This assignment focused on developing a care plan regarding this woman with a history of Diabetes Mellitus and non-compliance with her scheduled therapy resulting in presentation of Diabetic Ketoacidosis. The Nanda/ NIC/ NOC Framework (NANDA, 2014) lends itself to the development of an evidence-based care plan to provide best practice care to Sinead regarding the issues of (i) Fluid and electrolyte imbalance and (ii) Anxiety, which are associated with DKA. While this student is very aware of the numerous acute nursing interventions this patient required on admission in the Emergency Department, due to word count limitations, she had to focus on just two issues only.
Diabetic Ketoacidosis is a complete state of insulin deficiency resulting in metabolism of carbohydrate, protein, and fat. It is manifested by hyperglycaemia, dehydration, electrolyte loss and acidosis (Ball, Bindler & Cowan, 2014). Patients may die from cerebral oedema, hypokalaemia, or aspiration pneumonia as a result of D.K.A. The main causes of DKA include insulin omission, untreated diabetes, inadequate insulin dosage, failure to adhere to prescribed diet plan, physical/emotional stress, and illness (Hinkle & Cheever, 2014).
Nursing Diagnosis 1: Risk for fluid and electrolyte imbalance related to dehydration resulting from fluid loss/shifts.
Goal: Sinead will remain hydrated with normal electrolyte levels as indicated by a balanced intake and output chart, blood electrolyte levels and blood pressure within normal range, moist mucosa, and normal pulse.
Two large bore IV cannulae were sited (one for bloods and one for medication/fluids) and baseline bloods taken in order to confirm DKA diagnosis: venous glucose (>12mmol/L); finger-prick ketones (>6mmol/L); Hypokalaemia on admission (<3.5mmol/L) urinalysis (electrolytes present); venous/arterial blood gas (pH <7.0); electrolytes (potassium, corrected sodium, renal function); full blood count (neutrophilia is a common stress response); Bicarbonate level (<5mmol/L). This nurse also measured Sinead’s baseline weight for future comparison (Hinkle & Cheever, 2014).
Other indicators include: oxygen saturation below 92%; Systolic BP below 90mmHg; Pulse over 100 or below 60bpm (Hinckle & Cheever, 2014); Glasgow Coma Score <12 (indicates reduced functioning) and abnormal AVPU score (NHS, 2010).
Investigations performed to eliminate other causes of symptoms included: Urea and electrolytes; blood cultures; electrocardiograph; urine and culture; and a pregnancy test (menstruating age) (NHS, 2010).
The nurse took hourly blood glucose (BG) and ketone measurement, with 2 hourly serum potassium and bicarbonate for the first six hours (Fowler, 2009; cited in Hinkle & Cheevers, 2014). A detailed history and list of usual medication was established to gain knowledge of Sinead’s baseline health status. The diabetes specialist team was involved at the earliest possible stage in case specialist intervention was required (NHS, 2010).
Restoring circulating volume:
This nurse assessed Sinead’s degree of dehydration: mild (3%), moderate (5% – dry mucosa, decreased skin turgor), severe (8% – sunken eyes, poor capillary refill) or hypovolemic shock (severely ill, poor perfusion and rapid thready pulse) (Hockenberry, Wilson &Rodgers, 2016). In event of shock, this nurse would have administered a fluid bolus of 0.9% NaCl over 30 minutes and repeated if the peripheral pulses remain poor (Lenehen & Holoway, 2015). A 1L bolus of 0.9% sodium chloride solution was administered over 15 minutes as prescribed. If Sinead’s systolic blood pressure had remained below 90mmHg, procedure would be to contact the registrar and repeat the bolus once more until further instruction is given. Most patients require between 500 to 1000ml given rapidly (MMUH, 2017; NHS, 2010). Hypotension is likely due to low circulating volume, but other causes such as heart failure or sepsis were investigated (Reynolds, 2012). Without clinical improvement, this nurse would reconsider the other causes of hypotension and seek an immediate registrar assessment. Because of Sinead’s age, admission to a HDU facility was considered. Fluids were replaced cautiously, guided by the central venous pressure measurements (NHS, 2010).
If systolic BP exceeds 90mmHg, the rate of fluid replacement depends on the age, fitness and degree of dehydration of the patient. Fluid replacement was planned and clinical judgment used, and the conclusion was to follow the routine procedure as outlined in hospital guidelines:
• 0.9% sodium chloride 1L with potassium chloride over 2 hours.
• 0.9% sodium chloride 1L with potassium chloride over the next 2 hours.
• 0.9% sodium chloride 1L with potassium chloride over the following 4 hours.
If blood glucose falls below 14mmol/L, add 10% glucose at 125ml/hr to the infusion.
Constant close monitoring is required as rapid infusion increases risk of respiratory distress and cerebral oedema (MMUH, 2014; Saenggkaew, et al., 2016).
Restoring Potassium Level
Hypokalaemia and hyperkalaemia are life threatening conditions which are common with DKA. Serum potassium is often high on admission (although total body potassium is low) but decreases quickly upon insulin administration (Hinkle & Cheevers, 2014). Regular monitoring is mandatory. In the first 24 hours, if the potassium level is over 5.5, no replacement is required. At 3.5-5.5, add 20mmol/L of infusion, and below 3.5 a medical review is needed as additional potassium is required to prevent serious complications and Sinead must be admitted to HDU/ICU (NHS, 2010).
