A Reflective Approach to Diabetic Ketoacidosis Management

Introduction

The essay will use a reflective approach to assess a 50-year-old male patient named Mr Bull presenting the symptoms of pain in the abdomen, nausea, tachycardia and dehydration. The patient had a past medical history of type 2 diabetes mellitus (T2DM). The patient was found in an altered mental state and was diagnosed with Diabetic Ketoacidosis (DKA). An exploration of the interventions of nursing for an acutely ill patient with complex health needs will be discussed and the step by step approach for clinical diagnosis, assessment, evaluation and implementation will be used to offer a holistic patient-centred care approach to the patient. The detailed pathophysiology of the disease condition will be discussed to understand the past and present status of the patient and for the proper management and formulation of the future care plan for the patient.

There is a lot of significance of the evidence and experience in the field of nursing and healthcare. Combination of all these aspects helps the nurses to formulate a reflective case study and also to evaluate their professional skills. The term reflection is very essential in the field of nursing as it is a method of experienced-based investigation and explains the alternative approaches. Therefore, the study aims to evaluate critically the care plan formulated for the patient under my guidance using the principles of the theory of nursing and the current pieces of evidence. Moreover, as an adult nursing student, I value reflection as a tool to evaluate my professional skills.

The rationale of the care plan to manage the complex health conditions of the patient and also the improvement observed in the leadership skills will be highlighted in the reflective practice of the essay. The opinion of the patient will be constantly monitored to evaluate the care plan that had been adopted. The importance of communication skills with the other professionals in health care will also be discussed.

As per the reports of Global Diabetes Community 2019, the number of individuals diagnosed with diabetes in the United Kingdom was approximately 3.5 million. The data indicated that the total numbers of individuals living with the condition of diabetes in the UK which includes both the diagnosed and undiagnosed were above 4 million. This data represented approximately 6% of the population of the UK or 1 out of 16 people. The data also suggested that about 56% of the men and 44% of the women suffered from diabetes in the UK. The overall data of the world stated that about 415 million people were suffering from diabetes which represented about 1 out of 11 of the adult population. Approximately 46% of the population living with diabetes were undiagnosed. It was predicted that the figure was expected to rise to 642 million people by the end of 2040. The prevalence of the T2D is considered to be the most prevalent one in the UK as it accounted for about 90% of the total diabetic cases and only 10% of the cases are due to type1diabetes. According to the report of the International Diabetic Federation, T2D cases are rising constantly among most of the countries (Shaw, et al, 2010; Ohlson, et al, 1988).

The primary classification of diabetes includes the following two types: type 1 and type 2 diabetes (T2D). The rate of incidence of T2D can be observed among 90 -95% of cases and it occurs due to the consistent lower insulin production or due to the resistance developed against insulin. Type 2 diabetes is common among adults and also among the youths who are obese and are part of a certain ethnic group. The risk of developing T2D is also because of the family genes but the exact factors are not clear. The risk also increases with age, sedentary lifestyle of the patient and obesity. The T2D is most often observed among the people with hypertension, high cholesterol level, women suffering from the gestational diabetic mellitus (GDM). Therefore the disease is considered to be a multifactorial disease which involves multiple genes and a wide range of environmental factors. The pathophysiology of the type 2 diabetes includes the following conditions such as the peripheral insulin resistance, the damaged regulation of the glucose production by the hepatocytes, reduced function of the β cells which ultimately leads to the failure of the cells (American Diabetes Association, 2016). The condition of the diabetic ketoacidosis (DKA) is more associated with type 1 diabetes and less commonly with type 2 diabetes. In the condition of DKA, the blood sugar level becomes very high and this leads to the development of high acidic substances known as ketones which reaches a dangerous level within our body though it takes a long time to reach that level. Though the condition of ketoacidosis is less commonly associated with type 2 diabetes but with age a similar condition may develop called HHNS (hyperosmolar hyperglycemic nonketotic syndrome) which results in severe dehydration. The blood ketones level of the patient should be checked with the blood sugar level higher than 240 mg/dL along with the associated symptoms such as drying of the mouth, feeling thirsty and with urinating more often than normal. Following symptoms of the patients should be immediately reported to the clinicians such as feeling queasy or abdominal pain, fruity smell of the breath if the patient is too tired or fatigued and in a confused mental state and if the patient feels difficulties during breathing. The condition of DKA is associated with the rise in the level of hormones regulatory in nature such as catecholamines, glucagon, cortisol and growth hormones which leads to the development of the associated conditions of dehydration, acidosis and disturbances in the electrolyte balance (Kerl, 2001).

