Академический Документы
Профессиональный Документы
Культура Документы
Lyceum-Northwestern University
College Of Nursing
BS Nursing - II
Nathan Vince Cruz
Jameelah Tamayo
Jan Abigaile Salisi
Lyka Mae Retuya
Charanjit Sangar
Jaqui Villanueva
Introduction
This 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.
PATIENTS PROFILE
Patients name: B.D.M.
Gender: Male
Pangasinan
Age: 18 y/o
(Stage V)
Final diagnosis: Diabetic Ketoacidosis
w/ Chronic Kidney disease (Stage V)
PATIENT MEDICAL
HISTORY
Chief Complaint
Difficulty of breathing
History of past illness
Patient 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.
PERSONAL MEDICAL HISTORY
A. Nutritional History
Patient 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.
ENVIRONMENTAL HISTORY
Patient 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.
PHYSICAL ASSESSMENT
A. GENERAL APPEARANCE/ SURVEY
The client is conscious, coherent, and
cognitive.
B. MEASUREMENTS
FINDINGS
Height
Weight
BMI
153 cm
32.9 kg
32.9 / (1.53m)2
= 14.06
Vital
Signs
ANALYSIS/INTERPRETATIO
N
-The patient is underweight
and suffering from severe
malnutrition.
Assessment
Neurological
Skin
I P P A
E
*
*
*
Result
Responsive
GCS score 15/15
(+)conscious (+)coherent (+)cognitive
(-) lesions
(-)rashes
(-)scars
(-)flushing, warm and moist
(+)poor skin turgor
Head
P PE A
*
Result
(-)lumps/masses
Significan
ce
NORMAL
NORMAL
NORMAL
NORMAL
ABNORMA Skin is dry
L
due to
dehydratio
n
ABNORMA Due to
L
dehydratio
n
Tongue
(-)stomatitis
NORMAL
(+)moist
(+)pink in color
NORMAL
NORMAL
(-)masses
NORMAL
(-)tenderness
(-)deviation to the side of the
mouth
(-)mass noted
(-)dull sound
NORMAL
NORMAL
Chest
*
*
NORMAL
NORMAL
NORMAL
Smooth
NORMAL
(-)sagging of breast
NORMAL
NORMAL
(-)tenderness
round face
(-)no presence of nodules an infestation
symmetrical
(-) Facial edema
Evenly distributed
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
Heart sounds
NORMAL
(-)lesion
NORMAL
Fine
Black in color
NORMAL
NORMAL
Coarse/dry
NORMAL
(-)masses
(-)numbness at right arm
(+)nail beds
NORMAL
NORMAL
NORMAL
NORMAL
(-)dandruff
NORMAL
(-)scars
NORMAL
(-)tenderness
NORMAL
Assessment I
(-)wearing eyeglasses
NORMAL
Genitourina
Hair
*
*
* *
Indication
NORMAL
NORMAL
*
* *
Eyes
Assessment I
Symmetrical
Face
Scalp
Significanc Indication
e
NORMAL
NORMAL
NORMAL
Cardiovasc
ular
Upper
* *
extremities
*
Abdomen
* * *
P PE A
(-)large abdomen
(-)peristalsis
(-)mass
(-)scars
(+)tympanic sound
(-)abdominal pain
Results
(+)polyuria
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
Significan Indication
ce
ABNORMA Due to excretion of
L
important minerals along
KC - kreb cycle
AcA - Acetyl coenzyme A or
Co-A
ATP Adenesine
triphosphate
Fatty acid
AT
P
Glucos
e
HO
AcA
K
C
Cell wall
AcA
Glycolysis
Pyruv
ate
insulin
Pathophysiology
Insulin
Deficiency
counter-regulatory hormones
Proteolysis
Gluconeogenic Substrates
Hepatic gluconeogenesis
Glycogenol
ysis
Blood
glucose
Acetone
Breath
Hyperglycemia
Beta-Hydroxybutyrate
Glucosur
ia
Loss of
electrolytes
Osmotic
diuresis
Urine output
Nausea &
Vomiting
Dehydrati
Ketonuri
a
lipolysis
FFA
Ketogenesis
Ketoacidosis Impaired kidney function