Commence Fixed Rate Intravenous Insulin Infusion
A continuous FRIII was started via an infusion pump. This consisted of 50 units of soluble insulin made up to 50ml with 0.9% sodium chloride solution. A fixed rate of 0.1 unit/kg/hr was infused. A bolus stat dose of intramuscular insulin (0.1 unit/kg) would have been given if there was a delay in setting up the FRIII. As Sinead normally takes insulin subcutaneously, this routine was continued at the usual dose and usual time. Insulin was infused in the same line as the intravenous replacement fluid because a Y connector with a one way, anti-siphon valve was used and a large-bore cannula has been sited (MMUH, 2014).
Constant monitoring and assessment
After the acute stage of DKA, the main aims of nursing care included: Clearing the blood of ketones at a rate of 0.5mmol/L/hr; Bicarbonate levels should rise by 3.0mmol/L/hr and blood glucose should fall by 3.0mmol/L/hr; Sinead’s serum potassium and blood glucose should stay within normal range once stabilized, avoiding hypoglycaemia (NHS, 2010).
Sinead required hourly monitoring of all vital signs, as well as blood ketone and glucose levels to assess level of dehydration and hyper/hypoglycaemia, recording all on the Early Warning Score chart, and following escalation procedures as necessary (NHS, 2010).
If Caroline had not passed urine within the first hour of hospitalisation, the nurse would consider catheterisation to prevent oedema (HSE, 2015). If Caroline's oxygen level was dropping, her arterial blood gas would be monitored and achest X-ray requested to investigate causes (HSE, 2015).
Caroline’s response to FRIII was reviewed hourly by calculating change of ketone, glucose and bicarbonate level to monitor acidosis. This nurse observed for infection and gave antibiotics s prescribed. Blood tests were repeated, accounting for the fact that the WBC is not helpful because it may be markedly raised from DKA alone (NHS, 2010).
IV Fluid and insulin administration were continued and the nurse repeatedly assessed Sinead for complications such as fluid overload and cerebral oedema. Fluid overload can occur because of rapid infusion rate and is indicated by pitting oedema and abdominal distention. To prevent this, a detailed and closely monitored fluid balance record must be taken (Hinkle & Cheevers, 2014).
Cerebral oedema is thought to be caused by rapid correction of hyperglycaemia resulting in fluid shifts and can be prevented by gradual reduction of blood glucose. An hourly flow sheet should be kept to enable close monitoring of blood glucose level, serum electrolytes, fluid balance, mental status and neurological changes (Hinckley & Cheever, 2014).
Nursing Diagnosis 2: Anxiety related to diabetes knowledge deficit and loss of bodily control.
Goal: Sinead will be supported and informed about her diabetes while in hospital and exhibit understanding of diabetes survival skills and necessity and implementation of self-care.
During her admission, Sinead’s anxiety was eased through cognitive strategies such as imagery (concentrating on a restful experience/scene); distraction (thinking of a favourite story/song); optimistic self-recitation (repeating positive thoughts aloud); or music (listening to soothing music) (Hinckley & Cheever, 2014). This nurse took into consideration that although this woman is technically an adult requiring patient centred care, at 22 years old it is important to consider the need for parental involvement and education in decreasing anxiety (Ball, Bindler & Cowan, 2014). However, the most efficient way to decrease anxiety was proven to be through education. This nurse carefully assessed Sinead’s understanding of and adherence to her individualised diabetes management plan which should include information around dietary needs, exercise, medication management and glucose monitoring. The dietitian was involved to develop and explain a meal plan based on Sinead’s body weight (Gulanrick & Myers, 2015). The diabetes clinical nurse specialist was called on to provide further education with regard to how and when to take insulin and other anti-diabetic agents as well as ensuring that Sinead uses the correct technique (HSSE, 2015). Demonstrating and educating Sinead regarding blood glucose monitoring and normal ranges was prioritised. She was observed while undertaking all of these activities to ensure safety on discharge. Sinead’s blood glucose should be kept to 4-7mmol/L before meals and approximately 8mmol/L when testing 2 hours after eating, as carbohydrate intake tends to increase glucose levels after digestion (Diabetes Ireland, 2016). It proved useful for Sinead to start a diary of her daily intake and glucose levels which she could continue on discharge. This nurse taught Sinead about the consequences of non-compliance with her management plan such as further DKA incidents; hypertension; cardiovascular disease; diabetic retinopathy and neuropathy (HSE, 2015). By maintaining a healthy blood pressure, cholesterol level, diet and exercise regime, Sinead should be able to manage her diabetes.
Overall Critical Evaluation of Care/Key Performance Indicators (KPIs);
This student feels that patient satisfaction is the most important KPI. Sinead and her family stated that they were pleased with her overall care, suggesting that it was individualised and flexible to her personal needs and that she felt confident in herself regarding self-management of diabetes in the future.
The care-giver’s perspective is also a crucial KPI. On reflection using the Gibbs cycle, this student felt that the care plan devised here both identified necessary nursing priorities for Sinead and provided excellent care which was based on the best evidence-based practice available (Gibbs, 1998). She believes that this episode of DKA was well managed in a way that suited Sinead as an individual. The patient’s education deficit was addressed and clinical needs adhered to. This student believes that the patient truly received holistic care in accordance with hospital guidelines (MMUH, 2016) and with both national and international guidelines (HSE, 2015; NICE, 2014).
A final consideration here was the use of this framework. This student felt that the NIC/NOC/NANDA framework landed to a holistic, cohesive, flexible and integrated approach to Sinead’s care.