Dorothy Onyemah

Nursing Care of Adults Case Study

Type 1 Diabetes Mellitus/Ketoacidosis

November 29, 2010

1. Type 1 diabetes formally known as juvenile diabetes or insulin dependent diabetes is a lifetime disease, which occurs when there is no insulin production or secretion by the pancreas to control blood glucose levels. According to Brunner & Suddarths, it is characterized by autoimmune (islet cell antibodies) destruction of the beta cells of the islets of the langerhans in the pancreas. Also as Lewis stated, there is a link to genetic predisposition and exposure to virus that contributes to development of immune related type 1 diabetes mellitus. This genetic tendency is found in individuals with human leukocyte antigen (HLA-DR3 and HLA-DR4) types. The risk is very high if individual possess both of these types of HLA. The onset of type 1 diabetes is very quick (acute) following the inability of the pancreas to produce and release insulin. The basic symptoms are, sudden weight loss, and three classic symptoms of polydipsia, polyuria and polyphagia. As the level of glucose in the blood rises above the renal threshold (180 t0 200 mg/dL), there will be a spill over in the urine (glucosuria). The excessive glucose excreted in the urine creates a condition whereby fluids and electrolytes are lost (osmotic diuresis), thus leading to excessive thirst (polydipsia). As individual drinks more fluids, it follows with excessive urination (polyuria). According to Burnner and Suddarths, the continued production of insulin by the pancreas inhibits the breakdown of stored glucose (glycogenolysis) and production of glucose from amino acids (gluconeogenesis). However, with the deficiency of insulin and the condition of hyperglycemia, fat breakdown occurs resulting in production of toxic waste called ketone bodies leading to acidosis, which is poisonous to the body. This condition manifests as polyphagia, an excessive hunger that results due to breakdown of the body fat, and hence the individual will lose weight and looks thin. There is currently no cure for this type of diabetes. Individuals with Type 1 diabetes usually require exogenous insulin (insulin source from outside the body) to treat and control blood glucose levels. Obviously, without synthetic insulin, type 1 diabetic individual will develop metabolic derangement known as diabetic ketoacidosis (DKA), the brake down of the bodys own stored fat. This is a life threatening condition that develops when the body cannot obtain glucose to use as energy source. DKA is a one common complication of type I diabetes mellitus resulting in hyperglycemia, dehydration, electrolyte imbalance, and ketoacidosis. Ms X a 48 year old type I diabetic woman who arrived at the emergency department with daughter who stated that the mother has not eaten or drank much, and not sure if she has taken her insulin for the past 24 hours. The fruity odor is an indication of ketoacidosis. The blood sample was drawn and according to Lewis et al, the expectations from the test results are presented as follows: y y The serum blood glucose level should be greater than 250 mg/dL The plasma pH level should be less than 7.3
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Dorothy Onyemah

Nursing Care of Adults Case Study

Type 1 Diabetes Mellitus/Ketoacidosis

November 29, 2010

y y y y y y y

The plasma bicarbonate level should be less than 15 mEq/L Elevated serum creatinine and BUN levels Serum osmolarity is between 300 and 350 mOsm/L Serum amylase and lipase is elevated The serum ketone should be present in both blood and urine Serum potassium and chloride levels should be elevated Serum sodium (hyponatremia), phosphate and magnesium (hypomagnesemia) levels should be decreased

2. Type 1 diabetic mellitus ketoacidosis client when hospitalized, the nurse should monitor the blood and urine tests closely. If not hospitalized the individual should contact his/her healthcare provider immediately or go to a nearby emergency room. The reason is that diabetic ketoacidosis has a high mortality rate. Not enough insulin means that the body will not be able to use glucose for energy and has to look for where to get it. Normally, the alternative is the stored fat as explained in paragraph three above. High ketones accumulation in the blood creates a chemical imbalance, which is life-threatening. The most serious complication of it is cerebral edema especially in children. Keeping in mind the complications of ketoacidosis, the primary course of treatment for Ms X, the 48-years old woman will include intravenous fluid resuscitation, insulin infusion to restore blood glucose level, correction of electrolytes and acid-base imbalance. Also, if the serum potassium levels fall below 4.5 mEq/dL, potassium chloride should be added to the IV infusion to correct imbalance of this important body electrolyte. On the other hand, the therapies must be monitored carefully, because an excessive amount of hydration could lead to brain swelling (cerebral edema). The resuscitation of fluid loss should begin with 4 liters of isotonic sodium chloride or lactate ringer solution. The first 1 liter should be administered within the first 30 minutes, followed by another in the second hour, 2 hours later and 4 hours respectively until the client becomes euvolemic, then infusion should be changed to half isotonic solution. In addition to fluid resuscitation, insulin treatment is needed to restore the normal serum blood glucose. According to Lewis et al, regular and analog insulin are used for treating and correcting hyperglycemia, except in a situation where bovine or pork insulin is the only available insulin. Hamdy, Osama presented some clinical considerations in treating diabetic ketoacidosis (DKA) as following: y y only short-acting insulin is used for correction of hyperglycemia in DKA the optimal rate of glucose decline is 100 mg/dL/h
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Dorothy Onyemah

