Professional Nursing Continuum: DKA Case Study and Analysis

This report presents a detailed case study of a nurse's experience in the step-down ICU unit, focusing on the care of a patient admitted with diabetic ketoacidosis (DKA). The report outlines the patient's initial presentation, including abnormal arterial blood gas results and symptoms of distress. The nurse's interventions, such as administering insulin, monitoring glucose and electrolyte levels, and providing emotional support, are described. The report also discusses the complications associated with DKA and the importance of continuous monitoring. The patient's progress, including improvements in vital signs and eventual transfer to the general medical ward, is documented. The narrative emphasizes the development of a therapeutic relationship between the nurse and the patient, highlighting the importance of compassionate care. The report concludes with a bibliography of relevant sources on DKA management and nursing practice.

Running head: NURSING PRACTICE
NURSING PRACTICE
Name of Student:
Name of the University:
Author Note:

Employee #: __________________ Professional Nursing Continuum Generic Narrative
It was like any other day in the step down ICU unit where I have been working as a
nurse. It was almost the end of the patient rounds when a patient was shifted from the ER to
the SDICU who has been suffering from Diabetic ketoacidosis (DKA). She was brought into
the SICU ward and it was evident that she was suffering from distress due to difficulty in
breathing. That day the staff count was less in the emergency unit since this was the end of
the shift for most of the staffs therefore on seeing the patient I at once took charge. I was
informed that the doctor had asked for the conduction of the Arterial Blood Gas test on her.
The test had been conducted at approximately 9.30 pm. The reports had shown that the health
was deteriorating of the patient. The results had been reported to the doctor in charge. The lab
work results were as follows: FIo2 arterial was 21, pH arterial- 7.16(LL), pCO2- 18 (LL),
pO2- 137 (H), Bicarbonate – 6.9 (L), Total CO2- 6.9 (L), base deficit was – 20.3 (H), O2
saturation – 99.4, Haemoglobin was 12.1, chloride – 123 (H), hematocrit – 37, potassium-
4.3, sodium- 148 (H), glucose- 205(H) and Wh blood lactate was 0.8. Again at 2.30 am,
another set of Arterial Blood Gas test had been conducted on the patient which showed no
evident improvement in the patient. After the results of the 2.30 am results had come on in,
that the patient was shifted to our ward. The results were as follows: FIo2 arterial was 21, pH
arterial- 6.99 (LL), pCO2- 9 (LL), pO2- 133 (H), Bicarbonate – 2.1 (L), Total CO2- 2.3 (L),
base deficit was – 27.5(H), O2 saturation – 98.8, Haemoglobin was12.9, chloride – 122 (H),
hematocrit – 40, potassium- 4.7, sodium- 148 (H), glucose- 306(H) and Wh blood lactate was
1.0. As a night charge I went to attend the patient as she seemed to be in lot of pain. It was
also my duty to properly assign the patient to a particular nursing team. I felt that it would be
appropriate to assign her to a novice RN. On arriving near the patient, she looked at me with
sad eyes, and asked me to be by her side until her family arrives in the morning. She has been
feeling lonely and helpless since her illness has worsened few hours ago before she was
brought in into the ICU. I was informed by the nurses of her previous medical ward that she

Employee #: __________________ Professional Nursing Continuum Generic Narrative
has been on an insulin drip even since she was brought in into the hospital. The insulin drip
had been titrating bases on the patient’s hourly glucose level l. Apart from this, there was
replacement of Potassium level according to the protocol so levels less than 3.8. There was a
repetition of BMP lab work being done at every 4 hours interval in order to monitor the anion
gap which is base off the sodium +potassium divided by Chloride +bicarbonate.
In the morning after the patient was awake I found that the patient looked quite
relieved. I asked for updates from the primary RN. Immediately I took to monitoring her
glucose and ketone levels, since this is a must for which should be conducted at an interval of
every 4 hours. I noticed that the blood glucose level was still higher than the normal range so
I immediately informed the doctor about the situation. In the morning when the patient was
served breakfast, she had difficulty in consuming the food and even vomited after having it.
Therefore the doctor prescribed that she should be given only fluids and drinks in order to
maintain proper nutrition. Later several other tests were also conducted which included
checking the presence of ketone in her urine. Later in the day she showed symptoms like
excessive thirst, frequent urination, abdominal pain, nausea and vomiting, acetone breath. I
immediately noted all these down so that I could report these when the doctor gain came for
his rounds in the ICU.
For taking care of patients suffering from diabetic ketoacidosis, several interventions
are required which included correction of fluid loss, insulin therapy, electrolyte correction,
correction of acid-base balance and treatment of concurrent infection. An important aspect of
taking care of such patients included long-term monitoring therefore I tried to keep an eye on
the blood glucose monitor as long as I was on my duty.
In patients with diabetic ketoacidosis, hypoglycemia may result from inadequate
monitoring of glucose levels during insulin therapy. Insulin sensitivity improves after

