A client is admitted to the emergency department with a diagnosis of severe diabetic ketoacidosis (DKA). The client is lethargic with Kussmaul respirations and a capillary blood glucose of 580 mg/dL (32.2 mmol/L). The nurse is preparing to initiate the prescribed treatment plan. In what order should the nurse implement the following actions? Arrange the interventions from highest priority to lowest priority.
- 1Administer a rapid bolus of 0.9% sodium chloride intravenously.
- 2Verify the serum potassium level is above 3.3 mEq/L (3.3 mmol/L).
- 3Start a continuous intravenous infusion of regular insulin.
- 4Perform hourly capillary blood glucose monitoring.
- 5Add 5% dextrose to the intravenous fluid replacement.
Answer
The correct sequence is: 1) Administer a rapid bolus of 0.9% sodium chloride intravenously; 2) Verify the serum potassium level is above 3.3 mEq/L (3.3 mmol/L); 3) Start a continuous intravenous infusion of regular insulin; 4) Perform hourly capillary blood glucose monitoring; 5) Add 5% dextrose to the intravenous fluid replacement.
The standard protocol for Diabetic Ketoacidosis prioritizes immediate circulatory support followed by safe metabolic correction. Fluid resuscitation with isotonic saline is the absolute first step to correct severe hypovolemia and restore kidney perfusion. Next, the nurse must verify that serum potassium is sufficient (typically > 3.3 mEq/L) because insulin therapy will cause an intracellular shift of potassium, which could lead to fatal hypokalemia. Once a safe potassium level is confirmed, an intravenous continuous regular insulin infusion is started to halt lipolysis and clear ketoacids. With insulin running, hourly blood glucose monitoring is essential to titrate the dose accurately and avoid a precipitous drop. Finally, when blood glucose drops to approximately 250 mg/dL, the IV fluids are changed to include 5% dextrose to prevent sudden hypoglycemia and the rapid fluid shifts that cause fatal cerebral edema.
Step-by-Step Solution
Key Concept
The priority sequence for Diabetic Ketoacidosis (DKA) management centers on resolving life-threatening hypovolemia first, followed by careful electrolyte management before initiating insulin therapy, to prevent severe complications such as hypokalemia and cerebral edema.