Nursing Care of Adults Case Study

Type 1 Diabetes Mellitus/Ketoacidosis

November 29, 2010

y y

the blood glucose level should not be allowed to fall below 200 mg/dL during the first 4 to 5 hours of treatment and to avoid induction of hypoglycemia because it may develop rapidly during correction of ketoacidosis and may not provide sufficient warning time.

Also, to stop further ketones formation and stabilized tissue function by driving available potassium back into the tissue; insulin must be administered promptly as a continuous infusion and not as a bolus. When the blood glucose falls to a particular level (300 and 200 mg/dL), insulin and glucose should be administered together to prevent the incident of hypoglycemia (DKA, Medical Treatment). If decompensated acidosis starts to threaten life, sodium carbonate (100 to 150 ml of 1.4% concentration) should be administered, but not rapidly or early in the treatment to avoid hypoglycemia. Also, as I explained above there may be a need to correct potassium imbalance if it falls below 4.5 mEq/dL. Potassium levels should be monitored every hour even after the infusion. In case of severe hypokalemia, insulin infusion should be put on hold, until replacement is given in order to avoid cardiac dysrhythmia. Finally, if the client is afflicted with some kind of infection like Ms X who arrived at the the hospital with a flu virus as stated by her daughter, the treatment for infection should come last. 3. As I mentioned above hospitalized patients with diabetic ketoacidosis are mornitored with appropriate blood and urine tests. While administering patient's' IV fluid and insulin, it is important to continue assessing the renal and cardiopulmonary status in relation to hydration, electrolyte level, and the client level of consciousness. Also, it is important to keep an eye on the signs of potassium imbalance that may result from hyperinsulinemia and osmotic diuresis. The reason why potasium should be mornitored is because treating hyperglycemia with insulin could result in rapid depletion of potassium as potassium moves back into the cells once insulin becomes available. The movement of potassium out of extracellular fluid into the cells affects cardiac functioning. For this reason, cardiac mornitoring is very important in detecting hyperkalemia or hypokalemia characteristic changes, which can be observed on the electrocardiogram. To put all together, the imbalance in serum potassium level could lead to Myocardial infarction (MI) as a precipitating cause of diabetic ketoacidosis in older clients or cerebral edema in children as mentioned above (Lewis et al; Trashtenbarg, David E). 4. During the first 24 hours of continous insulin infusion, there is a risk for hypoglycemia. As insulin is administered during the course of treatment, glucose is rapidly picked up by the cells as stated in the above paragraph, thus causing the serum blood glucose level to drop. It may significantly drop to a lower level and hypoglycemia may result. In view of this, hypoglycemia is one of the major complications of diabetic ketoacidosis to monitor during the first 24 hours of treatment. Cerebral edema is the most fearful complication that could result in the first 24 hours of treatment as well. Cerebral edema normally occurs as a result of excessive hydration during fluid
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Dorothy Onyemah

