THE ROLE OF A NURSE IN TREATING A PATIENT WITH DIABETIC KETOACIDOSIS

To understand DKA, we first have to understand Ketones (Laffel, 1999). These are molecules, acidic that is formed when we burn fat to produce energy.

 As fat is broken down, this acidic molecules will build up in the blood and urine. When the particles are at high levels, dehydration also occurs, this will lead to Diabetic Ketoacidosis. The disease can also affect a person with high blood sugar levels, resulting in low insulin levels. The low insulin levels result in an upsurge of unused glucose in the body since insulin is responsible for the conversion of glucose into energy (Dong, 2017).

Signs and Symptoms;

  • High Blood Glucose levels.
  • Ketones (in blood and urine).
  • Confusion
  • I am tired, sluggish, or weak.
  • Nausea, vomiting, and abdominal pains.
  • She flushed hot, dry skin.
  • Blurred vision.
  • Rapid, deep breathing, and shortness of breath.
  • Excessive thirst and frequent urination.

Assessments

In general, the following are the assessment modes employed during diagnosis:

Observation/Inspection; This is where the physician uses sight to check for any disparities in the person’s physical appearance such as dry skin, irregular breathing, tiredness, sluggishness, or some form of body weakness. The physician will use optical aids to inspect the patient’s vision. Chest movements and breathing patterns can be looked at during this assessment model to check for issues in breathing.

Palpation; is a standard assessment mode where the sense of touch is used to check for any inflammations on the body. Tenderness of skin can be seen as a symptom for individual diseases, and with palpation, it can be identified during an exam. 

Percussion; In this kind of assessment, the sense of hearing is applied. The examiner will use their finger to tap parts of your body and listen for the sound produced. Depending on the music presented, the examiner can determine whether there is a buildup of fluid in your lungs by tapping your chest or whether there is a mass in your stomach by tapping your abdomen. This exercise will lead to a better further diagnosis.

Auscultation; Here, the examiner using a stethoscope listens to your heart, lungs, and neck. They look for changes in breathing and also changes in heartbeat count or frequency. It is a critical exam that states to explain the kind of peril at hand and the appropriate course of action. It is a handy tool in cases of unconsciousness where the patient is unable to speak.

The neurologic exam focuses on the nervous system, i.e., the cranial nerve, the motor functioning, sensory nerves, and the person’s reflexes.

  1. Cranial nerves

This test checks the performance of some of the twelve cranial nerves functions like the gag reflex.

  • Motor functioning

The primary focus will be on the person’s muscles, strength, and coordination.

  • Sensory functioning

Focus on the person’s sensory nervous response, their proprioception, and finally conduct a Romberg test. The sensory functioning test is usually subjective.

  • The reflex assessment test

The test’s objective is to look at the central nervous system (CNS); the focus will be on the spinal cord area and ensuring that it is perfectly poised.

This assessment methods can be used individually or concurrently depending on the severity of the condition stated. Hence clinical judgment should be used to determine the type of evaluation used for any given situation.

ASSESSMENT FOR A DKA PATIENT

Upon admission, an initial rapid assessment should be done by the attending nurse to check the extent of the patient’s damage. Physical examination is done whereby the pulse, heartbeat, and skin appearance is looked at. The ABC approach is commonly used to assess the patient (Judge, 2016); however, the clinician is keen to ensure life-threatening situations are addressed swiftly. 

Patient A: The patient is somniferous, but they can respond to the questions asked by the nurses. This means that the patients’ airways are patent and have enough circulation. Once any immediate threats to life such as difficulty in breathing, allergic reactions, significant injuries which we have determined can lead to DKA for a diabetes type I patient, a detailed test can be done which includes;

  • Checking the minimum heart rate
  • The minimum heart contraction rate
  • Oxygen concentration
  • Body temperature

The tests should be done in intervals of not more than twelve hours.

Patients experiencing severe episodes might quickly slump, so the nurses should use the track and trigger system. This will enable the clinical staff to know when the patients’ health is worsening.

The new version of the Early Warning Score can also be used to determine the extent of the illness affecting an individual patient. The nurses will focus on the patient’s vital scores, starting with the rate of respiration up to the AVPU response. The score gotten is assessed, and the nurses will then use their judgment to determine the severity of the patients’ illness. The EWS score can be calculated using the vital signs but should be used in combination with clinical experience.

On admission to the hospital, let’s say a Patient As’ vital signs have been recorded, and they record an EWS score of six. All the clinical staff is responsible for ensuring that they recalculate the score after every thirty minutes until the count drops to a four. This means that the nurse in charge, the doctor and consultant should be contacted for immediate review, as well as the critical outreach team. NICE clinical guidelines recommend that the frequency of calculation of a MEWS should be increased if abnormal physiology is recorded. Patient A has a MEWS of six. The work plan indicates that their MEWS should be recalculated every half an hour until it has decreased to below four.

Patients might show abnormal signs due to the presence of the following diseases hyperglycemia, ketonuria, and acidaemia. Hyperglycemia and ketonuria tests (Luethi, 2016) may be done using a finger prick test to determine the blood sugar levels and ketone levels. These tests should be done initially, and the results checked if the results show glucose levels more than 11mols/l or ketone levels of less than 3mols/l. This means that the patient might be suffering from diabetic ketoacidosis.

