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Difficulty: HardPhysiological Adaptation

A client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client is lethargic and exhibiting deep, rapid Kussmaul respirations. The initial capillary blood glucose is 650650 mg/dL (36.136.1 mmol/L). The healthcare provider has entered multiple collaborative prescriptions.

Arrange the following collaborative and nursing interventions in the correct chronological order of implementation for this client. (Place the first priority action at the top and the final action at the bottom.)

  1. 1Establish intravenous access and begin a rapid infusion of 0.9% sodium chloride.
  2. 2Obtain a STAT serum potassium level.
  3. 3Initiate a continuous intravenous infusion of regular insulin.
  4. 4Add 5% dextrose to the continuous intravenous fluid infusion.
  5. 5Transition the client to scheduled subcutaneous insulin injections.

Answer

The correct sequence begins with fluid resuscitation, followed by verifying the potassium level, initiating continuous IV regular insulin, adding 5% dextrose when glucose drops below 250 mg/dL, and finally transitioning to subcutaneous insulin.
The precise sequencing of interventions in DKA is critical to prevent fatal complications. Fluid resuscitation must occur first to reverse hypovolemic shock. Potassium levels must be verified next because insulin therapy causes a rapid intracellular shift of potassium, risking lethal dysrhythmias. Once potassium is confirmed safe, IV regular insulin is initiated to halt ketogenesis. As glucose levels fall to approximately 250250 mg/dL, dextrose is added to the IV fluids to prevent hypoglycemia. Finally, once ketoacidosis has fully resolved, the client is transitioned to subcutaneous insulin.

Step-by-Step Solution

1
Prioritize fluid resuscitation
Intravenous access is established and 0.9% sodium chloride is rapidly infused.
Clients with DKA experience profound osmotic diuresis, leading to severe hypovolemia. Restoring intravascular volume is the absolute first priority to maintain perfusion to vital organs.
2
Verify serum potassium
A STAT potassium level is obtained.
Insulin administration forces potassium back into the cells. If the client is already hypokalemic, insulin can trigger life-threatening dysrhythmias. Potassium must be known before insulin is started.
3
Administer regular insulin IV
A continuous regular insulin infusion is started.
Insulin is required to stop lipolysis, halt ketone production, and slowly lower the blood glucose levels.
4
Prevent hypoglycemia
5% dextrose is added to the IV fluids.
When blood glucose reaches approximately 250250 mg/dL, dextrose is added to prevent hypoglycemia and cerebral edema, allowing the insulin drip to continue until the anion gap closes.
5
Transition to maintenance therapy
Subcutaneous insulin is initiated.
Once the acidosis resolves and the client can eat, subcutaneous insulin is administered. The IV insulin is typically overlapped with the first subcutaneous dose for 1 to 2 hours.

Key Concept

Prioritization in Diabetic Ketoacidosis (DKA) Management
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Topics

Physiological Adaptation

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