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Difficulty: MediumPhysiological Adaptation

A client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client is lethargic, exhibiting Kussmaul respirations, and has a blood glucose level of 520 mg/dL (28.9 mmol/L). The healthcare provider has entered multiple initial prescriptions. In what order should the nurse perform the following actions? Arrange the interventions in the correct clinical sequence from first to last.

  1. 1Initiate a rapid intravenous infusion of 0.9% sodium chloride.
  2. 2Evaluate the client's initial serum potassium laboratory result.
  3. 3Start a continuous intravenous infusion of regular insulin.
  4. 4Add 5% dextrose to the intravenous fluids when blood glucose decreases to 250 mg/dL (13.9 mmol/L).
  5. 5Administer the first dose of subcutaneous insulin before discontinuing the intravenous insulin infusion.

Answer

The correct sequence for managing severe DKA is: 1) Initiate 0.9% sodium chloride, 2) Evaluate serum potassium level, 3) Start a continuous IV regular insulin infusion, 4) Add 5% dextrose to IV fluids when glucose drops to 250 mg/dL, and 5) Administer the first subcutaneous insulin dose before stopping the IV insulin.
The management of Diabetic Ketoacidosis (DKA) follows a strict, evidence-based sequence designed to stabilize the client and prevent life-threatening complications. The absolute immediate priority is fluid resuscitation with isotonic saline (0.9% NaCl) to restore intravascular volume and tissue perfusion resulting from severe osmotic diuresis. Second, before administering any insulin, the serum potassium level must be evaluated. Insulin administration causes an intracellular shift of potassium, which can lead to profound hypokalemia and fatal cardiac arrhythmias. Third, once a safe potassium level is verified, a continuous IV infusion of regular insulin is initiated to steadily correct the hyperglycemia and resolve the metabolic acidosis. Fourth, as the blood glucose level decreases to approximately 250 mg/dL (13.9 mmol/L), 5% dextrose is added to the IV fluid regimen to prevent a rapid drop in glucose, which could precipitate hypoglycemia and cerebral edema. Finally, once the ketoacidosis has resolved (evidenced by a normalized anion gap), the client is transitioned to a subcutaneous insulin regimen. The first subcutaneous dose must be administered prior to discontinuing the IV insulin to provide overlapping coverage and prevent a rebound into ketoacidosis.

Step-by-Step Solution

1
Restore intravascular volume.
Initiate a rapid intravenous infusion of 0.9% sodium chloride.
Fluid resuscitation is the immediate first priority in DKA to reverse severe dehydration caused by osmotic diuresis and to improve tissue perfusion.
2
Assess electrolyte status.
Evaluate the client's initial serum potassium laboratory result.
It is critical to verify the potassium level before giving insulin, as insulin therapy causes an intracellular shift of potassium, potentially leading to severe hypokalemia.
3
Correct hyperglycemia and acidosis.
Start a continuous intravenous infusion of regular insulin.
After fluid resuscitation has begun and potassium is confirmed to be in a safe range, IV insulin is administered to lower glucose levels and stop ketone production.
4
Prevent hypoglycemia and cerebral edema.
Add 5% dextrose to the intravenous fluids when blood glucose decreases to 250 mg/dL (13.9 mmol/L).
As blood glucose drops closer to normal, adding dextrose prevents a rapid fluid shift into the brain cells (cerebral edema) and avoids inducing hypoglycemia.
5
Transition to maintenance therapy.
Administer the first dose of subcutaneous insulin before discontinuing the intravenous insulin infusion.
Providing a subcutaneous insulin dose while the IV insulin is still running ensures continuous insulin coverage, preventing a rebound into ketoacidosis.

Key Concept

Diabetic Ketoacidosis (DKA) Acute Management Sequence
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Topics

Physiological Adaptation

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