Mr. D, a 19-year-old pre-med student with type 1 diabetes, presented to the emergency department with abdominal pain, polyuria, vomiting, and thirst. He reported skipping insulin doses while studying for finals. On examination, he appeared flushed with dry lips and mucous membranes, poor skin turgor, and fruity breath odor. Initial labwork showed diabetic ketoacidosis. The priority was to treat his fluid and electrolyte imbalances with IV fluids and monitor for complications like hypokalemia during his transfer to the ICU.

1. Diabetic
Ketoacidosis
HAROLD LEONARDO SUAREZ
ROJAS

2. Clinical Case
• Mr. D, a 19-year-old premed student, has been brought to the emergency department
(ED) by his roommate, who is a medical student and a family friend. Mr. D reports
abdominal pain, polyuria, vomiting, and thirst. He appears flushed, and his lips and
mucous membranes are dry and cracked. His skin turgor is poor. He has deep, rapid
respirations, and there is a fruity odor to his breath. He has type 1 diabetes and “may
have skipped a few doses of insulin because of cramming for finals.” He is alert and
conversant but is having trouble focusing on the nurse's questions. Mr. D's vital signs and
blood glucose are as follows:

3. Introduction
DKA is a serious acute complications of
Diabetes Mellitus. It carries significant
risk of death and/or morbidity especially
with delayed treatment.
The prognosis of DKA is worse in the
extremes of age, with a mortality rates of
5-10%.
With the new advances of therapy, DKA
mortality decreases to > 2%. Before
discovery and use of Insulin (1922) the
mortality was 100%.

4. Consequences
The latter observation is annoying
because it implies the following:
The late presentation of DKA,
which is associated with risk of
morbidity and mortality
Death of young children with DKA
undiagnosed or wrongly diagnosed
as malaria or meningitis.

5. Pathophysiology
• Secondary to insulin deficiency,
and the action of counter-
regulatory hormones, blood
glucose increases leading to
hyperglycemia and glucosuria.
Glucosuria causes an osmotic
diuresis, leading to water and Na
loss.
• In the absence of insulin activity
the body fails to utilize glucose
as fuel and uses fats instead.
This leads to ketosis.

6. Pathophysiology/2
The excess of ketone bodies will cause
metabolic acidosis, the later is also
aggravated by Lactic acidosis caused
by dehydration and poor tissue
perfusion.
Vomiting due to an ileus, plus increased
insensible water losses due to
tachypnea will worsen the state of
dehydration.
Electrolyte abnormalities are secondary
to their loss in urine and trans-
membrane alterations following
acidosis and osmotic diuresis.

7. Pathophysiology/3
 Because of acidosis, K ions enter
the circulation leading to
hyperkalemia, this is aggravated
by dehydration and renal failure.
 So, depending on the duration of
DKA, serum K at diagnosis may be
high, normal or low, but the
intracellular K stores are always
depleted.
 Phosphate depletion will also
take place due to metabolic
acidosis.
 Na loss occurs secondary to the
hyperosmotic state and the
osmotic diuresis.

8. Pathophysiology/4
• The dehydration can lead to decreased kidney perfusion and
acute renal failure.
• Accumulation of ketone bodies contributes to the abdominal
pain and vomiting.
• The increasing acidosis leads to acidotic breathing and acetone
smell in the breath and eventually causes impaired
consciousness and coma.

10. Clinical Case
• Mr. D, a 19-year-old premed student, has been brought to the emergency department
(ED) by his roommate, who is a medical student and a family friend. Mr. D reports
abdominal pain, polyuria, vomiting, and thirst. He appears flushed, and his lips and
mucous membranes are dry and cracked. His skin turgor is poor. He has deep, rapid
respirations, and there is a fruity odor to his breath. He has type 1 diabetes and “may
have skipped a few doses of insulin because of cramming for finals.” He is alert and
conversant but is having trouble focusing on the nurse's questions. Mr. D's vital signs and
blood glucose are as follows:

11. To clarify
pertinent data,
what
questions are
appropriate to
ask Mr. D?
Select all that
apply.
• 1. “When did your symptoms start?”
• 2. “How many times have you vomited?”
• 3. “When were you diagnosed with
diabetes?”
• 4. “Where does your abdomen hurt?”
• 5. “Did you take any insulin today?”
• 6. “Do you have any allergies?”

12. To clarify
pertinent data,
what
questions are
appropriate to
ask Mr. D?
Select all that
apply.
• 1. “When did your symptoms start?”
• 2. “How many times have you vomited?”
• 3. “When were you diagnosed with
diabetes?”
• 4. “Where does your abdomen hurt?”
• 5. “Did you take any insulin today?”
• 6. “Do you have any allergies?”