Case study:

Mr Bull was a 50 years old man with a history of type 2 diabetes mellitus (T2DM) reached the hospital with the symptoms of abdominal pain, nausea, tachycardia and dehydration. He was alert, disorientated with mild altered mental state and was diagnosed with diabetic ketoacidosis (DKA).

The social life of the patient highlighted that he lived alone and had a habit of smoking. He used to smoke about 1 ½ packet of cigarette every day and was an occasional drinker. He used to consume about 4 pints a week. The patient had recently gone through a tough patch of life as he got separated from his partner of 9 years and therefore could not accept the situation and therefore he resorted to drinking as a coping mechanism.

The past medical history of the patient revealed that Mr Bull was suffering from the condition of type 2 diabetes mellitus (T2DM) for the past seven years and had managed his condition with the use of antidiabetic drug metformin hydrochloride of dosage twice daily. The stressful phase of the relationship moved him into the state of depression and eventually resulted in the increased uptake of alcohol. He equally skipped his medicine metformin as he was not sure when last he took them. He was also reported to suffer from hypertension. The other medications that he used to consume were Bisoprolol, Citalopram.

The initial findings of the patient on the investigation were:

Respiratory rate: 24bpm

Pulse: 122bpm

BP: 148/90 mmHg

Temperature: 38.2

Oxygen saturation: 92%

Capillary glucose 28 mmol/dl

Arterial blood gas with pH: 7.12

pCO2: 17 mmHg

Bicarbonate: 5.6 mEq/l

The analysis of urine of the patient revealed 4+ glucose and 3+ ketones.

Blood glucose level: 420 mg/dl

BUN: 16 mg/dl

Creatinine: 1.3 mg/dl

Sodium: 139 mEq/l

Chloride: 112 mEq/l

CO2: 11.2 mmol/l

Potassium: 5.0 mEq/l

Confirmed Findings of the Patient:

Diabetic ketoacidosis is defined as the condition with the plasma glucose level >250 mg/dl, the level of plasma bicarbonate was <15 mEq/l, elevated anion gap and ketonemia. The pH was <7.35. Therefore, the patient meets the criteria of diabetic ketoacidosis with the blood glucose level of 420 mg/dl, the CO2 level of 11.2 mmol/l; pH in the range of 7.12 and anion gap of 15.8, with obvious signs of ketonemia.

Airway Assessment:

The immediate step that was taken after the admission of the patient was the utilization of ABCDE approach which is generally applied for the critical assessment of the critically ill or injured patients (Resuscitation council, 2011). The necessary interventions should be taken into consideration for the life-threatening issues that could eventually result in death or disability if not treated or detected early. The importance of the assessment is to monitor the vital signs of the patient and an appropriate meaningful assessment should be carried on with an electronic device (Clarke and Ketchell, 2011). The method of airway assessment was carried out to assess any obstruction in the airway. The abdomen and the chest of the patient were assessed for any kind of movement, to listen and observe any sounds of airflow by keeping the hands around the nose and mouth of the patient and it was done to rule out any obstruction (Clarke and Ketchell 2011; Resuscitation council, 2011).

After the airway assessment, the patient was assessed by the physical assessment approach. The head of Mr Bull was tilted in a way to open the passage of the airway. This process was carried out for proper ventilation as obstruction can be lethal within a few minutes. When the process was performed a foreign substance along with a bubbling noise was heard which indicated about an obstruction. Thereafter a suction pressure was utilized for the removal of the foreign object and precautions were taken that no more harm should be done by pushing the objects further (Bush and Ray, 2015). The condition of the airway obstruction is always considered as an emergency situation and the application of suction approach prevents the forcing out of contents of the gastrointestinal tract that would block the respiratory system and result in blockage because of the infection in the respiratory pathway (Overend et al., 2009). Mr Bull reported that he was feeling nausea for a long time and that was taken as an indication of the threat to the airway passage. Previous studies had revealed that the excess breakdown of stored fats resulted in the production of ketones and due to the struggle to release the stored form of energy, the tendency of nausea and vomiting appeared among the individuals with the type 2 diabetes.

