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Brief Background: 24 y.o. non-English speaking man brought to ER 3 hours ago for change in L.O.C.

and
extreme weakness. Found to be in DKA.
Assessment Problem Statement Goals Actions Evaluation
Observations:
Thin, lethargic
young man, family says
hes confused, not
making sense.
Vomited x1
Skin warm, dry
Vital signs:
T 96.8, P 128, R 28
and labored, BP
102/48, %sat 100 on
RA
Examination:
Heart sounds
normal S1/S2, very
tachycardic, scant JVD
even when supine.
Pulses thread.
Breath sounds
clear
Abd. normal Bowel
sounds
PEERL, MAE,

Insufficient fluid
volume
RT
Prolonged
osmotic diuresis
AEB
HR, BP,
glucose 733,
BUN and
creatinine


Potassium
deficiency
RT
Prolonged
metabolic
acidosis
AEB
Serum HCO
3
-
10
Kussmal

W/in 1 hr
intake will exceed
output.
W/in 4 hr pulse
will be below 100,
BP syst. above 110







Serum K+ will
not 4.0 during fluid
resuscitation and
insulin admin..
Serum glucose
to fall no faster
than 70 mg/dL per
hour. (per protocol)
Collaborative actions:
Ringers
solution bolus and
maintenance fluids
as ordered.
NPO and
Zofran for now,
explain to family.
Independent actions
Explain to
pt/family that all
urine is to be
collected, for I&O

Collaborative actions:
Per order,
after 3 liters of
Ringers begin 10
mEq KCl and 10 mEq
KPO
4
-

Insulin bolus
now
Titrate insulin

At 0400
P 98, BP
108/58

@ 0400
patient is
plus 3000 ml

AAOx ? due to
language problems.
Labs:
Chemistries:
Na
+
133, K
+
4.0, Cl
-
109,
HCO
3
-
10, BUN 35,
Creatinine 1.9, Glucose
733
Heme:
Hgb 18, Hct 52, WBC
15,000, platelets
390,000
ABGs
PaO2 90, PaCO2 20, pH
7.26 %sat 100 on room
air.
UA: 4+ ketones
Diagnostics:
CXR: clear
EKG: Sinus tach, mixed
bag non-specific
changes..
Interview:
Unable to interview at
this time. Awaiting
certified Spanish-
breathing
pH 7.26












Inadequate
nutrition (whole
body and cellular)
RT
Nausea and
vomiting
Lack of insulin


















Serum PO
4
-
will
remain 3 mg/dL
during fluid
resuscitation and
insulin therapy
No further
episodes of emesis
during fluid
resuscitation and
insulin therapy.
Regular diet
drip per order
Hourly finger
sticks
Basic Metabolic
Panel q2h
Independent actions:
Monitor
respiratory rate and
depth q1h
Continuous
cardiac monitoring
Neuro checks
q4h and prn

Collaborative action:
Administer
phosphorous as
ordered
Serum
phosphorous level
(Complete
Metabolic Panel)
q12h
Independent action
Request
dietary consultation
English translator


































Knowledge
deficit
RT
new onset
diabetes
AEB
no when asked
if he has ever
been diabetic
within 24 hours
Patient and
family will give
nurse and dietician
typical daily food
intake w/in 24h


W/in 48 hours
patient will be able
to explain that DKA
is due to no insulin
W/in 24 hours
pt will state that
diabetes is a life-
time disease and
insulin does not
cure it.
W/in 24 hours
patient will do own
finger sticks and
demonstrated
insulin
administration
(and Spanish
translator)
Diabetic recipe
manual for family
Diabetic ap for
smart phone/tablet


Spanish
translator/diabetic
educator to discuss
with patient
complications of
DM.
(With
translator) show
carb counting with
every meal Mr. V.
gets.
Have patient
count carbs on
snack tray
Explain long
acting and short
acting insulin pens
to patient and
relate to diet/carbs
Information
packet, glucometer
prior to discharge
Case
manager/social
worker to discuss
access to testing
strips and insulin.

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