Bicarbonate serum
levels
Kassmauls
Respirations
Management:
Medication
Dec. 23, 2014
Pen G IM per soluset q4 ANST
Dec. 27 2014
D/c omeprazole
Hydralazine PRN
Racemic epinephrine q15 x 3
doses then q4 x 6
doses
Hydralazin 7mg q6
Dec. 28 2014
Paracetamol
PRN
Omeprazole
Furosemide 20mg
Hydralazine
Dec. 26 2014
Continue meds: pen G & omeprazole
Jan. 7 2015
Jan. 2, 2015
Cefroxine
Jan 11 2015 Paracetamol
NaCl tablet
Jan. 4, 2015
D/c kalium durule
D/c NaCl tab
Cont. cefuroxine
IV FLUIDS
Dec 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/hr
Dec. 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 1L
Dec. 29, 2014
Consume IVF & insert heplock
Dec. 31 2014
Consume IVF & insert heplock
Jan. 2 to 7, 2015
Jan. 8, 2015
300cc IV
check BP
Give PNSS
bolus then re
PNSS 350cc IV
then repeat BP
DIET
Jan. 1, 2015
Diet as Tolerated (DAT)
Increase oral fluid intake
Jan. 2, 2015
Diet as Tolerated (DAT)
Jan.3, 2015
Diet as tolerated (DAT)
Jan. 8, 2015
Low salt, low fat diet
Jan. 11, 2015
NPO
LABORATORY EXAMINATION
Jan. 1, 2015
Leptospira test
Jan. 2, 2015
RBS q6
Dec. 24, 2014
Repeat CBC 6 hours post BT
(blood transfusion)
D/c q6 of CBC, serum electrolytes,
RBS
D/c q1 of HGT
Dec. 29, 2014
Repeat Creatinine
(10PM)
Jan. 10, 2015
Serum electrolytes, BUN,
Creatinine, CBC, CKMB (7:15 AM)
Repeat CBC w/ PTT,
serum electrolytes, BUN, creatinine,
HGT
Jan. 11, 2015
Repeat serum
DIAGNOSTIC EXAMINATION
TREATMENT
Insert IJ Catheter
Hemodialysis 3x a week
TEST
NORMAL VALIES
ACTUAL
RESULT
INTERPREATTION
HEMOGLOBIN
140-180g/L
103 g/L
HEMATOCRIT
0.400-0.540
0.30
RED BLOOD
CELLS
4.3-5.6x10^12/L
3.58
WHITE BLOOD
CELLS
9.19
Normal
NEUTROPHIL
S
50.0-70.0
94.1
LYMPHOCYT
ES
20.0-40.0
2.9
MONOCYTES
3.0-12.0
2.5
EOSINOPHIL
S
0.5-5.0
0.4
RESULT
UNITS
REMARK
REFERE
NCE
VALUE
INTERPRETATION
POTASSIU
M
2.69
mmol/L
Low
3.5-5.3
CHLORID
E
93.7
mmol/L
Low
98-107
SODIUM
125.1
mmol/L
Low
BLOOD
UREA
NITROGEN
44.6
mmol/L
High
3.2-7.4
CREATANIN
E
1032.3
umol/l
HIgh
63.6110.5
NORMAL
VALUE
INTERPRETATI
ON
COLOR
Light Yellow
Pale to Dark
Yellow to
Amber
Normal
TRANSPARENCY
Turbid
Clear
Abnormal
SPECIFIC
GRAVITY
1.010
1.010-1.020
Normal
Ph
6.0 Acidic
5.0-6.0
Normal
SUGAR
395 mg/dl
120-160 mg/dl
Abnormal
SIGNIFICANCE
TEST
NORMAL
VALUES
ACTUAL
RESULT
INTERPRETATION
SODIUM
3.5-5.3
125.1
POTASSIUM
98-107
2.69
135-148
93.7
CHLORIDE
TEST
BUN
CREATINI
NE
NORMAL
VALUES
RESUL
T
INTERPRETATION
3.2-7.4
44.6
63.6-110.5
1023.
3
NORMAL VALUE
INTERPRETATIO
N
SIGNIFICANCE
LEUKOCYTES
+++
4.00-11.0 x
109/L
No result
Leukocytes in
the urine is a
sign of
damaged
kidneys, urethra
or bladder
RBC
/uL 6
/uL 0-11
Normal
Signifies lost
blood in the
lower urinary
tract
EPITHELIAL
CELLS
0 o/hpf
0-1.8 epithelial
cells/hpf
Normal
Epithelial cells
in the urine may
indicate a
tumor
DRUG ORDER
GENERIC NAME:
Potassium
Chloride
BRAND NAME:
Kalium Durule
CLASSIFICATION:
Electrolytes
DOSAGE:
10 meqs/durule
FREQUENCY:
1 durule 3x/day
ROUTE:
PO
MECHANISM OF
ACTION
INDICATION CONTRAINDICATIO
S
NS
Maintain acid-base
Treatment/
balance,
Prevention of
Isotonicity, and
potassium
electrophysiologic
depletion.
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.
