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Difficulty: Very hardReduction of Risk Potential

A critically ill adult client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The initial laboratory results indicate a blood glucose level of 715 mg/dL715\text{ mg/dL}, an arterial pH of 7.127.12, and a serum potassium level of 3.1 mEq/L3.1\text{ mEq/L}. To reduce the risk of fatal complications during treatment, arrange the following collaborative interventions in the safest chronological order from first to last.

  1. 1Initiate a rapid intravenous infusion of 0.9%0.9\% sodium chloride.
  2. 2Administer a prescribed intravenous potassium chloride infusion.
  3. 3Start a continuous intravenous infusion of regular insulin.
  4. 4Add 5%5\% dextrose to the intravenous maintenance fluids.
  5. 5Administer a scheduled dose of subcutaneous basal insulin.

Answer

The correct sequence is to first initiate intravenous fluid resuscitation, followed by intravenous potassium chloride, then continuous intravenous regular insulin, followed by adding dextrose to the fluids, and finally administering subcutaneous basal insulin.
The prioritization of DKA management centers on mitigating life-threatening physiological decompensation. First, the profound osmotic diuresis caused by severe hyperglycemia leads to hypovolemic shock; therefore, restoring intravascular volume with isotonic fluid (0.9%0.9\% sodium chloride) is the paramount initial action. Second, while insulin is the definitive treatment for DKA, this client has a critically low serum potassium of 3.1 mEq/L3.1\text{ mEq/L}. Insulin drives potassium into the intracellular space. Administering insulin before correcting the hypokalemia would cause a precipitous drop in serum potassium, placing the client at imminent risk for fatal ventricular arrhythmias. Thus, intravenous potassium chloride must be infused prior to initiating insulin. Third, once potassium reaches ≥3.3 mEq/L\ge 3.3\text{ mEq/L}, a continuous intravenous insulin infusion is started to halt ketogenesis. Fourth, as blood glucose levels drop to approximately 250 mg/dL250\text{ mg/dL}, 5%5\% dextrose is added to the maintenance fluids to prevent hypoglycemia and subsequent cerebral edema. Finally, once the anion gap has closed and DKA is resolved, subcutaneous basal insulin is administered. The intravenous insulin is continued for 11 to 22 hours post-subcutaneous injection to prevent rebound ketoacidosis.

Step-by-Step Solution

1
Analyze the client's laboratory values and physiological state.
The client is in severe DKA with critical hypokalemia (3.1 mEq/L3.1\text{ mEq/L}).
Identifying life-threatening abnormalities determines the priority of interventions.
2
Determine the priority of initial medical management.
Isotonic fluid resuscitation is the immediate priority.
DKA causes profound osmotic diuresis leading to hypovolemic shock. Restoring perfusion prevents cardiovascular collapse.
3
Evaluate the safety of initiating insulin therapy.
Insulin must be held until the serum potassium is replaced.
Insulin rapidly drives potassium into cells. Administering insulin when serum potassium is <3.3 mEq/L< 3.3\text{ mEq/L} causes fatal hypokalemia and arrhythmias.
4
Sequence the remaining interventions as the client's condition stabilizes.
Insulin is started, followed by adding dextrose when glucose falls, and finally overlapping with subcutaneous insulin.
Dextrose prevents cerebral edema, and overlapping insulin prevents rebound ketoacidosis.

Key Concept

Reduction of Risk Potential: DKA Protocol Sequencing
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Topics

Reduction of Risk Potential

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