Assessment of Breathing:

The listen and feel approach (LLF) was applied to check the respiration of the patient. The respiration was assessed for 60 minutes along with the depth, equal movement of the chest on both sides and rhythm of the patient (Resuscitation Council, 2011). Mr Bull was showing the symptoms of tachycardia, so fast laboured and deep breathing also known as Kussmaul respiration was observed. The phenomenon was observed due to the formation of carbonic acid because of the disproportionate build-up of the carbon dioxide gas (Singhi et al., 2011; Adrogué and Madias, 2010). The respiratory rate was observed as 24bpm indicating the condition of tachypnoeic as the normal rate of respiration among the adults is between 12 -20 bpm (Berman et al., 2010). According to the guidelines of my service, I informed my mentor about the condition of the patient and utilized the red code template for the documentation of the happenings so that it can be easily accessible by all the other professionals. The red code system is considered to be a speedy system of response applied in the hospital settings to prevent any unnecessary complications related to a complicated case or death of the patient (Navarro and Castillo, 2010). Mr Bull did not require the use of oxygen as the saturation rate was 92%. Moreover, the patient was constantly monitored for the respiration rate and the saturation of the oxygen level after every 30 minutes as the rate of the oxygen fluctuated within 92% to 95% and any new changes were constantly reported to the senior staff nurse. The patient was observed at regular intervals because any further complications or alterations can be detected with constant monitoring (Jevon et al., 2012).

Circulation:

The listen and feel approach (LLF) was applied to check the pulse rate of Mr Bull and for the assessment of strength, elasticity and rhythm (Resuscitation Council, 2011). The rhythm of the patient was found to be irregular and it was easy to identify. The patient showed the signs of tachycardia with 122 beats per minute. The condition of the patient was confirmed on a twelve lead ECG. The report findings of the patient highlighted about sinus tachycardia, the P wave was present and upright and a QRS complex preceding which also indicated that the pacemaker originated from the sinus node with an artrial beat of 100 every minute. The condition was recorded in the documentation and the clinicians were informed regarding the situation (Hilliard, et al, 2016). The significance of ECG confirmed the other findings of the other investigations and raised the red flags and this approach also ruled out the condition of the inappropriate management of the patient (NICE, 2016).

The reported capillary refill time (CRT) of Mr Bull was recorded to be 5 seconds which indicated the condition of shock and dehydration. This was carried out as the patient-reported about the feelings of nausea and dehydration along with a further increase in the CRT and the respiratory rate. Therefore, the condition of dehydration was confirmed for the patient (Rushing, 2009). The particular condition was informed to the senior staff nurse who cannulated the patient for the administration of the fluids. The blood pressure of Mr Bull was reported to be 148/90 mmHg which was reported to be normal according to his age, but it was monitored at regular intervals of 30 minutes. It was observed that there was a drop in the BP of the patient with the systolic pressure in the range of 75mmHg and the diastolic pressure of 52mmHg. The condition of the patient was immediately reported to the senior nurse who instructed me to call the on-call physician for the particular ward and the pharmacist for the administration of the fluids to the patient. After the following the above instruction, I waited for the physician to attend the patient and in the mean time I recorded all the happenings regarding the severe condition of the patient and the action taken in response to that using the red code template. In the beginning, Mr Bull scored 6 with 1 for the temperature, 2 for respiration, 3 for the heart rate. A sudden drop in the BP as per the National Early Warning Score (NEWS) which increased 2 to 8 indicated the need for escalation immediately. The NEWS was utilised for the standardization of the scores and the management of diseases based on the degree of the severity (Royal College of Physicians, 2012). The application of the Situation Background Assessment and Recommendation approach (SBAR) which is a tool used for detailed communication was applied to handover the patient in the current situation along with the results of the investigation conducted to the doctor. This tool provides the details for sending important messages. After the handing over of all the relevant information related to the patient, i.e., the clinical manifestations of the patient, his current prescriptions, the administered dosage and date of the medications, I also informed that the patient was suspected with DKA based on the clinical findings of the patient. The physician requested to have a conversation with my mentor and suggested the application of fluid replacement therapy and the collection of blood for further diagnosis and investigation. After getting the instruction from the doctor, the ward sisters were informed of the collection of blood. My leadership and management skills were elaborated with the way of handing over the responsibility to a healthcare assistant (HCA) whose duty was to collect the blood to the pathology unit. The aspect of the delegation is considered to be an important initiative in the field of nursing as it involves the procedures for the transfer of task by a competent individual to a selected individual and providing them the authority to be a part of the given situation (NMC, 2016). By adopting the process of delegation, the condition of the patient was alleviated before as anticipated due to the often monitoring of the condition of the patient at regular intervals. Therefore, leadership demands the skill of delegation and with the process, confidence can be gained (Kærnested and Bragadóttir, 2012). Due to acquired confidence about the capability of the person, I did not hesitate to delegate that task to the concerned HCA as he was there in the organisation for the past few years and was aware of the consequences of any delay or effects in his duty. Therefore, another important part of delegation is the choice of the right person for handing over the task because a wrong choice of the person can threaten the risk of the life and condition of the patient.

