Assignment On Critical Care Unit

Running head: CASE STUDY 1
Case Study
Student Name
Institutional Affiliation

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Case Study
Introduction
Critical care unit is a section where patients whose normal survival functions have been
compromised hence require intensive care, close monitoring, and supportive management to
attain healthy body function. In this setting, the provision of individualized patient-centered care
is integral in nursing practice. In the provision of patient-centered care, the caregiver focuses on
evidence-based care and a holistic patient approach in establishing the priority care plan for the
patient (Farrell, Smeltzer, & Bare, 2017). Since the unit is a sensitive area, the nurse has a
responsibility to provide care based on the legal-ethical issues in the ICU. This leads to the
improved patient outcome as well as satisfaction.
The clinical reasoning cycle is one of the frameworks that are primarily applied in the
clinical areas in ensuring patient-centered care. The framework is systematic in guiding medical
practitioners to collect essential information concerning the patient, process the data as well as
understand the condition the patient is suffering from. Evaluation of the patient outcome for the
planning of further management is an essential part of the cycle. It ensures continuity of care as
time elapses. Therefore, the use of the clinical reasoning cycle boosts the clinical reasoning of
the care providers as well. The objective of this article is to analyze a case study utilizing the
clinical reasoning cycle in managing the condition presented.
Consider the person's situation
Mr. Brad Taylor was admitted to the High Dependency Unit (HDU) through the
emergency department with chief complains of polydipsia, general body weakness, and
vomiting. He was recovering from the mild cold with a temperature of 37.3° Celsius on

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admission. He also complained of abdominal pains rating the pain 3 out of a scale of 10 on
admission.
Health information
The patient is reported to have developed the above complaints two days ago. There is no
alleviating or aggravating factors identified. He is a known Type 1 diabetic patient for ten years
now. He has once been admitted to ICU 5 years ago due to Diabetes Ketoacidosis, after which he
recovered well. He is reported to have undergone an appendectomy five years ago.
The patient is a nonsmoker; takes alcohol on social occasions. He lives with his girlfriend
and works at a full-time job. The patient has been on medication; Humalog 8 -16 u/s and Lantis
28u/s. On admission, the patient portrayed Kussmaul breathing with acetone breathe odor. Vital
signs recorded were: SpO2 and Blood pressure were within normal ranges, Heart Rate- 125bpm,
Respiratory Rate was 35breathes/minute. Generally, the patient was restless, complained of being
thirsty with a feeling of nausea. Episodes of intermittent vomiting were observed.
Upon investigations, the Blood Glucose Level was high, 26.1 mmol/l. The blood ketone
levels were high on finger prick. Micro hematuria, presence of glucose, and ketones in urine
were realized during a urinalysis. Full blood examination indicated a slight elevation of
leukocytes and hematocrit. Sodium was slightly high, 150mmol/l, while potassium levels were
somewhat low, 3.3mmol/l. C - reactive protein was mildly elevated. Arterial Blood Gas indicated
slight acidity with a Ph of 7.1, HCO3 levels of 14, PaO2 levels of 105, and PaCO2 levels of 35.
Processing of gathered Information
From the presentations, it is evident that the patient is suffering from Diabetes
Ketoacidosis, which is a complication that commonly occurs in diabetes type 1 patients. DKA is

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a life-threatening condition that occurs when the blood sugars remain high for long hours in the
blood (Dhatariya, Savage, Sampson, Matfin, & Scott, 2018). Usually, the condition occurs when
the insulin levels in the body are low hence limiting uptake of sugars by body cells. When
fasting, the average blood glucose levels range between 3.5-5 mmol/L, while 2 hours after the
eating, the blood glucose sugars can be up to 7.8mmol/L. With the high blood glucose sugars of
26.1 mmol/l, the DKA crisis might have set in.
The body system interprets the inability of cells to uptake blood sugars as a lack of sugars
in the body, leading to the breakdown of fats to produce fuel for body cells (Hirsch, 2017).
Metabolism of lipids leads to the production of ketones, which build up in the body. Usually, in
normal circumstances, no ketone bodies are expected to appear in the urine test, while normal
body levels range between 0.3 and 1.5 mmol/L. Due to the high metabolism of fats in the
patient's body, ketone bodies were identified in the urine test, and even ketone levels in blood
were high upon finger prick.
Accumulation of ketones which are ketoacids overwhelms the body bicarbonates, the
body buffering system leading to metabolic acidosis (Gosmanov, Gosmanova, & Kitabchi,
2018). This explains the acidity or low Ph of blood and low bicarbonate levels. As a
compensatory mechanism for metabolic acidosis, respiratory hyperventilation sets in. This
explains the Kussmaul (fast and deep breathes), breathing pattern. Great ketoacids in the body
are also responsible for the acetonic bad odor experienced. Excessive loss of body fluids through
urination and vomiting leads to electrolyte imbalance and dehydration. Low body potassium
levels lead to general malaise and even muscle cramps, which can cause pain (Martini, Nath, &
Bartholomew, 2018).

