1. Under supervision:
Mrs. Omnia Helaly

2.  Patient data.
 Medical diagnosis.
 Diagnostic &lab results.
 Medications.
 Psychosocial.
 Nursing care plan.
 Preventing complications.
 Research questions.

3.  Effective critical care.
 Connect between theory and practice.
 Simple nursing care have great outcome.
 Critical thinking.

4.  patient’s initials: RL, 42 years male. From
Nmsa. admission date 12-3-2015.
allergies: NKA admitting diagnosis: atrial
fibrillation and diabetic ketoacidosis. past
medical history: Hernia. current vital
signs: Pulse is 82, Bp 11070 mmHg, temp
37.2 and Spo2 100%.

5.  Ambulance
 Emergency
 ICU
 CCU

6.  Medical diagnosis: diabetic ketoacidois
(DKA )and atrial fibrillation ?

7.  Pathophysiology:
(DKA) is caused by a profound
deficiency of insulin and is characterized by
hyperglycemia, ketosis, in conditions of
severe illness or stress when the pancreas
cannot meet the extra demand for insulin.
(Lewis 2014).

8.  Change in diet and exercise regimen.
 Undiagnosed diabetes mellitus
 Inadequate treatment of existing diabetes
mellitus
 Insulin not taken as prescribed
 Infection
(Lewis 2014).

9. 1-lethargy and
weakness.
2dry mouth.
3. Thirst .
4. Abdominal
pain.
5. Nausea and
vomiting.
6. confusion.
7. Flushed skin.
8-Sunken eyes
11- Labored
breathing (Kussmaul
respirations)
10- Breath odor
of ketones
12- Glucosuria
and ketonuria)
9- Serum glucose >250
(Lewis 2014).

10.  Pathophysiology:
Total disorganization of atrial electrical
activity due to multiple ectopic foci resulting
in loss of effective atrial contraction
(Lewis 2014).

11.  Fluid Electrolyte disturbance.
 Alcohol intoxication.
 Caffeine use.
 Stress.
 Cardiac surgery.
(Lewis 2014).

12. 1-Palpitations.
2-Weakness,
Reduced
ability to
exercise
3-Fatigue
4-Lightheadedness5-Dizziness
6-Confusion
6-Shortness of
breath and
chest pain
(Lewis 2014).

13.  First ABCD: Maintain patent air way.
 Administer O2 via nasal canula or non re-breathing
mask.
 Assess respiratory rate and lung sound.
 Administration of IV fluids.
 Assessment of mental status.
 Electrolyte replacement.
 The main goal of treatment is to maintain adequate
cardiac output and tissue perfusion.
 Cardiac assessment.
 ECG monitoring.
(Lewis 2014).

14.  ECG.
 Blood Glucose level.

16.  ECG:
 Atrial fibrillation: ECG Characteristics.
atrial rate may be as high as 350 to 600
beats/minute.
 P waves are replaced by chaotic,
fibrillatory waves.
 ventricular rate is between 60 and 100
beats/minute usually irregular.
(Lewis 2014).

17.  1221 MGdl.
 Hyperglycemia.
 pancreas cannot meet the extra
demand for insulin.
 When the circulating supply of insulin is
insufficient, glucose cannot be properly
used for energy. The body compensates
by breaking down fat stores as a
secondary source of fuel (ketones).
(Lewis 2014).

18. •Insulin.
•Cordarone.

19. INSULINS (rapid acting)
antidiabetics, hormones
GT name
Classification
Control of hyperglycemia in patients with type 1 or type 2
diabetes mellitus.
Indications
stimulating glucose uptake in skeletal muscle and fat,
inhibiting hepatic glucose production.
Action
Hypoglycemia, erythema, lipodystrophy, pruritis, swelling.
Allergic reaction.
Side effect
erythema, lipodystrophy, pruritis, swelling, Corticosteroids,
thyroid supplements, estrogens. Hypoglycemia.
Contraindicati-
ons.
interaction
generally 0.5–1 unit/kg/day.Dose
Subcutaneous.Route
hypoglycemia (anxiety; restlessness; tingling in hands, feet,
lips, or tongue.
Assess patient for signs of allergic reactions (rash, shortness of
breath, wheezing, rapid pulse, sweating, low blood pressure)
during therapy.
Monitor blood glucose.
Nursing
assessemnt

20. Cordarone amiodarone
Antiarrhythmics.
GT name
Classification
Life-threatening ventricular arrhythmias.Indications
Prolongs action potential and refractory period. Inhibits
adrenergic stimulation. Slows the sinus rate, increases PR and
QT intervals, and decreases peripheral vascular resistance
(vasodilation).
Action
Respiratory distress syndrome, confusional states,
disorientation, hallucinations, dizziness, fatigue, malaise,
headache, insomnia.
Side effect
Patients with cardiogenic shock; Severe sinus node
dysfunction; 2nd- and 3rd-degree AV block.
↑ levels of digoxin, beta blockers, calcium channel blockers.
Contraindicati
-ons.
interaction
10 mg/kg/day.Dose
PO.Route
Monitor ECG continuously. Assess ARDS.
Assess for signs of pulmonary toxicity (rales/crackles,
decreased breath sounds, pleuritic friction rub, fatigue,
dyspnea, cough, wheezing, pleuritic pain, fever, hemoptysis,
Nursing
assessment

21.  Patient have no religion.
 Patient feel lonely. He is not married.
 He have insurance.

22.  With the patient I used: broad opening
:”what do you want to talk about”
 With the patient I used: Summarizing :
“we disused…”.

