An adult client arrives at the emergency department presenting with profound lethargy, deep and rapid Kussmaul respirations, and a fruity breath odor. Laboratory results reveal a blood glucose of 680 mg/dL (37.7 mmol/L), a serum pH of 7.15, and positive serum ketones. Arrange the following collaborative interventions in the correct sequence of priority.
- 1Establish large-bore intravenous access and initiate a rapid infusion of 0.9% sodium chloride.
- 2Obtain a serum potassium level and a basic metabolic panel.
- 3Administer a continuous intravenous infusion of regular insulin.
- 4Add 5% dextrose to the maintenance intravenous fluids.
- 5Administer the first scheduled dose of subcutaneous insulin.
Answer
The correct sequence prioritizes hemodynamic stability and safety: administer intravenous fluids first, check the potassium level second, start the continuous regular insulin infusion third, add dextrose to the fluids when glucose falls below 250 mg/dL fourth, and transition to subcutaneous insulin fifth.
The established protocol for severe metabolic decompensation prioritizes ABCs and hemodynamics. Dehydration from osmotic diuresis requires immediate 0.9% sodium chloride to restore vascular volume. Next, potassium must be evaluated because insulin drives potassium into cells, risking life-threatening hypokalemia. Only after volume and electrolytes are secured is regular insulin infused to correct the acidosis. Dextrose is later added when glucose drops below 250 mg/dL to prevent hypoglycemia while waiting for ketones to clear. Finally, a subcutaneous insulin dose provides overlapping coverage before the intravenous drip is stopped.
Step-by-Step Solution
Key Concept
The acute management of diabetic ketoacidosis (DKA) strictly prioritizes fluid resuscitation followed by electrolyte evaluation before the administration of insulin.
Estimated Time:1m 30s