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Zorluk: Çok zorPharmacological and Parenteral Therapies

A nurse is caring for a client with diabetic ketoacidosis (DKA) who is receiving a continuous intravenous (IV) infusion of regular insulin at 0.1 units/kg/hr0.1\text{ units/kg/hr}. The client's most recent laboratory results reveal a blood glucose of 215 mg/dL215\text{ mg/dL} (11.9 mmol/L11.9\text{ mmol/L}), a serum potassium of 3.1 mEq/L3.1\text{ mEq/L} (3.1 mmol/L3.1\text{ mmol/L}), and an anion gap of 18 mEq/L18\text{ mEq/L}. The current maintenance IV fluid is 0.45%0.45\% sodium chloride infusing at 150 mL/hr150\text{ mL/hr}. Which of the following is the priority nursing action?

  1. Pause the regular insulin infusion and request an immediate prescription for intravenous potassium replacement.Cevap
  2. B
    Change the maintenance IV fluid to include 5%5\% dextrose and maintain the current regular insulin infusion rate.
  3. C
    Continue the regular insulin infusion and administer a prescribed intravenous bolus of sodium bicarbonate.
  4. D
    Discontinue the continuous intravenous insulin and administer a prescribed dose of subcutaneous regular insulin.

Cevap

The priority action is to pause the regular insulin infusion and request an immediate prescription for intravenous potassium replacement.
The correct action is to pause the insulin infusion and replace potassium. Regular insulin causes an intracellular shift of potassium, rapidly depleting serum levels. In DKA protocols, if the serum potassium falls below 3.3 mEq/L3.3\text{ mEq/L} (3.3 mmol/L3.3\text{ mmol/L}), continuous IV insulin must be withheld immediately, and intravenous potassium must be administered to prevent life-threatening cardiac dysrhythmias.

Adım Adım Çözüm

1
Analyze the client's potassium level in relation to the pharmacological effects of the insulin infusion.
The serum potassium is 3.1 mEq/L3.1\text{ mEq/L} (3.1 mmol/L3.1\text{ mmol/L}), which is critically low (hypokalemia).
Intravenous insulin drives potassium into the intracellular space. Continuing the infusion will further lower serum potassium levels and can precipitate fatal cardiac dysrhythmias.
2
Evaluate the blood glucose level and ongoing fluid management requirements.
The blood glucose is 215 mg/dL215\text{ mg/dL} (11.9 mmol/L11.9\text{ mmol/L}), crossing the typical threshold (<250 mg/dL< 250\text{ mg/dL}) that indicates the need to add dextrose to IV fluids.
Adding dextrose prevents hypoglycemia while allowing insulin to continue clearing ketones, but this intervention is secondary to addressing an immediate risk of cardiac arrest.
3
Assess the anion gap to determine the resolution status of the diabetic ketoacidosis.
The anion gap is 18 mEq/L18\text{ mEq/L}.
A normal anion gap is 8−12 mEq/L8-12\text{ mEq/L}. An elevated gap means ketoacidosis is ongoing, signifying that IV insulin therapy must eventually be resumed once potassium is stabilized.
4
Prioritize the nursing interventions based on immediate physiological threats.
Holding the insulin infusion and replacing potassium is the most critical immediate action.
According to the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy of needs, preventing a lethal cardiac arrhythmia (Circulation) takes strict precedence over managing blood glucose levels or correcting metabolic acidosis.

Anahtar Kavram

Safe administration of intravenous insulin in DKA requires continuous monitoring of serum potassium; insulin must be held if potassium falls below 3.3 mEq/L to prevent fatal arrhythmias.
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Pharmacological and Parenteral Therapies

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