18
When his mother got home from work, 15 year old Roberto Cruz was found very lethargic and lying in vomit at his home. His heart was racing and he was breathing abnormally. His mother called 911 when she could not get him to the car to transport him to urgent care. When the paramedics arrived at the house, Roberto was complaining that he needed to go to the bathroom and repeatedly asking for water. He was transported to the ER.
On ER admission, Roberto’s VS were BP 85/53. HR 119, RR 32, T 99.1 and O2 96% on room air. He was A&O x3 (name, place, date) but drowsy, lethargic, and slow to respond to questions. His breathing was deep and labored with “fruity breath.” He had polydipsia and polyuria, with abdominal pain rated 5/10.
Significant lab values: Blood glucose 444, ABGs: pH 7.22, Bicarb 14, paCO2 33, anion gap 13.0, paO2 90. Positive urine ketones and acetone. Potassium 5.3. He has no medical history and no health insurance.
Diagnosis: Diabetic Ketoacidosis
Treatment:
- Administer oxygen and provide airway support
- Establish IV access
- Administer NS fluid resuscitation
- Regular insulin via IV drip
- Monitor potassium, assess for signs of hypokalemia or hyperkalemia
- Provide electrolyte replacement as needed.
- Monitor vital signs
- Blood sugar checks Q1H
- Monitor blood pH
- Assess for changes in mental status
- Monitor intake and output
- Provide seizure and safety precautions
- Report any critical lab values or changes in patient status to physician
Patient is transferred to the ICU for correction of acidosis, slow stabilization of blood glucose levels, fluid resuscitation, potassium replacement, and monitoring.
At discharge, the diabetic educator provided the patient with diabetes education with return demonstration of correct blood glucose check and subcutaneous insulin injection. Social services met with the patient and family to assist them with financial and insurance questions, follow up appointment was scheduled with primary physician.
Questions:
- As Roberto was initially triaged and treated, what were the priority assessments and treatments?
- What risk factors did Roberto have for developing DKA?
- As Roberto is discharged from the hospital, what continued health care and education needs will he and his family have? What are appropriate long term goals for Roberto and how can they be measured?