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
Vomiting
ADVERSE
EFFECT
Arrhythmias
NURSING
RESPONSIBILITY
PRECAUTION
Heart block
Hypotension
Cardiac arrest
Hyperkalemia
Respiratory
paralysis
Nausea and
vomiting
Abdominal
pain
DRUG ORDER
MECHANISM OF
ACTION
GENERIC NAME:
Omeprazole
BRAND NAME:
Omepron
CLASSIFICATION:
Proton Pump
Inhibitor
DOSAGE:
1 CAP
FREQUENCY:
2x/day 07001900H
ROUTE:
G-TUBE
INDICATIONS CONTRAINDICAT
IONS
GERD, Erosive
Esophagitis,
Short term
treatment
Duodenal
ulcer, Gastric
ulcer,
Pathologic
hypersecretor
y condition,
including
ZollingerEllison
Syndrome,
frequent heart
burn
ADVERSE
EFFECT
Hypersensitivit
y
Hepatic
Disease
Pregnancy
Children
Posterior
Laryngitis
Nausea and
Vomiting
NURSING
RESPONSIBILITY
PRECAUTION
Dizziness
Headache
Asthenia
Nausea
Vomiting
Diarrhea
Constipati
on
Abdominal
Pain
Back Pain
Cough
Upper
Respirator
y Infection
Rash
DRUG ORDER
MECHANISM
OF ACTION
Generic Name:
Penicillin G
Trade Name:
Penadur
Classification:
Pharmacologic
Classification
Penicillin
Therapeutic
Class
Anti-ineffective,
antibiotic
Pregnancy Risk
Factor
B
Route:
Intravenous
Maximum Dose:
2-4 million units
IM weekly for 3
weeks
Minimum Dose
300,000 Units IM
Interferes with
bacterial cell
wall synthesis
during active
multiplication,
causing cell
wall death and
resultant
bactericidal
activity
against
susceptible
bacteria.
INDICATIONS
CONTRAINDICATIO
NS
ADVERSE EFFECTs
General
Contraindications
Concentrations:
Indications:
Allergies to
Severe
penicillins,
infections
cephalosporins
caused by
, or other
sensitive
allergens
organisms
(streptococci) Precaution:
URTI caused Renal disorder
by sensitive Pregnancy
streptococci Lactation
Treatment of Drug interaction
syphilis, bejel, drug to drug:
Deceased
congenital
effectiveness
syphilis,
with
pinta, yaws
tetracylines
Prophylaxis or
Inactivation of
rheumatic
parenteral
fever and
amino
chorea
glycosides.
lethargy,
hallucinations,
seizures, glossitis,
stomatitis, gastritis,
sore mouth, furry
tongue, nausea,
vomiting, diarrhea,
abdominal pain,
colitis, nonspecific
hepatitis, nephritis
Thrombocytopenia,
anemia, leukopenia,
neutropenia,
prolonged bleeding
time
Rash, fever,
wheezing,
anaphylaxis
Pain, phlebitis,
thrombosis at
injection site
Superinfections,
sodium overload
leading to heart
failure
NURSING RESPONSIBILITY
PRECAUTION
Before:
Observe 15 rights of administration
Reduce dosage with hepatic or renal
failure
Assess for any contradictions to the
drug
Educate about side effects of drug
During:
Do not inject or mix with other IV
solutions
Give IM injections in upper outer
quadrant of the buttock
Avoid contact with the needle
Withdraw the needle as quickly as
possible to avoid discomfort
Stay with the patient throughout
whole duration of administration
After:
Monitor client for at least 30 minutes
Arrange for regular follow-up,
including blood tests, to evaluate
effects
Instruct to report difficulty breathing,
rashes, severe pain at injection site,
mouth sores
Instruct to take medications as
directed for the full course of
therapy, even if feeling better
Do proper documentation
Assessment
UPON
ADMISSION
Subjective:
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/dL
Diagnosis
Fluid & electrolyte
imbalance related
to
diabetes as
evidence by
glucose 395 mg/dl
and K+ 2.69
Planning
intervention
Short term
Independent:
goal:
1. The nurse will
-patients
verbalize & provide
blood glucose
printed material to pt.
will be 180
on the side effects of
mg/dl within
an managed diabetes.
24hours.
level will be
sugars and give
Lack of glucose 3.5 -5.0 within
insulin injection
Utilization in
12 hours.
properly and will ask
muscle and
the patient to
adipose
Long term
reciprocate
goal:
Rationale
Evaluation
After 12 hours
- To give knowledge of nursing
to the client for the intervention,
side effects that
the patients
may occur.