Nursing Care of Adults Case Study

Type 1 Diabetes Mellitus/Ketoacidosis

November 29, 2010

resuscitation. As stated in the paragraph above, hyperkalemia and hypokalemeia are another serious complications that could occur as a result of insulin therapy, hence leading to myocardial infarction. 5. Urine test strips are popular and convenient for monitoring glucose and ketones levels. However, despite its convenience there are some disadvantages as listed below: 1. Urine Ketone Testing is not specific because it can be interfered by many things. 2. There are three types of ketones: the acetone, the acetoacetate and Beta-hydroxybutyrate. The most common ketone associated with ketoacidosis is Beta-hydroxybutyrate. Unfortunately urine tests don't detect -hydroxybutyrate. 3. Ketones accumulate in urine over several hours, so measuring those in urine cannot tell you what the levels are right now. 4. With dehydration associated with ketoacidosis obtaining urine sample can be difficult. In view of these disadvantages, it is recommended one tests the blood -Ketone because Ketones are detectable in the blood far earlier than in urine. Blood -Ketone testing can give early warning of impending DKA than the urine test (Abbott diabetic care). Also, as Lippincott, WIlliams and Wilkins stated, despite their convenience, urine tests don't always reflect blood glucose levels accurately. 6. Self-care management of diabetes mellitus is largely the responsibility of the individual, with more emphasis on prevention of complications. Adherence to treatment regimens can be difficult and requires the client to make some lifestyle changes. In addition to monitoring the blood glucose and ketone levels and adhering to lifestyle changes (exercise and dietary), the nurse should emphasize on foot-care, which tends to be forgotten, but obviously carries high consequences when neglected. Foot-care is important, because diabetes affects all kinds of nerves of the body, including peripheral, autonomous, and spinal nerves. The decrease in sensation of pain and temperature places the individual at high risk for injuries and infections especially in the lower extremeties. In view of this fact, the nurse should instruct Ms. X to inspect her feet on a daily basis by looking at the bare feet, using a mirror to check the bottoms of the feet. She should monitor for changes in temperature, blisters, cuts, red spots, and swelling. Ms X should be taught how to wash and dry her feet every day using warm water, but not to soak them. The toe nails should be trimed every week, and the shoes and socks should just fit, and not too tight to allow for blood to flow freely (Lippincot, WIlliams, and Wilkins). In case of diabetic neuropathy and the client happens to sustain foot injury, the healing of the wound may be impaired due to poor peripheral circulation. It is important to note that most foot amputees are diabetic client, and for this reason, foot care is very important and must be discussed with each diabetic client before discharged.
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Dorothy Onyemah

Nursing Care of Adults Case Study

Type 1 Diabetes Mellitus/Ketoacidosis

November 29, 2010

7. Individuals diagnosed with DM type 1 should use exogenous insulin to sustain life, because their body has lost its ability to produce insulin. The use of insulin in treating diabetes may require two or more (frequency) administration a day. However, that depends on the level of glucose in the persons blood, thus accurate level of blood glucose is esseential. As already stated insulin is needed for treating and sustaining life of diabetic individuals especially in type 1 diabetes where the pancrease is not producing enough insulin or not at all. In the past exogenous insulin are derived from the animals (beef and pork) and used as a treatment of choice for DM, but today insulin is derived from human through genetic engineering. Exogenous Insulin is grouped in categroies of onset, peak and duration of action. There are rapid-acting, short-acting, intermediate-acting, long-acting, and combination (premixed) insulin (Lewis et al). Using insulin to treat DM is not just prescribed for individuals. Its properties are matched with the individual's diet and activities before prescribing. Insulin can also be mixed together in order to tailor treatment to client's lifestyle, eating and activity patterns. Which ever insulin treatment is chosen, all insulin preparations start with the regular insulin as the base. To achive different onsets, peak and duration, zinc, protamine and acetate buffer may be added and manipulated as needed. For example zinc and protamine when added will produce an intermediate-acting NPH (Neutral Protamine Hagedom) insulin. Normally the body produces more insulin during and after meal time to convert ingested carbohydrate to glycogen. If that's the case, the administration of synthetic or exogenous insulin that mimics endogenous insulin should be targeted towards mealtime for effective treatment. Ms. X was prescribed 10 units of regular and 18 units of NPH insulin to be taken before breakfast, and 5 units of regular and 12 units NPH at dinnertime. According to Lewis et al regular insulin is short-acting and NPH is an intermediate acting insulin as stated in two paragraphs above. Unlike the rapid acting, which has onset of 15 minutes, peak of 60 to 90 minutes for a duration of 3 to 4 hours, the short -acting insulin has an onset of 30 to 60 minutes with 3 to 3 hours peak and lasting effect 3 to 6 hours. The intermediate-acting NPH has an onset of 2 to 4 hours with peak of 4 to 10 hours and could last from 10 to 16 hours (Lewis et al). Putting these facts all together, I should assume that a mixed-dose of short-acting and intermediate-acting could have an onset as short as 30 minutes to 4 hours with the peak ranging from 2 to 10 hours for a lasting effect of 3 to 16 hours. Although hypoglycemia is not out of question, but the duration effect of the mixed dose is long enough to protect individual against hypoglycemia in between meals. The discharged teaching learning about the mixed-dose of short and intermediate acting insulin should be stated as follows: Insulin preparation y For infection control purposes especially at the injection sites, handwashing before handling insulin and syringe is very important and must be emphasized
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Dorothy Onyemah