13. The nurse has completed the triage assessment and
history taking. Now what is the priority action?
1. Page the ED
health care
provider (HCP)
to come to triage.
1
2. Call the
client's parents
for permission to
treat.
2
3. Notify the
client's primary
HCP.
3
4. Take the client
immediately to a
treatment room.
4

14. The nurse has completed the triage assessment and
history taking. Now what is the priority action?
1. Page the ED
health care
provider (HCP)
to come to triage.
1
2. Call the
client's parents
for permission to
treat.
2
3. Notify the
client's primary
HCP.
3
4. Take the client
immediately to a
treatment room.
4

15. What is the priority
nursing concept to
consider in planning
the initial emergency
interventions for Mr.
D?
1. Gas exchange
2. Acid-base imbalance
3. Fluid and electrolyte
imbalance
4. Adherence

16. What is the priority
nursing concept to
consider in planning
the initial emergency
interventions for Mr.
D?
1. Gas exchange
2. Acid-base imbalance
3. Fluid and electrolyte
imbalance
4. Adherence

17. Which tasks are
appropriate to
delegate to an
experienced
unlicensed assistive
personnel (UAP)?
Select all that apply.
Measuring and reporting Mr. D's vital signs every 15 minutes
Measuring
and
reporting
Checking and reporting Mr. D's blood glucose level
Checking
and
reporting
Bagging and labeling Mr. D's belongings
Bagging
and labeling
Updating the roommate regarding Mr. D's status
Updating
Measuring emesis and cleaning the basin as needed
Measuring
Obtaining an infusion pump from the supply room
Obtaining

18. Which tasks are
appropriate to
delegate to an
experienced
unlicensed assistive
personnel (UAP)?
Select all that apply.
Measuring and reporting Mr. D's vital signs every 15 minutes
Measuring
and
reporting
Checking and reporting Mr. D's blood glucose level
Checking
and
reporting
Bagging and labeling Mr. D's belongings
Bagging
and labeling
Updating the roommate regarding Mr. D's status
Updating
Measuring emesis and cleaning the basin as needed
Measuring
Obtaining an infusion pump from the supply room
Obtaining

19. For the initial
emergency
care of Mr. D,
what is the
priority
collaborative
treatment
goal?
• 1. Correction of hyperglycemia with IV
insulin
• 2. Correction of acid-base imbalance using
IV bicarbonate
• 3. Correction of fluid imbalance with IV
fluids
• 4. Correction of potassium imbalance with
IV potassium

20. For the initial
emergency
care of Mr. D,
what is the
priority
collaborative
treatment
goal?
• 1. Correction of hyperglycemia with IV
insulin
• 2. Correction of acid-base imbalance using
IV bicarbonate
• 3. Correction of fluid imbalance with IV
fluids
• 4. Correction of potassium imbalance with
IV potassium

21. What does the nurse
anticipate the HCP will
order for the initial fluid
replacement?
1. Normal saline (0.9% sodium
chloride)
2. Half-strength saline (0.45%
sodium chloride)
3. 5% dextrose in water and half-
strength saline
4. Normal saline with potassium
chloride

22. What does the nurse
anticipate the HCP will
order for the initial fluid
replacement?
1. Normal saline (0.9% sodium
chloride)
2. Half-strength saline (0.45%
sodium chloride)
3. 5% dextrose in water and half-
strength saline
4. Normal saline with potassium
chloride

23. The arterial blood gas results for
Mr. D are: pH 7.25 PaO2 97 mm
Hg Paco2 25 mm Hg
Bicarbonate 19 mEq/L (19
mmol/L)
What physical assessment finding is most
likely to accompany these laboratory results?
1. Kussmaul respirations
2. Dilated pupils
3. Increased urination
4. Elevated blood pressure

24. The arterial blood gas results for
Mr. D are: pH 7.25 PaO2 97 mm
Hg Paco2 25 mm Hg
Bicarbonate 19 mEq/L (19
mmol/L)
What physical assessment finding is most
likely to accompany these laboratory results?
1. Kussmaul respirations
2. Dilated pupils
3. Increased urination
4. Elevated blood pressure

25. The nurse is reviewing
the potassium values
that were obtained when
Mr. D first arrived in the
ED. Which serum
potassium level is most
concerning?
1. 3.5 mEq/L (3.5 mmol/L)
2. 2 mEq/L (2 mmol/L)
3. 5.8 mEq/L (5.8 mmol/L)
4. 6 mEq/L (6 mmol/L)