After admission the patient, Mr Bull was found to be in the state of mental alertness though slightly altered or disoriented. The condition might be attributed to the high blood sugar level of the patient. The assessment of the condition level of the patient was done using the Alert, Verbal, Pain, Unresponsive (AVPU). The patient responded to voice and obeyed some of the commands; the pain response was assessed using the trapezius squeeze. There are some conditions where the pain response should be assessed using a more elaborative approach such as with the application of trapezius squeeze instead of just shaking or shouting (Lower, 2010). The altered mental state of the patient was assessed using the Glasgow Coma Score (GCS), which is a detailed assessment tool, as I was concerned about the mental state of the patient (Resuscitation Council, 2011). Initially, the assessment was performed after regular intervals of 30 minutes to monitor the mental state of the patients (NICE, 2014). The evaluation of GCS was necessary for the airway patency. The complying of the patient to the pain technique was assessed using the eye-opening and verbal response and the patient scored around 3 or 4. By squeezing the trapezius muscle a score of 5 was obtained as a response to pain. The pupils of both the eye of the patient were found to be normal, reacted equally and obtained a score of 12. The monitoring or observations of the patient was conducted after every 30 minutes, and it continued till the 15/15 mark was achieved within a span of 4 hours after which the monitoring span was altered to 24 hours. The approach of ABCDE was repeated after the GCS score to repeatedly assess the condition of the patient.

Exposure:

The temperature of the patient was found to be 38.2 which ruled out the signs of any infection or sepsis. However, the temperature was routinely observed after every hour to monitor any deterioration. The early diagnosis of the condition of DKA is necessary as it leads to the development of acidosis resulting in hypoxia and hypothermia (Rose and Clarke, 2010; Faulds and Meekings, 2013; Gosmanov et al., 2014). Intravenous paracetamol was administered to the patient to manage the pain as per the prescription of the doctor. After the administration, the pain score of the patient dropped down from 6 to 2. The pain assessment of the patient is included within a holistic approach as it influences the judgement of the clinicians. The fluid balance chart every hour, the observation at regular intervals of 30 to 60 minutes and the GCS charts were all recorded to ease the communication procedures. Therefore, documentation is considered to be an important tool in the field of nursing to explain the rationale and also as a means of communication among the multidisciplinary team.

Communication:

According to JBDS, 2010 the diabetic team should be contacted within an hour of the admission, and also to assess the condition of the patient after the 24 hours of admission. My patient, Mr Bull requires the service of the multidisciplinary team involving the diabetic team and a dietitian as he was diabetic. The patient was referred to the team for proper review and follow up. The patient had recently undergone a stressful phase in his relationship due to which the blood glucose level had increased (Hilliard et al., 2016); after that, a follow-up assessment schedule was also fixed to monitor any event of a recurrence. The dietitian also educated the patient about the harmful consequences of skipping meals. The patient was administered with metformin to control the blood sugar level and a healthy diet at a proper time. The patient was also advised to be disciplined to take the medications at the right time so that the recurrences could be prevented. The patient reported no more pain in the abdomen though he was advised to inform about any discomfort in the abdomen as it might indicate about any underlying cause.