A ketone meter is usually used to determine the levels of ketone in a patient’s body. But the patients’ urine can also be applied using the dipstick test to test for ketonuria.

The test will look at the acetone and acetoacetic levels in the urine. An alkaline called nitroprusside combines with the acids to form a complex compound, which is usually purple. The intensity of the color will be contrasted with the colors on a pre-determined chart. If the chart results are more than two, this is an indication of diabetic ketoacidosis.

For the case of acidaemia, a blood sample must be taken from the patient. The preferred blood sample must be drawn from a vein. The test will aim at finding out the blood pH if the pH is less than seven points three. This is an indication that the patient has diabetic ketoacidosis.

Additional tests for DKA include;

The electrolyte tests;

 The test looks at the salts and mineral balances in your blood. The spices include sodium, potassium, and bicarbonates, which are responsible for the electrical impulses in our bodies.

A chest x-ray;

The x-ray result will show if there are any changes in the intra-alveolar pressure gradient on the patients’ lungs. Speaking this shows if there were signs of hyperventilation which is caused by diabetes ketoacidosis.

Al the tests mentioned above give a clear description of the patient’s metabolic profile.

CARE FOR ADMITTED PATIENTS

How the diabetic ketoacidosis patient is handled for the first time by the nurses is imperative and decides if the patient will heal at a faster rate or not (Barski, 2018). Patients with severe symptoms are usually placed in intensive care units. The nurses will first have to:

  • Inject some fluids containing sodium chloride via a vein to restore the circulating volume of the blood. This is because some of the symptoms of DKA include dehydration and frequent urine loss.
  • Injection of artificial insulin;

The artificial insulin will reduce the concentration of blood sugar that may be present in the patient’s body. This will also correct the acidosis levels resulting in a reduction in the ketones level.

  • Giving the patient potassium supplements

Potassium supplements will help prevent the accumulation of ketones in the patients’ body

Fluid loss treatment;

A DKA patient loses typically about six to nine liters of fluids, and the therapy is aimed at replacing the fluids’ losses in about 24 hours. And includes administering the patient with 0.9 percent sodium chloride for the first eight to twelve hours depending on how the patients’ blood is flowing. Afterward, the patient is administered with about 0.45 percent based on the present sodium concentration.

Insulin treatment;

For better results, the nurses will infuse the insulin through the patient’s veins, and the insulin will utilize all the available glucose by converting it into energy or storing it as fat under the skin. This will also reduce the glycogenolysis process, which is responsible for the conversion of glycogen into glucose.

Levels of insulin infusion into the patient’s body can be done in two ways an earlier way, which includes giving the patient around six units of insulin after every hour. But if there are no significant changes in blood sugar levels, the amount can be increased to ten units per hour.

The other more modern method is to administer the insulin according to a pre-determined way. The purpose of intravenous insulin administration depends on the nurse’s judgments.

Electrolyte or potassium treatment

The use of potassium supplements aids in reducing academia by increasing the phosphate concentration in the blood. If insulin levels affect the potassium levels, it may lead to arrhythmias, which results in giving the patient a cardiac arrest. It is, therefore, necessary for the nurses to look at the insulin levels while keeping a keen eye on the potassium levels in the blood.

If the patient is out of danger, they might still need insulin injections to live a healthy life. It is up to the nurse to teach the patient and their families on how to infuse the artificial insulin into their blood system without harming their bodies.

CONCLUSION

Diabetic ketoacidosis is a type of diabetes disease that occurs when the human body produces too much glucose and other molecular acids called ketones. Just like most diabetic diseases, patients usually have low insulin and electrolyte levels in the blood.

 The disease might end a patient’s life if it is not handled correctly and fast.

The medical staff and nurses who are assigned to patients with the disease must have the technical know-how on how to help the patient from conducting the necessary tests that show if a patient might have the condition.Managing a patient who has the disease be it administering the required insulin dosage to balancing the electrolytes.

A report shows that about four percent of adults worldwide die from the disease although the number is small it is up to the nurses to ensure that they follow all the treatment methods mentioned above to save the lives of people.

Reference

Laffel, L., 1999. Ketone bodies: a review of physiology, pathophysiology, and application of monitoring to diabetes. Diabetes/metabolism research and surveys15(6), pp.412-426.

Dong, B., Qiao, L., Yahong, L.I., and Zhang, J., 2017. Analysis of the value of using real-time dynamic blood sugar monitoring during the insulin pump treatment process in ICU patients. Chongqing Medicine46(31), pp.4370-4372.

Judge, R., 2020. 1304: ASSESSMENT OF A NURSE-DRIVEN DIABETIC KETOACIDOSIS MANAGEMENT PROTOCOL AT A SMALL COMMUNITY HOSPITAL. Read Online: Critical Care Medicine| Society of Critical Care Medicine48(1), p.629.

Luethi, N., Cioccari, L., Crisman, M., Bellomo, R., Eastwood, G.M., and Mårtensson, J., 2016. Prevalence of ketosis, ketonuria, and ketoacidosis during liberal glycemic control in critically ill patients with diabetes: an observational study: critical Care20(1), p.297.

Barski, L., Sagy, I., Golan, Y.B.B. and Almog, Y., 2018. Optimal Management Site of Hospitalization for Patients with Diabetic Ketoacidosis. Current Research in Diabetes & Obesity Journal5(3), pp.1-4.

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