Nursing Care of Adults Case Study

Type 1 Diabetes Mellitus/Ketoacidosis

November 29, 2010

y y y

Ms X must identify the correct insulin to be injected, and check the expiration date She should gently rotate the NPH insulin bottle and wipe the vails with alcohol sponge Ms Xs maximum mixed-dose is 28 units, so she should use 0.3 mL syringe, which is the normal size for injecting 30 units or less of insulin

For breakfast: 1. Draw back 28 units of air which is equal to total amount of both regular and NPH insulin to be administered into the stringe 2. Inject 18 units of air into NPH vail and remove syringe 3. Inject 10 units of air into regular vail, and while the syringe is still in the regular, invert the vial and draw up 10 units of regular insulin, then withdraw syringe 4. Insert syringe into NPH and, without adding more air to NPH vail, carefully withdraw 18 units of NPH For dinner: 1. Draw back 17 units of air which is equal to total amount of both regular (5 units) and NPH (12 units) insulin to be administered into the stringe 2. Inject 12 units of air into NPH vail and remove syringe 3. Inject 5 units of air into regular vail, and while the syringe is still in the regular invert the vail and draw up 5 units of regular insulin, then withdraw syringe 4. Insert syringe into NPH, without adding more air to NPH vail, carefully withdraw 12 units of NPH Ms X should be instructed that insulin is injected into the preferred site (common sites is the abdomen) by keeping the syringe at 45 degree angle. Ms X should be advice to rotate injection site (in the abdomen) to prevent irritation of skin Caution Ms X not to inject insulin to the site that will be exercised, for example the client should not inject insulin into the thigh and then go jogging. This is because exercise will increase the body heat and circulation, which may increase rate of absoption and speeds up the onset of insulin. Ms X should be cautioned to avoid storing insulin in extreme hot or freezing temperature, which could alter the molecule. 8. Nursing management of diabetes mallitus

Ignorance is one of the major factors that affect management of diabetes mellitus. The diabetes
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Dorothy Onyemah

Nursing Care of Adults Case Study

Type 1 Diabetes Mellitus/Ketoacidosis

November 29, 2010

may not be diagnosed until one or two complications are manifested. Hence, a little bit of learning about diabetes and associated complications will help Ms X to manage the disease. As I may have stated in one of the paragraphs above, diabetes mellitus are of two kinds, type 1 and type 2, and both present with the same most common signs and symptoms of three Ps such as polyuria, polydipsia, and polypgagia. Diabetes type 2 occurs most often at older age as a result of the body becoming resistant to insulin and hence the manifestation of hyperglycemia. The type 1 diabetes can occur at any age for one reason, genetic and/or bacterial infection that causes autoantibodies against the beta cells of the pancrease and resultant destruction of 90% of the beta cells. The major complications of type 1 diabetes mellitus include hyperglycemia, lipolysis (fat decomposition) and protein catabolism, which leads to diabetic ketoacidosis. Ketoacidosis occurs as a result of marked deficiency of insulin, and it is characterized by high blood glucose, ketosis, acidosis and dehydartion. As I have stated multiple times in the above paragraphs, individuals with type 1 diabetes depend on exogenous or synthetic insulin to sustain life. Insulin prescription is based on individual needs and activity level. Individuals with diabetic ketoacidosis can slip into coma and may die. In addition to other risk factors and for the fact that diabetes can involve variety of physiological disorders (blindness, kidney disease, and neuropathy leading to amputation), most importantly it requires lifetime management and client must learn to balance multiple factors. Client must learn daily self-care to minimize or prevent fluctuation of blood glucose and its complications. It is the nurse's responsibilty to assess each client's readiness to learn and determine teaching method that will impact proper knowledge. Having stated this, the nurse will provide the following survival skills to Ms. X in order to be able to manage her diabetes at home: y The basic definition of diabetes as explained above, and also, includes knowledge about normal blood glucose levels , the effect of insulin and how exercise could lower blood glucose level, effect of food (high caloried food) and stress (illness, infections), and the basic treatment approaches. The treatment regimen for Ms X includes insulin administration and possible other oral medications the doctor may prescribe. It is nurse's responsibility to educate the client the need for continuous insulin therapy as prescribed without missing a dose. Missing doses could result in more episodes of hyperglycemia and subsequently ketoacidosis. Also, Ms X should be educated on the meal planning such as the nutritional values of the five food groups, and the timing of each meal. The timing is very important because of the administration of insulin (onset, peak and the duration) and its effect. Ms X should be tought how to monitor blood glucose and ketones levels. Her doctor ordered blood glucose monitoring instead of urine testing, the nurse should enphasis on the importance of complying with this change. As I explained above, urine testing though convinient is not very effective in detecting ketones. Blood test detects the beta ketones
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Dorothy Onyemah