23.  Read about the new disease.
 Nutrition intake for diabetic person.
 Body care.
 Insulin injections.

25. 1. Acute pain: Related to disease affect on the CNS as
evidenced by patient was moaning and he feel
pain .
2. Risk for decreased cardiac output: RT Altered
electrical conduction. Reduced myocardial
contractility.
3. Imbalanced blood glucose level: related to Insulin
deficiency—decreased uptake or utilization of
glucose by the tissues resulting in increased protein
and fat metabolism. as evidenced by increased the
blood glucose level.
(Sparks,2014).

26.  Acute pain:
Patient verbalizes adequate relief of pain or
ability to cope with incompletely relieved pain.
 Risk for decreased cardiac output :
Maintain or achieve adequate cardiac
output as evidenced by BP and pulse within
normal range, adequate urinary output,
palpable pulses of equal quality, and usual
level of mentation.
 Imbalanced blood glucose level:
Maintain glucose in normal range.
(Sparks,2014).

27.  Acute pain:
 Assess pain characteristics.
 Assess for probable cause of pain.
 Administer pain medication. (Pethidine
50 Mg)
(Sparks,2014).

28.  Palpate pulses, noting rate, regularity,
amplitude (full or thready), and symmetry.
Document presence of pulse deficit.
 Auscultate heart sounds, noting rate, rhythm,
presence of extra heartbeats, and dropped
beats.
 Determine type of dysrhythmia and document
with rhythm strip if cardiac or telemetry
monitoring.
(Sparks,2014).

29.  Review type(s) of insulin used.
 Observe for signs of hypoglycemia—
changes in LOC, cool and clammy skin,
rapid pulse, hunger, irritability, anxiety,
headache, lightheadedness, and shakiness.
 Monitor laboratory studies, such as serum
glucose, acetone, pH, and HCO3
.
(Sparks,2014).

30. Acute pain:
Met, patient bcame more comfort and
relived of moaning sound.
Risk for decreased cardiac output:
Met, achieve adequate cardiac output as
evidenced by BP and pulse within normal
range, adequate urinary output.
Imbalanced blood glucose:
Met, patient has decreased blood glucose
level.
(Sparks,2014).

32.  Neurologic, patient is confused (safety).
 ECG atrial fibrillation (cardiac output).
 Patient blood glucose decreased very
fsat.

33.  Follow up.
 Best Nutrition.
 Body care.
 Medication.
 Injection.
(Kornusky,2014).

34.  At home.
1. Continue prescribed diabetic medications .
2. Report a glucose reading > 300 mg/dL or urine
ketones to the treating clinician
3. If nauseous, eat frequent (e.g., 6–8times a day),
small meals of soft foods such as gelatin, soup,
custard, or crackers
4. If vomiting, diarrhea, or fever persists, continue
calorie intake through liquids (e.g., orange juice,
broth, or Gatorade) every 30–60minutes
5. Report nausea, emesis, or diarrhea promptly to
the treating clinician
6. If unable to keep liquids down, hospitalization may
be necessary to prevent DKA
(Kornusky,2014).

35.  Diabetic food pyramids.
 Diabetic nutrition.
 Insulin injection technique.
(Kornusky,2014).

36.  What are you alert for in this patient?
hypoglycemia, fluid and electrolyte
imbalance, cardiac embolism , non
compliance. And hyperglycemia.

2. What are the important assessments to make
blood glucose monitoring, ECG.

3. What complications may occur?
Complications of DKA include electrolyte
imbalances, cerebral edema, thrombotic
events(e.g., pulmonary embolism, stroke,
deep vein thrombosis), and acute renal failure

37.  4. What interventions will prevent
complications? monitor blood glucose
level, administer anti coagulant thereby
and anti arrhythmic drugs, ECG
monitoring.

5. What will you do if complications do
occur?
ABCD, need mobilization from the team.

38.  Is there any relation between atrial
fibrillation and DKA?
 How can DKA cause fluid and electrolyte
disturbance?

39.  DKA cause metabolic acidosis that lead to
increased concentration of hydrogen ions
(H+) or decreased concentration of
bicarbonate (HCO3–).
 In which make potassium shift from
intracellular to extracellular.
 When potassium decreased from cardiac
cells it effect on the conduction system
which results in arrhythmia(atrial fibrillation).
(Kornusky,2014).

40. the kidneys also excrete water and
electrolytes, leading to dehydration and
electrolyte imbalances.
Electrolyte imbalances and
hyperosmolarity (i.e., increased solution
concentration expressed as osmoles of
solute/kg of serum water) can result in
cardiac arrhythmias and even coma.
(Adler,2013).

41.  Kornusky, J. 2014. Metabolic Acidosis.
Cinahl Information Systems. Vol1.Pag 1-3.
 Adler,A. Cabrera,G. 2013. Diabetic
Ketoacidosis in Adults. Pag1-4.
 MYOJO, T. 2012. Recurrent Ventricular
Fibrillation Related to Hypokalemia in Early
Repolarization Syndrome. Wiley Periodicals,
Vol 35. pag 1-4.

42.  Lewis S, Dirksen S, Heitkemper M,
Bucher L, Camera I (2013) Medical-
Surgical Nursing: Assessment and
Management of Clinical Problems (8th
ed) p1218-1253 St. Louis Elsevier
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