Employee #: __________________ Professional Nursing Continuum Generic Narrative
clearance of ketones. Hypokalemia is a complication that is precipitated by failing to rapidly
address the total body potassium deficit brought out by rehydration and insulin treatment,
which not only reduces acidosis but directly facilitates potassium re-entry into the cell. Other
complications that may arise due to the complications that arise as a result of the treatment
given for DKA involves Cerebral edema, Cardiac dysrhythmia, Myocardial injury,
Pulmonary edema and Diabetic retinopathy. Therefore intensive care should be taken of the
patients in order to avoid the occurrences of such complications.
In the early hours that morning, some members of the patient’s family had arrived.
The patient was sleeping at that time, therefore I her primary nurse to wake her up. Using the
primary nurses’ help I helped her to sit up since she insisted so. When her family came in, her
face immediately was lit up and all the pain she was suffering from, seemed to disappear.
Inspite of the family of her family, she did not forget me and made sure to introduce me to
her family. She said all nice things about me and her primary nurse. That day I left a bit later
than my shift timings after assigning the CNAs and 1 RN to this task of cleaning the room,
and bathing the patient. Her vitals were better than before and she could now consume her
food in a better way. However the doctor had instructed to keep administering insulin at
proper intervals through IV. While administering the same I tried to take care of the fact that
K+ is normal that is below 3.3. Care should also be taken that the patient’s blood glucose
should not be immediately brought down. If such case occurs, the brain will not be able to
cope up.
When the doctor had arrived earlier, he had checked on her and declared that she was
now much better than before and now can be shifted to the general medical ward. Although
she was relieved that her condition was getting better, however at the same time she was sad
because she would not see me once she was shifted from the SICU to the general ward.

Employee #: __________________ Professional Nursing Continuum Generic Narrative
Next day as I was passing by the general ward, I caught a glimpse of the patient. I
went inside to find her sleeping peacefully. I was informed by the other nurses of the ward
that she had been much better since the last day and the doctor had agreed to release her on
the next day. They also informed me that she had been looking for me every now and then
after she came in to the ward. This gave me an unexpected joy and I wished for the recovery
to the earliest.
At the time of leaving the hospital the next day, she held my hand and thanked me for
my service. I told her that I had only done my duty, and one in my place would do the same. I
also made attempts to assure her that she was going to get all better very soon. It was just a
matter of few hours that she would again be together with her family. In just two days I had
developed a relationship with her, through our communications and her trust towards me.

Employee #: __________________ Professional Nursing Continuum Generic Narrative
Bibliography
American Diabetes Association, 2017. 14. Diabetes care in the hospital. Diabetes
Care, 40(Supplement 1), pp.S120-S127.
Anon, 2018. [online] Available at: https://www.glowm.com/lab_text/item/3 [Accessed 5 Jul.
2018].
Barski, L., Kezerle, L., Zeller, L., Zektser, M. and Jotkowitz, A., 2013. New approaches to
the use of insulin in patients with diabetic ketoacidosis. European journal of internal
medicine, 24(3), pp.213-216.
Crasto, W., Htike, Z.Z., Turner, L. and Higgins, K., 2015. Management of diabetic
ketoacidosis following implementation of the JBDS guidelines: Where are we and where
should we go?. British Journal of Diabetes, 15(1), pp.11-16.
Diabetes.co.uk. 2018. Diabetic Ketoacidosis - Causes, Symptoms and Treatment of DKA.
[online] Available at: https://www.diabetes.co.uk/diabetes-complications/diabetic-
ketoacidosis.html [Accessed 5 Jul. 2018].
Emedicine.medscape.com. 2018. Diabetic Ketoacidosis Treatment & Management:
Approach Considerations, Correction of Fluid Loss, Insulin Therapy. [online] Available at:
https://emedicine.medscape.com/article/118361-treatment#d1 [Accessed 5 Jul. 2018].
Gosmanov, A.R., Gosmanova, E.O. and Dillard-Cannon, E., 2014. Management of adult
diabetic ketoacidosis. Diabetes, metabolic syndrome and obesity: targets and therapy, 7,
p.255.

Employee #: __________________ Professional Nursing Continuum Generic Narrative
Mayo Clinic. 2018. Diabetic ketoacidosis - Symptoms and causes. [online] Available at:
https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-
20371551 [Accessed 5 Jul. 2018].