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Difficulty: MediumPhysiological Adaptation

A nurse is evaluating a client admitted with diabetic ketoacidosis (DKA) four hours ago. The client has been on a continuous intravenous infusion of regular insulin and 0.9%0.9\% sodium chloride. Current laboratory results indicate a serum glucose level of 235 mg/dL235\text{ mg/dL} (13.0 mmol/L13.0\text{ mmol/L}). The arterial blood gas (ABG) analysis shows a pH of 7.287.28, PaCO 2_2 of 28 mm Hg28\text{ mm Hg}, and HCO 3−_3^- of 14 mEq/L14\text{ mEq/L}. The client presents with deep, rhythmic respirations at a rate of 2424 breaths per minute. Which of the following actions should the nurse perform next?

  1. Change the continuous intravenous fluids to include 5%5\% dextrose.Answer
  2. B
    Discontinue the continuous regular insulin infusion.
  3. C
    Instruct the client to take slow, shallow breaths to reduce the respiratory rate.
  4. D
    Administer a prescribed intravenous bolus of sodium bicarbonate.

Answer

Change the continuous intravenous fluids to include 5% dextrose.
In the management of diabetic ketoacidosis (DKA), continuous intravenous insulin is required to halt ketogenesis and resolve the underlying metabolic acidosis. Because blood glucose levels typically decline faster than the acidosis resolves, 5%5\% dextrose must be added to the intravenous maintenance fluids once the serum glucose reaches 250 mg/dL250\text{ mg/dL} (13.9 mmol/L13.9\text{ mmol/L}) or lower. This critical physiological adaptation intervention prevents severe hypoglycemia and rapid fluid shifts that can cause cerebral edema, while allowing the insulin infusion to continue until the metabolic acidosis is fully corrected.

Step-by-Step Solution

1
Analyze the client's current serum glucose level.
The blood glucose has fallen to 235 mg/dL235\text{ mg/dL} (13.0 mmol/L13.0\text{ mmol/L}).
Identifying that the glucose level is below the critical threshold of 250 mg/dL250\text{ mg/dL} (13.9 mmol/L13.9\text{ mmol/L}) dictates a necessary change in intravenous fluid management.
2
Evaluate the arterial blood gas (ABG) results.
The ABG shows a pH of 7.287.28 and HCO 3−_3^- of 14 mEq/L14\text{ mEq/L}, indicating ongoing uncompensated metabolic acidosis.
This confirms that continuous intravenous insulin must be maintained to halt ketogenesis and resolve the acidosis, regardless of the dropping glucose levels.
3
Determine the priority nursing action based on the combined physiological findings.
The nurse must add dextrose to the maintenance intravenous fluids.
Adding dextrose prevents hypoglycemia while allowing the necessary insulin infusion to continue treating the unresolved metabolic acidosis.

Key Concept

In diabetic ketoacidosis (DKA), intravenous fluids must be changed to include dextrose when blood glucose reaches 250 mg/dL to prevent hypoglycemia, while insulin is continued until the metabolic acidosis fully resolves.
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Topics

Physiological Adaptation

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