26. The nurse is reviewing
the potassium values
that were obtained when
Mr. D first arrived in the
ED. Which serum
potassium level is most
concerning?
1. 3.5 mEq/L (3.5 mmol/L)
2. 2 mEq/L (2 mmol/L)
3. 5.8 mEq/L (5.8 mmol/L)
4. 6 mEq/L (6 mmol/L)

27. The nurse overhears the UAP talking to someone on the phone. The UAP says,
“Yes, Mr. D is doing much better than when he first got here. I will tell him that you
called, and I will give him your message.” What will the nurse do first?
1. Ask the UAP
about the phone
conversation that
was just
overheard.
1
2. Remind the
UAP that release
of information is
outside her scope
of practice.
2
3. Report the UAP
to the nurse
manager for client
privacy violation.
3
4. Give positive
feedback for
trying to help the
client and the
caller.
4

28. The nurse overhears the UAP talking to someone on the phone. The UAP says,
“Yes, Mr. D is doing much better than when he first got here. I will tell him that you
called, and I will give him your message.” What will the nurse do first?
1. Ask the UAP
about the phone
conversation that
was just
overheard.
1
2. Remind the
UAP that release
of information is
outside her scope
of practice.
2
3. Report the UAP
to the nurse
manager for client
privacy violation.
3
4. Give positive
feedback for
trying to help the
client and the
caller.
4

29. As the nurse is getting ready to transfer Mr. D to the ICU, the unit
secretary hands the nurse the last blood glucose result, which is 150
mg/dL (8.33 mmol/L). What should the nurse do first?
1. Proceed with the
transfer because
blood glucose is
trending toward the
normal value.
1
2. Stop the insulin
infusion, proceed
with the transfer,
and inform the ICU
nurse on arrival.
2
3. Immediately
notify the HCP and
anticipate an order
for IV fluid of 10%
glucose.
3
4. Slow the insulin
infusion and obtain
an order to have the
blood glucose
redrawn.
4

30. As the nurse is getting ready to transfer Mr. D to the ICU, the unit
secretary hands the nurse the last blood glucose result, which is 150
mg/dL (8.33 mmol/L). What should the nurse do first?
1. Proceed with the
transfer because
blood glucose is
trending toward the
normal value.
1
2. Stop the insulin
infusion, proceed
with the transfer,
and inform the ICU
nurse on arrival.
2
3. Immediately
notify the HCP and
anticipate an order
for IV fluid of 10%
glucose.
3
4. Slow the insulin
infusion and obtain
an order to have the
blood glucose
redrawn.
4

31. The nurse is preparing to transfer Mr. D to the ICU
and notices the cardiac monitor display. Which
ECG pattern is cause for greatest concern?

32. The nurse is preparing to transfer Mr. D to the ICU
and notices the cardiac monitor display. Which
ECG pattern is cause for greatest concern?

33. In caring for Mr.
D, the nurse is
vigilant for signs
and symptoms of
hypokalemia.
What signs and
symptoms
should the nurse
watch for?
Select all that
apply.
1. Fatigue
2. Cold, clammy skin
3. Muscle weakness
4. Hypotension
5. Weak pulse
6. Shallow respirations

34. In caring for Mr.
D, the nurse is
vigilant for signs
and symptoms of
hypokalemia.
What signs and
symptoms
should the nurse
watch for?
Select all that
apply.
1. Fatigue
2. Cold, clammy skin
3. Muscle weakness
4. Hypotension
5. Weak pulse
6. Shallow respirations

35. Which tasks can the nurse direct an experienced UAP to perform
to facilitate Mr. D's transfer to the ICU? Select all that apply.
1. Giving Mr. D's
roommate
directions to the
ICU waiting room
2. Independently
transporting Mr. D
to the ICU
3. Collecting and
organizing the
chart and
laboratory reports
4. Obtaining a
portable oxygen
tank and cardiac
monitor
5. Connecting Mr.
D's ECG leads to
the portable
cardiac monitor
6. Obtaining the
last set of vital
sign values

36. Which tasks can the nurse direct an experienced UAP to perform
to facilitate Mr. D's transfer to the ICU? Select all that apply.
1. Giving Mr. D's
roommate
directions to the
ICU waiting room
2. Independently
transporting Mr. D
to the ICU
3. Collecting and
organizing the
chart and
laboratory reports
4. Obtaining a
portable oxygen
tank and cardiac
monitor
5. Connecting Mr.
D's ECG leads to
the portable
cardiac monitor
6. Obtaining the
last set of vital
sign values