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Difficulty: HardPhysiological Adaptation

An emergency nurse is evaluating a client with type 1 diabetes mellitus who presents with altered mental status, profound lethargy, and a distinct sweet-smelling breath odor. The client is exhibiting heavily labored respirations with an increased depth at a rate of 3434 breaths per minute. Cardiac monitoring displays sinus tachycardia at 132132 beats per minute, and the non-invasive blood pressure reads 84/4484/44 mm Hg. Laboratory results indicate a capillary blood glucose of 612612 mg/dL, pH\text{pH} of 7.157.15, PaCO2\text{PaCO}_2 of 2323 mm Hg, and HCO3−\text{HCO}_3^- of 1010 mEq/L. Which action should the nurse execute immediately?

  1. Commence a rapid intravenous bolus of isotonic saline.Answer
  2. B
    Start a continuous intravenous infusion of regular insulin.
  3. C
    Administer a prescribed dose of intravenous sodium bicarbonate.
  4. D
    Provide a rebreather mask to help the client correct their respiratory alkalosis.

Answer

Commence a rapid intravenous bolus of isotonic saline.
In Diabetic Ketoacidosis (DKA), extreme hyperglycemia causes severe osmotic diuresis, leading to profound dehydration and hypovolemic shock (evidenced by the hypotension and tachycardia). The most critical initial intervention is massive fluid resuscitation with isotonic crystalloids (0.9% sodium chloride) to restore intravascular volume and maintain organ perfusion. Only after fluid resuscitation has begun should insulin therapy be initiated.

Step-by-Step Solution

1
Analyze the clinical presentation and laboratory data.
The combination of extreme hyperglycemia, metabolic acidosis, and Kussmaul respirations confirms Diabetic Ketoacidosis (DKA).
Accurate diagnosis dictates the treatment algorithm.
2
Evaluate the client's vital signs for immediate life threats.
A blood pressure of 84/4484/44 mm Hg and heart rate of 132132 beats/minute indicate severe hypovolemic shock secondary to massive osmotic diuresis.
ABC (Airway, Breathing, Circulation) prioritization requires addressing shock immediately.
3
Determine the optimal sequencing of pharmacological interventions.
Isotonic fluid resuscitation must precede insulin therapy.
Insulin shifts water and potassium intracellularly. Administering it before restoring vascular volume will acutely worsen the circulatory collapse.

Key Concept

Diabetic Ketoacidosis (DKA) Hemodynamic Prioritization
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Topics

Physiological Adaptation

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