Plan of care:

The first line of treatment for DKA patients is the replacement of fluid and insulin for appropriate monitoring of the blood glucose level. The patient was catheterized as because he was unconsciously passing urine due to the disoriented mental state. I informed my senior staff nurse and she also agreed with my point of view. Therefore, I assembled my trolley, catheterized and took a sample of urine for the laboratory testing of the glucose and ketones level and showed ++++ presence. After consulting with the physician, he suggested commencing fluid replacement therapy.

Fluid replacement therapy:

My patient reported severe dehydration, and the amount of fluids replaced depends upon the degree of dehydration (Kanaka-Gantenbein et al, 2013). 1 litre of 0.9% of normal saline was administered for an hour and due to the condition of DKA, 0.9% potassium chloride was administered for the next two hours. The therapy was continued for the next 4 to 6 hours. The fluids administered were recorded in the documentation and the skin of the patient was monitored for the sign of oedema due to fluid overload.

Interpretation of the blood results:

The arterial blood gas (ABG) is carried for critically ill patients to determine the risk of the patient for the management of oxygenation and the acid-base balance (Sood et al., 2010). The normal value of ABG ranges between 7.35-7.45. The ABG result of my patient was 7.12 signifying the low value of pCO2 and low value of HCO3 indicated metabolic acidosis. The increased excretion of CO2 returns the pH to the normal level by the reduction of acidity. If the level of the ketones of the blood is lower than 0.6mmol/L then it is considered to be normal, but the higher level of ketones indicates about the burning of fat and conversion into energy (Dhatariya, 2016). The normal range of potassium is within 3.5 - 5 mEq/L (Usman, 2018). The potassium level of my patient was 5 mEq/L so it was not taken into consideration. For patients with DKA, continuous monitoring of the potassium level is necessary to investigate the cause of hypokalaemia (Liamis, 2014). The osmolarity level of the serum increases during hyperglycaemia. Due to the fact, the water moves out of the cell and the sodium levels drop resulting in nausea or vomiting. A similar condition was observed in the case of Mr Bull. The patient reported about abdominal pain which is a typical symptom of DKA, ultrasonography was conducted which did not identify anything (Van de Vyver et al., 2017).

The feelings of the patient:

The feeling of the patient was hard to demonstrate as after gaining stabilization, the patient was showing harsh mood which might be due to the stressful phase in the relationship with his partner. Based on his interpretation, it was felt necessary to educate the patient about the consequences of type 2 diabetes and DKA. The plan of treatment was communicated and as per advice, the MDT educated the patient about the disease and its complications.

Conclusion:

Therefore, it can be concluded that leadership is a fundamental tool in nursing and this allows the professionals in the decision-making process (Ledlow and Coppola, 2014). Therefore, during nursing education, nurses should be allowed to learn about leadership skills (Middleton, 2011). Though I was very much tensed and anxious about my performance, but I performed well and up to the requirements. I also need to improve my skills on communication as throughout the task I had minimal interaction with the patient. This particular experience has enhanced my confidence levels (Pike and O’Donnell, 2010).

References:

Shaw, J.E., Sicree, R.A. and Zimmet, P.Z., 2010. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes research and clinical practice, 87(1), pp.4-14.

Ohlson, L.O., Larsson, B., Björntorp, P., Eriksson, H., Svärdsudd, K., Welin, L., Tibblin, G. and Wilhelmsen, L., 1988. Risk factors for type 2 (non-insulin-dependent) diabetes mellitus.

Thirteen and one-half years of follow-up of the participants in a study of Swedish men born in 1913. Diabetologia, 31(11), pp.798-805.

American Diabetes Association, 2016. Erratum. Classification and diagnosis of diabetes. Sec. 2. In standards of Medical Care in Diabetes-2016. Diabetes Care 2016; 39 (Suppl. 1): S13-S22. Diabetes care, 39(9), p.1653.

Kerl, M.E., 2001. Diabetic ketoacidosis: pathophysiology and clinical and laboratory presentation. Compendium, 23(3), pp.220-228.

