEQUATE INSULIN MISSED INSULIN DOSE NEW-ONSET DIABETES KETOSIS KETOGENESIS INCREASED LIPOLYSIS OF ADIPOSE TISSUE
  17. 17. PATIENTS BODY : Average built VITAL SIGNS: GCS 15/15 BP 102/68MMHG PR 93BPM TEMP 36.4 RR 24BPM RESPIRATORY: -breathing with normal pattern -02 sat : 98% CARDIOVASCULAR: -no chest pain noted -pulse rate on normal range -cardica rhythm on monitor, normal and stable -capillary refill normal
  18. 18. GASTROINTESTINAL -with colostomy on left lower quadrant of abdomen slightly distended. GENITOURINARY -FC 14 size -urine color: slightly hazy MUSCULOSKELETAL -with spontaneous but cautious movements -upper and lower extremities in full range of motion. INTEGUMENTARY -with slightly pale complexion, warm skin -with good skin turgor -no edema noted -with light skin peeling and redness at left lower back
  19. 19. 08-05-2015 -received patient on side lying position, with et tube in place connected to mechanical ventilator on vcv mode; fio2 40%, tv 500, rt 12, peep 6, i:e 1:2, pmax 35 -with arterial line at right radial artery -iv cannula g20 at right cephalic vein, g16 at right brachial vein, with ongoing nss at 100 ml/hr -with remifentanyl at 0.04mcg/kg/hr, midazolam 2mg/hr -with colostomy left lower quadrant of abdomen with brownish colored output -surgical wound on abdomen with clean and dry dressing -gcs 9/15 (e3m5v1) -with full rom, pale looking, pupils 3mm bilateral brisk reactive to light, +bowel sounds, clear breath sounds, with symmetrical chest rise. -attached to cardiac monitor -on DKA protocol 09-05-2015 -received patient on right side lying position, awake, with et tube in place connected to mechanical ventilator on pcv mode; fio2 40%, pinsp 14, rtae 10, peep 6, i:e 1:2, pmax 35 -with arterial line at right radial artery -with NGT connected to free drain with greenish output -with foley catheter connected to urometer draining to a yellowish colored urine -iv cannula g20 at right cephalic vein, g20 at right metacarpal vein, g16 at right brachial vein, with ongoing D10 nss at 150 ml/hr -with remifentanyl at 0.04mcg/kg/hr, midazolam 2mg/hr, labetalol 0.2mg/min, insulin infusion @0.05units/kg -with colostomy left lower quadrant of abdomenwith brownish colored output -surgical wound on abdomen with clean and dry dressing -gcs 9/15 (e3m5v1) -with full rom, pale looking, pupils 3mm bilateral brisk reactive to light, +bowel sounds, clear breath sounds, with symmetrical chest rise. -attached to cardiac monitor -on DKA protocol
  20. 20. 10-05-2015 -received patient on right lateral position, with head elevated at 30 degrees. -GCS 15/15 (E4V5M6) -with ivf of D10nss+40 meqs [email protected]/hr via infusion pump -with NGT fr.14 in place, on open draining with greenish output -with colostomy @ left lower quadrant of abdomen, abdomen slightly distended. -iv cannula g20 at right cephalic vein, g20 at right metacarpal vein, g16 at right brachial vein -with redness and skin peeling on the left side of the trunk -still on DKA protocol 11-05-2015 -received patient on right lateral position -GCS 15/15 -breathing spontaneously with O2 3LMP via nasal cannula -iv cannula g20 on left and right hand [email protected]/min -attached to cardiac monitor, febrile -with foley catheter in place with adequate output -with colostomy @ left lower quadrant of abdomen -with redness and skin peeling on the left side of the trunk 12-05-2015 -received patient on right side lying position -conscious and coherent, GCS 15/15 - with nasal [email protected], saturating [email protected]% -connected to cardiac monitor: BP 134/65mmhg, RR 15bmp, HR 86bmp, Temp. 36.8 -with IV cannula g20 @ right hand connected to Nitroglycerine infusion -with arterial line @ left radial artery -on foley catheter f14 with urine output 30-40ml/hr -noted blister @ left lower back and burn-like wound - with colostomy @ left lower quadrant of abdomen
  21. 21. Urea 6.1 mmol/L N: 2.78-8.07mmol/L Creatinine 76 umol/L N: 62-106umol/L Potassium 4.7mmol/L N:3.5-5.1mmol/L Sodium 139mmol/L N:136-145mmol/L WBC 6.95K/UL N:4-11K/UL Neutrophils 4.58K/UL N:2-6.9K/UL Hgb 9.5g/dl N:13-17.4g/dl Hematocrit 32.9% N:39-52%
  22. 22. 08-05-2015 Urea 8.1mmol/L N: 2.78-8.07mmol/L Creatinine 89umol/L N: 62-106umol/L Sodium 134mmol/L N:136-145mmol/L Potassium - N:3.5-5.1mmol/L Chloride 102mmol/L N:98-107mmol/L Bicarbonate 18mmol/L N:22-29mmol/L Magnesium 0.69mmol/L N:0.7-1.05mmol/L Phosphorus 1.62mmol/L N:0.87-1.45mmol/L WBC 10.33K/UL N:4-11K/UL Hgb 8.0g/dl N:13-17.4g/dl Hematocrit 27.7% N:39-52% Beta-OH 3.7 - Ca (serum) 2.0 2.15-2.55mmol/L
  23. 23. Continuation Urea 9.5 - - - - - - N: 2.78-8.07mmol/L Creatinine 109 - - - - - - N: 62-106umol/L Sodium 135 137 137 137 139 138 140 N:136-145mmol/L Potassium 5.31 5.35 4.70 4.37 4.72 4.39 4.30 N:3.5-5.1mmol/L Chloride 104 106 106 109 110 110 112 N:98-107mmol/L HCO3 18 17 18 19 - 19 19 N:22-29mmol/L Phosphorus - 1.57 1.33 0.79 0.88 0.71 0.61 N:0.87-1.45mmol/L magnesium - - - - - 0.69 - N:0.7-1.05mmol/L
  24. 24. 09-05-2015 HCO3 19 7 19 18 N:22-29mmol/L Sodium 144 143