Nursing Care of Adults Case Study

Type 1 Diabetes Mellitus/Ketoacidosis

November 29, 2010

before the manifestation of DKA. The nurse should educate Ms X on how to perform the blood test and where to obtain or buy the testing kit. Ms X should keep proper record of the test results. y The nurse should teach Ms X the signs and symptoms of acute complications of hypoglycemia and hyperglycemia to watch out for, and what to do in case of emergency. In case of hyperglycemic effect, Ms X should take 15 grams of fast-acting carbohydrate such as 4 to 6 oz of fruit juice or soda, 3 to 4 commercial glucose tablets, 6 to 10 hard candies, or 2 to 3 teaspoons of sugar or honey. Ms X should carry any one of these rescue glucose boost at all time. Ms X should be instructed on where to buy and store insulin, the syringes, and the monitoring kit. The nurse should also instruct her on when to contact her healthcare provider in an emergency situation. Lastly, while Ms X is complying with her insulin treatment, she should be taught how to adjust (increase or decrease) her insulin based on her blood glucose levels. Also the nurse should teach Ms X how to care for her legs and feet, and eyes to prevent further complications or manifestations of diabetes mellitus.

To prevent future emergency episodes, Ms X should comply with her treatment regimen and take all necessary precuations outlined by the nurse in her teaching. In addition to medications, Ms X should try to make necessary lifestyle changes to include exercise and dietary that will help her in managing and controlling her blood sugar and ketones levels. Ms X should carry all her glucose rescue medication or beverage of her choice all the time. It is important that she also carry medic-alert explaining her condition as well. Above all, Ms X should comply with blood glucose and ketone testing per physician's order.

References
Abbot diabetic care, Abbot Laboratories, 2001-2010, http://www.abbottdiabetescare.ca/adc_ca/url/content/en_CA/40.20.40:40/general_content /General_Content_0000315.htm Brunner & Suddarths, 2008, Textbook of Medical-Surgical Nursing, 11th edition, p1375-1433 DKA, Medical Treatment, p6, (http://www.emedicinehealth.com/diabetic_ketoacidosis/page6_em.htm Handy, Osama, MD, PhD, Medical director, Harvard medical school, 2009, Diabetes Ketoacidosis: Treatment & Medication,
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Dorothy Onyemah

Nursing Care of Adults Case Study

Type 1 Diabetes Mellitus/Ketoacidosis

November 29, 2010

http://emedicine.medscape.com/article/118361-treatment Lewis et al, 2007, Medical Surgical Nursing, Assessment and management of clinical problems, 7th edition, p1253-1288 Lippincott, WIlliams and Wilkins, 2004, Medical-Surgical Nursing made incredibly easy! p532 Trashtenbarg, David E, MD. University of Illinois Medical School, 2005, Diabetic Ketoacidosis, http://www.aafp.org/afp/2005/0501/p1705.html

http://www.merck.com/mmpe/sec12/ch158/ch158c.html http://type1diabetes.about.com/od/schooldaycareandlaws/a/keto_emergency.htm http://www.wrongdiagnosis.com/d/diabetic_ketoacidosis/book-diseases-19a.htm