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Nursing problems
Hypoglycemic state of body dells is the number one priority nursing issues in this case.
This is evident through fat metabolism hence high levels of ketoacids in the body. The presence
of ketoacids in the body manifests through the presence of acetonic breathe odor, high ketones in
the blood, and the presence of ketones in the urine (Umpierrez, 2018). Hypoglycemic state
comes about due to insufficient insulin in the body to facilitate uptake of blood glucose into the
cells. This leads to high levels of blood sugars.
The risk for dehydration is the next nursing issue to be addressed. Dehydration sets in as
a result of excessive loss of body fluids, in this case, through vomiting episodes and frequent
urination (Rewers et al., 2019). Continued loss of body fluids without sufficient replacement can
lead to hypovolemia and electrolyte imbalance (McCance, K., Heuther, Brashers, & Rote, 2019).
Dehydration can cause hypovolemic shock, a life-threatening condition. During hypovolemic
shock, there is insufficient blood supply to the vital body organs such as the kidney, heart, and
brain can lead to organ failure. Electrolyte imbalance on the other side due to excessive fluid loss
can cause seizures, muscle cramps, and even arrhythmias (Jarvis, Forbes, & Watt, 2016). In the
patient, dehydration is evident through the low levels of body temperatures, electrolyte
imbalance, dryness of body, and feeling thirsty.
The patient being at risk of infection is the third nursing issue to be addressed. The risk
for infection is evident through a slight elevation of leukocytes in FBE as well as Mildly
Elevated C-Reactive Protein (Nyenwe, & Kitabchi, 2016). The high blood sugar is one of the
risks associated with contracting an infection.

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Goals for the priority of nursing care
The establishment of the blood sugars to normal levels is the priority goal. The sugars
should lower to at least below 20mmol/l at the end of the shift. The level of ketones in urine and
blood should reduce to normal levels after 12 hours, accompanied by a reduction in acetonic
odor upon breathing (Rewers, Dong, Slover, Klingensmith, & Rewers, 2015). The patient will be
able to verbalize a reduced feeling of thirsty after an hour. The patient should also demonstrate
being energetic through the ability to turn and support himself while on the bed after 12 hours.
The arterial blood gas levels, as well as respiratory rate, should read within normal ranges after
12 hours.
Nursing care
Administration of intravenous soluble insulin as an infusion as indicated: Insulin infusion
commenced 50u/s Actrapid in 50mls of Normal saline (1u/ml) at 4mls/hr.). This will be the first
intervention (Kitzmiller, Frye, & Clark, 2019). Insulin infusion will run concurrently with
intravenous fluids; normal saline alternating with ringer's lactate solution. Supplementation of
potassium ions will also be essential through the intravenous fluids to elevate potassium levels
preventing the patient from experiencing cardiac arrhythmias, seizures, and even muscle cramps.
Through intravenous fluids and potassium supplementation, episodes of vomiting may cease
(Tran et al., 2017). I will administer broad-spectrum antibiotic; intravenous ceftriaxone 1g 12
hourly (McKenna, & Lim, 2015) to keep the infection under control. I will monitor body vitals
after every 2 hours, urine output every four hours as well as blood sugar levels, ensuring body
vitals are within the normal ranges. Since the patient is restless, mild sedation will be required to
enable the patient to calm down. All the care given will be correctly documented in the patient's
chart.

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Evaluation
After 12 hours of management, the blood glucose levels read 15mmol/L. This means the
blood sugars dropped to desired levels as per the objective. The patient was no longer
hyperventilating, the bad acetonic odor on breathing was reducing, and all vital signs were
reading within normal ranges. The patient verbalized a reduced feeling of thirst and
demonstrated reduced urgency to urinate. Urine output remained 25ml/hr. The patient
demonstrated some regained energy as well through being able to turn on his own. The findings
confirmed that the patient had received the necessary care.
Reflection
The involvement of relatives in inpatient care was minimal. Therefore, next time I will
improve on involving relatives in the care of the patient. This will be essential not only to the
patient but also to the relatives and the nurse as well. The involvement of patient relatives will
ensure the psychological wellbeing of both the patient and the close members hence contributing
to holistic care. Sometimes lack of time, space, and lack of knowledge amongst relatives are
among the constraints to be addressed in ensuring patients are effectively involved in inpatient
care. Therefore, relatives ought to be reassured of the condition of the patient and the areas they
will be needed to assist.
Conclusion
The provision of individualized care is essential in achieving a maximum outcome in
nursing care. This is even more vital when the patient needs multisystem attention. The use of
Clinical reasoning cycle strategy is one way to ensure personalized patient care is achieved. In

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the case of Mr. Brad Taylor use of Clinical reasoning cycle strategy provided all the needed
essential data was obtained from the patient, as well as needs prioritized and proper interventions
put in place. Evaluation of outcomes is critical in determining achievements from the nursing
intervention and the need for further management.

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References
Dhatariya, K., Savage, M., Sampson, M., Matfin, G., & Scott, A. (2018). Severe Hyperglycemia,
Diabetic Ketoacidosis, and Hyperglycemic Hyperosmolar State. Endocrine and
Metabolic Medical Emergencies: A Clinician's Guide, 5(2), 531-547.
Farrell, M., Smeltzer, S.C., & Bare, B.G. (2017). Smeltzer and Bare’s textbook of medical-
surgical nursing (4th Australian and New Zealand ed.). Sydney: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Gosmanov, A. R., Gosmanova, E. O., & Kitabchi, A. E. (2018). Hyperglycemic crises: diabetic
ketoacidosis (DKA), and hyperglycemic hyperosmolar state (HHS). In Endotext
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Hirsch, T. M. (2017). Diabetic ketoacidosis. Journal of the American Academy of PAs, 30(11),
46-47.
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Australian and New Zealand ed.) Chatswood, N.S.W. : Elsevier Australia.
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