Resuscitation Council UK, 2011. Advanced Life Support, 6e. Resuscitation Council UK, London.

Clarke DKetchell, A., 2011. Nursing the Acutely Ill Adult.

Bush, S. and Ray, D., 2015. Basic airway management. Emergency Airway Management, p.20.

Overend, T.J., Anderson, C.M., Brooks, D., Cicutto, L., Keim, M., McAuslan, D. and Nonoyama, M., 2009. Updating the evidence base for suctioning adult patients: A systematic review. Canadian respiratory journal, 16(3), pp.e6-e17.

Singhi, S.C., Mathew, J.L. and Jindal, A., 2011. Clinical pearls in respiratory diseases. The Indian Journal of Pediatrics, 78(5), pp.603-608.

Adrogué, H.J. and Madias, N.E., 2010. Secondary responses to altered acid-base status: the rules of engagement. Journal of the American Society of Nephrology, 21(6), pp.920-923.

Berman, A., Snyder, S.J., Kozier, B., Erb, G.L., Levett-Jones, T., Dwyer, T., Hales, M., Harvey, N., Moxham, L., Park, T. and Parker, B., 2014. Kozier & Erb's Fundamentals of Nursing Australian Edition (Vol. 3). Pearson Higher Education AU.

Navarro, J.R. and Castillo, V.P., 2010. The Red Code, an example of a rapid response system. Revista Colombiana de Anestesiología, 38(1), pp.86-99.

Jevon, P. and Ewens, B., 2012. Monitoring the critically ill patient. John Wiley & Sons.

Hilliard, M.E., Joyce, P., Hessler, D., Butler, A.M., Anderson, B.J. and Jaser, S., 2016. Stress and A1c among people with diabetes across the lifespan. Current diabetes reports, 16(8), p.67.

Kærnested, B. and Bragadóttir, H., 2012. Delegation of registered nurses revisited: Attitudes towards delegation and preparedness to delegate effectively. Vård i Norden, 32(1), pp.10-15.

Lower, J., 2010. Using pain to assess neurologic response. Nursing2020 Critical Care, 5(4), pp.11-12.

NICE, 2014. Overview | Head injury: assessment and early management | Guidance | NICE. [online] Available at: https://www.nice.org.uk/Guidance/CG176 [Accessed 21 Mar. 2019].

Rose, L. and Clarke, S.P., 2010. Vital signs. AJN The American Journal of Nursing, 110(5), p.11.

Faulds, M. and Meekings, T., 2013. Temperature management in critically ill patients. Continuing Education in Anaesthesia, Critical Care & Pain, 13(3), pp.75-79.

Gosmanov, A.R., Gosmanova, E.O. and Dillard-Cannon, E., 2014. Management of adult diabetic ketoacidosis. Diabetes, metabolic syndrome and obesity: targets and therapy, 7, p.255.

Hilliard, M.E., Joyce, P., Hessler, D., Butler, A.M., Anderson, B.J. and Jaser, S., 2016. Stress and A1c among people with diabetes across the lifespan. Current diabetes reports, 16(8), p.67.

Dhatariya, K., 2016. Blood ketones: measurement, interpretation, limitations, and utility in the management of diabetic ketoacidosis. The review of diabetic studies: RDS, 13(4), p.217.

Usman, A., 2018. Initial potassium replacement in diabetic ketoacidosis: the unnoticed area of gap. Frontiers in endocrinology, 9, p.109.

Liamis, G., Liberopoulos, E., Barkas, F. and Elisaf, M., 2014. Diabetes mellitus and electrolyte disorders. World Journal of Clinical Cases: WJCC, 2(10), p.488.

Van de Vyver, C., Damen, J., Haentjens, C., Ballaux, D. and Bouts, B., 2017. An Exceptional Case of Diabetic Ketoacidosis. Case reports in emergency medicine, 2017.

Ledlow, G.J.R. and Stephens, J.H., 2017. Leadership for health professionals. Jones & Bartlett Learning.

Pike, T. and O’Donnell, V., 2010. The impact of clinical simulation on learner self-efficacy in pre-registration nursing education. Nurse education today, 30(5), pp.405-410.

Dig deeper into A Reflection on Annes Case with our selection of articles.