K+ level is 3.6
and blood
glucose of 104
mg/dl. The
- To give the patient patient was
enough knowledge able to take his
on how to check
own blood
blood sugars and
sugar and
give insulin injection insulin
independently by
injections by
discharge.
himself.
- To determine if
blood glucose is
stable or not.
- Potassium works to
maintain proper
fluid balance
Assessment
UPON
ADMISSION
Subjective:
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 mmHg
Diagnosis
Deficient fluid
volume as
evidenced by
increased urine
output, vomiting,
poor skin turgor
and dry mucous
membranes.
High blood
glucose
Level
Increase in
urination
dehydration
Planning
Short 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.
Intervention
Independent:
1. assess patient
condition
2. increase fluid
intake &
encourage to
eat foods w/
high fluid
3. ensure
accurate intake
and output
monitoring
dependent:
4. Administer
0.9% sodium
chloride as
ordered.
Rationale
- To monitor for
other signs and
symptoms
- Content to
promote
hydration.
- Accurate records
are critical in
assessing the
patients fluid
- To rehydrated
the patient.
Evaluation
After 12 hours of
nursing
interventions, no
signs of
dehydration were
noted and the
mucosa of patient
was moist.
ASSESSMENT
UPON
ADMISSION
SUBJECTIVE:
hindi ako
makahinga as
verbalized by
the patient
OBJECTIVE:
-dyspnea
-difficulty
speaking
-restlessness
-productive
cough
-pale in
appearance
Hemoglobin
level:
= 103 g/L
(normal range:
120-160)
DIAGNOSIS
Abnormal
breathing
pattern due to
low
hemoglobin
level
Low
hemoglobin
level
Insufficient
O
circulating
in the body
Difficulty of
breathing
PLANNING
INTERVENTI
ON
Short term Goal:
Independent
-The patient will
1. Auscultate
have a normal
breath
respiratory rate of
sounds
12 20 breathes per
minute and signs of
dyspnea will regress
after 2 hours of
2. Monitor
nursing interventions
respiratory
patterns
3. Position
Long term Goal:
client to
-During the patients
optimize
stay in the hospital,
respiration
he will be able to
maintain patent
Dependent
airway as
manifested by:
4. Administer
-independence from
O
O2 and ventilator
inhalation
support
as
ordered.
RATIONALE
EVALUATION
- 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
- After 2 hours of
nursing
intervention,
airway patency
maintained
and signs of
dyspnea
disappeared.
-Clients
respiratory rateis
within normal
range:RR- 12 20
CPM
-Remained calm:
allay restlessness.
Assessment
Subjective:
agto gabay so
pising mapilid sira
balet agto met
papaulyanan ya
manpaeras
as 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 kg
Height: 153 cm
BP: 80/30 mmHg
PR: 60 BPM
RR: 23 CPM
Diagnosis
Imbalanced
nutrition related to
imbalance of
insulin ,food and
physical activity.
Nutritional
imbalance
Inability of the
body to absorb
nutrients
Weight loss
Planning
Intervention
Short term
Independent:
goal:
1. take into
after 4 hours
consideration about
of nursing
the patients
intervention,
lifestyle, cultural
the patient
background, activity
will be able to
level and food
eat food
preference
given by him 2. encourage the
patient to to eat full
long term
meals and snacks as
goal:
prescribed in the
during the
diet prescription
patients stay 3. control the glucose
to the
level
hospital ,
4. provide an
there will be a
appropriate caloric
reversal of
intake.
weight loss.
Dependent:
5. implement meal
planning
Rationale
Evaluation
After nursing
- To have a
interventions,
background about the the patient
patient and how to
achieves
manage him
metabolic
balance as
manifested by:
-the patient is
- It is the first step
able to eat his
towards the desired
full meals and
body weight
snacks given to
him each day.
-the patient
- To determine if blood exhibits
glucose is stable or
glucose levels
not.
within target
- It allows the patient range
to achieve and
DISCHARGE
PLAN
MEDICATION
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
SPIRITUAL
TREATMENT
Reference Page
http://www.drugs.com/
http://www.diabetesselfmanagement.com/
http://emedicine.medscape.
com/
http://www.bd.com
http://www.wisegeek.com/
http://www.ncbi.nlm.nih.gov/
When blood sugar levels are so high, some sugar "overflows" into the ur
sugar is carried away in the urine, water, salt andpotassiumare drawn in
urine with each sugar molecule, and your body loses large quantities of
and electrolytes, which are minerals that play a crucial role in cell functio
happens, you produce much more urine than normal. Eventually it may b
impossible for you to drink enough fluids to keep up with amounts that yo
urinate. Vomiting caused by the blood's acidity also contributes to fluid lo
dehydration.