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Difficulty: HardPhysiological Adaptation

A nurse in the emergency department is caring for a client who is admitted with severe diabetic ketoacidosis (DKA). The client is lethargic, has a blood glucose of 680 mg/dL680\text{ mg/dL} (37.7 mmol/L37.7\text{ mmol/L}), and an arterial pH of 7.127.12. Arrange the following collaborative and nursing interventions in the correct chronological order of implementation.

  1. 1Administer a rapid intravenous infusion of 0.9% sodium chloride.
  2. 2Verify the initial serum potassium level.
  3. 3Initiate a continuous intravenous infusion of regular insulin.
  4. 4Add 5% dextrose to the maintenance intravenous fluids.
  5. 5Administer the first scheduled dose of subcutaneous insulin.

Answer

1. Administer a rapid infusion of 0.9% sodium chloride; 2. Verify the initial serum potassium level; 3. Initiate an IV infusion of regular insulin; 4. Add 5% dextrose to the fluids; 5. Administer the first dose of subcutaneous insulin.
The evidence-based sequence for DKA management is: 1) restore intravascular volume with isotonic normal saline, 2) check potassium to ensure it is safe to administer insulin, 3) administer continuous IV regular insulin to stop ketogenesis, 4) add dextrose to the IV fluids when the blood glucose reaches 250 mg/dL to prevent hypoglycemia, and 5) transition to subcutaneous insulin once the anion gap is closed.

Step-by-Step Solution

1
Address the primary life threat: severe dehydration and hypovolemia.
Intravenous 0.9% sodium chloride is administered rapidly.
Patients with severe DKA can lose up to 10% of their body weight in fluids due to osmotic diuresis. Restoring perfusion is the absolute first step.
2
Assess electrolyte status prior to starting hormonal therapy.
The serum potassium level is verified.
Insulin shifts potassium into cells. If the patient is already hypokalemic, administering insulin could cause a fatal cardiac arrhythmia. Potassium must be known and, if necessary, replaced first.
3
Treat the underlying pathophysiology (ketogenesis).
A continuous intravenous infusion of regular insulin is initiated.
Insulin stops the breakdown of fats, halting ketone production and gradually lowering blood glucose.
4
Prevent complications of rapid glucose lowering.
5% dextrose is added to the intravenous fluids when blood glucose reaches approximately 250 mg/dL.
Adding dextrose prevents hypoglycemia while allowing the insulin drip to continue running in order to fully close the anion gap. It also prevents cerebral edema from rapid osmotic shifts.
5
Transition to maintenance therapy.
Subcutaneous insulin is administered.
Once the ketoacidosis resolves (the anion gap closes), the patient is transitioned to subcutaneous insulin prior to stopping the IV drip to prevent DKA recurrence.

Key Concept

Prioritization in Diabetic Ketoacidosis (DKA) Management
Estimated Time:2m 0s
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Topics

Physiological Adaptation

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