An emergency department nurse is managing a client admitted with severe diabetic ketoacidosis (DKA). The client is lethargic, with a blood pressure of 82/48 mm Hg, heart rate of 128 beats/minute, and Kussmaul respirations. Initial laboratory results reveal a blood glucose of 780 mg/dL (43.3 mmol/L), serum pH of 7.15, and serum potassium of 3.1 mEq/L (3.1 mmol/L). Arrange the following prescribed interventions in the correct chronological sequence of execution from first to last.
- 1Insert a large-bore intravenous catheter and administer a rapid bolus of 0.9% sodium chloride.
- 2Infuse an intravenous piggyback of potassium chloride.
- 3Initiate a continuous intravenous infusion of regular insulin.
- 4Add 5% dextrose to the continuous intravenous hydration fluids.
- 5Administer a prescribed dose of subcutaneous basal insulin.
Answer
The correct sequence is: Fluid resuscitation (0.9% NaCl), followed by Potassium replacement, then Intravenous Regular Insulin, later adding 5% Dextrose when glucose drops, and finally Subcutaneous Basal Insulin before discontinuing the drip.
The priority in DKA is always ABCs and perfusion; thus, isotonic fluid resuscitation is the first action for a client with severe hypotension. The critical secondary priority is electrolyte management. Because insulin drives potassium into cells, starting insulin with a baseline potassium of 3.1 mEq/L is highly dangerous. Potassium replacement must precede or accompany the insulin infusion. Once the client is hemodynamically stable and electrolytes are safe, insulin is initiated. As glucose approaches 250 mg/dL, dextrose is added to prevent hypoglycemia while allowing continuous insulin to resolve the acidosis. Finally, subcutaneous insulin is given prior to stopping the drip to maintain baseline glycemic control.
Step-by-Step Solution
Key Concept
Prioritization in Diabetic Ketoacidosis (DKA) Resuscitation