Peds Case Study #3: DKA Diabetic Ketoacidosis By: Michelle Scarlett & Emma Fleck

1. Peds Case Study #3: DKADiabetic KetoacidosisBy:Michelle Scarlett & Emma Fleck

2. Ryan is a 5 year old male transferred from the PICU to the med/surgunit • Dx: • Diabetic ketoacidosis • Diabetes type 1 (new diagnosis) • Hx: • Lethargic and decreased LOC this afternoon with increased appetite and fluid intake x 3 days. No other hospital admissions/surgeries Hx & Dx

3. Objective Findings: • Vitals: • BP 110/56, HR 88, RR 20, Temp 98.5 PO • Wt: • 36.2kg or 79.64lbs • Percentile on growth chart for Wt: >99% • Subjective Findings: • Patient active and playful. • No c/o pain Data & Labs

4. Labs: • Blood sugar =115-225 • Urine dip sticks=positive for ketones • Other blood work within normal limits • Other: • Parents present at bed side; father is a RT. While admitted in PICU, family’s home burned down along with the loss of two pets and pt is unaware Data & Labs Cont.

5. Humulin-R (sliding scale) SC • 70-130=0 unit • 131-180=2 units • 181-240=4 units • Lantus • 7 units SC q morning • Tylenol • 360mg PO pain/fever Medications

6. Diet: • Regular for age, limit sweets • Activity: • Ad lib (as desired) • Vitals: • Every 4 hours • BS check ac (TID) and HS • Daily weight • Initial diabetic educator consultation • nutrition, insulin administration,and location sites reviewed. • Call physician with any concerns or change in patient condition Orders

7. Patient assessment this morning: • BS at 0730 is 142 • Vital signs are stable • Lungs: clear • Heart: regular rhythm, no abnormal sounds • Patient is alert, playful, but appears to be afraid of needles • Patient’s mother is at bedside and appears exhausted but pleasant. Morning Assessment

8. BS 142 @ 0730 • Blood work within normal limits • Vital signs stable • Lung and Heart assessments within normal limits • Pt is alert and playful • Pt is fearful of needles Important Assessment Data:

9. Additional data to obtain before you notify the physician about this patient includes: • The trend of the patients weight since admission • If Ryan has a change in hunger and thirst since admission • Any change in LOC • The trend of ketones in the urine Notifying the Physician

10. It is not an emergency, just calling to update the physician about Ryan’s current status. • Patient's blood glucose is under control • Patient is stable and he does not show any signs or symptoms of DKA • Vital signs are stable • Assessment within normal limits • If any signs and symptoms of hypoglycemia, hyperglycemia and complications of DKA (cerebral edema) occurs, the physician and neurosurgeon will be notified immediately Contacting the Physician:

11. Nurse: “Hello Dr. Scarlett I’m Emma, the nurse taking care of Ryan, a 5 year old admitted the other day in the PICU for DKA. Ryan is newly dx with type 1 diabetes. Ryan is currently stable on the med surg floor. At 07:30AM this morning, Ryan’s BS was 142, his heart sounds are regular rhythm, no abnormal sounds, lungs are clear, and he is alert and playful. Vitals and labs are within normal limits with some traces of ketones. The diabetes educator came in this morning and discussed nutrition, insulin administration and sites with the family. The patient is taking Lantus 7 units SC q morning and Humilin-R (sliding) SC at this time.” “However, I’m concerned that because Ryan is afraid of needles at his age that it is going to be hard to manage his diabetes. Therefore, In order to reduce needle exposure I want to request getting him a insulin pump or consider changing his current insulin regimen to a mixture of rapid acting and a intermediate-acting insulin. That way it will cover Ryan throughout the day and reduce getting needle stick to only twice a day.” Physician: “Ok when I make my rounds, I will discuss the changes of insulin with the family and determine whether the patient should use the insulin pump. I want you to make sure the family understands this new medication change and for you to monitor the patient’s blood glucose closely to see how he tolerates the change. Notify me if there are any signs of hypo/hyperglycemia to which we will reevaluate the medication order.” Phone Conversation:

12. What orders might you expect or request from the physician if applicable? • Ryan is afraid of needles so request a insulin mixture to reduce needle exposure and cover the pt throughout the day. Or consider a insulin pump. Expected Orders from Physician:

13. Continuous reassessment and monitoring • Reduce the amount of needle sticks • Teach patient to cope with finger sticks/needles • Daily weight • Food/beverage log (intake and output) • BS check ac (TID) and at bedtime • Contact social worker because Ryan’s house was burned down and he and his family are homeless • Offer the mom a break Highest priority is BS check ac (TID) and at bedtime to monitor pt condition, because the physician changed the patient's insulin order. Patient Interventions:

14. Hypoglycemia • Chills, shakiness, sweating, headaches, and confusion • DKA • Hyperglycemia, ketones in the urine • Polyuria, polydipsia, polyphagia, • Hypokalemia • Blood pressure - Usually normal until terminal stages of illness • Tachycardia - May be present • Capillary refill - Initially maintained, but a combination of increasing acidosis and dehydration cause poor tissue perfusion • Kussmaul breathing may be mistaken for status asthmaticus, pneumonia, and even hysterical hyperventilation, • Fruity odor on breath - patient may have a smell of ketones on the breath, although many people cannot detect this smell • Weakness and fatigue. • Impaired consciousness- occurs in approximately 20% of patients • Coma - may be present in 10% of patients • Abdominal tenderness - tenderness is usually nonspecific or epigastric in location; bowel sounds may be reduced or absent in severe cases, nausea/vomiting • Cerebral edema Potential problems or Complications to be aware of

15. Hypoglycemia • Treated by giving 15 grams of fast acting carbohydrates (OJ or candy). Make sure patient, family members, and teachers are aware of the signs/symptoms of hypoglycemia and have something containing sugar with them at all times. Check BS afterwards. • DKA • Primary prevention involves making sure pt, family members, and teachers know how to identify DKA early signs /symptoms , check BS routinely, and to call 911/bring to the ED if symptoms occur • ABCs [airway, breathing, circulation]). • Give oxygen, Diagnose by clinical history, physical signs, and elevated blood glucose. • Restore fluid. child should be weighed and height .Once a line is established, an isotonic solution is infused. Normal saline (0.9% sodium chloride) is the fluid of choice. After initial 0.9% NaCl bolus, rehydration/maintenance should be continued with 0.45% NaCl. • Continuous intravenous insulin infusion is usually commenced one to two hours after starting fluid replacement. With insulin infusion the rate of glucose decline should be 50–150 mg/dL (2.8–8.3 mmol/L/hour), but not >200 mg/dL (11 mmol/L/hour). • Specifically designed recording charts (measurements of clinical and biochemical status, fluid balance, and insulin prescription. • Patients with diabetic ketoacidosis using an insulin pump, need it removed during treatment • Cerebral Edema • Frequent review of neurologic status—at least hourly (or any time a change in the level of consciousness is suspected)—is essential during the first 12 hours of diabetic ketoacidosis treatment. • Promptly treat any suspected cerebral edema with osmotic diuretic, CT scan and referral to a neurosurgeon. Preparing for complications***

16. Record blood pressure, temperature, pulse and respiration. • Record blood glucose levels • Obtain height and weight. • Administer and monitor intravenous fluids. • Cerebral edema- Mannitol 0.5-1 g/kg infused over 30 minutes, which can be repeated after 1 hour. The usual dose of hypertonic saline is 5-10 mL/kg, again infused over 30 minutes, which can be repeated after 1 hour. (preferred) • Strictly measure input and output. • Provide catheter care if necessary. • Carefully monitor labs such as potassium to prevent problems from hypokalemia. • Record capillary refill time. • Assist in administration and monitoring of insulin therapy. • Provide supportive care to family • Inquire about culture and health beliefs and how that can be included in the plan of care • Provide relief for them to care for themselves • Keep them informed regarding any changes in patients status and orders • Connect them to the right team member Nursing Responsibilities

17. Dietary regarding dietary guidelines while admitted and after admission • Neurosurgeon if cerebral edema is expected • Social work/case manager to discuss current case of patient, insurance coverage, resources needed to pay for insulin pump if needed, • Resources for temporary housing. How to go through the insurance process of obtaining new housing • Reaching out to family members and friends for support • Asking about spiritual support within the community Consultations

18. V/S every 4 hours • Monitor the patient Q1 for signs of hypo/hyperglycemia/DKA/LOC • Observe child after he eats • Notify physician immediately if a change occurs How often should the nurse reassess /reevaluate the patient’s status?

19. Do not to skip insulin doses • In the case of hypoglycemic shock rapid replacement of glucose with 15 grams of rapid carbohydrate such as 4 oz. of fruit juice (orange juice) or tablespoon of honey or syrup. Low-fat cheese sandwich Ham, roast beef, or turkey sandwich • Know when to test for ketones, such as when you are sick or BS >240mg/dl • If you use an insulin pump, check often to see that insulin is flowing through the tubing. Make sure the tube is not blocked, kinked or disconnected from the pump. • Do not skip meals or snacks and always carry a quick source of sugar especially when exercising. • Staying hydrated by drinking plenty of fluids • Check blood sugar before each meal and at bed time and to take medications at the same time everyday • Teach medication interactions, talk to pharmacist before taking other medications • Seek immediate medical attention if you recognize: • Ketones in urine • Polyuria, polydipsia, and polyphagia • Trouble breathing • Decreased LOC • High blood glucose • Fruity breath • Nausea/vomiting • Complains of abdominal pain Appropriate teaching for the this patient family.

20. Hx of symptoms upon admission • Admission v/s, subjective and objective data • Vitals • Lab values • Changes in blood glucose • Trend of ketones • Time and date of insulin initiation and administration • Changes in diet and intake/output • Changes in physical abilities • Changes in LOC • Complains of pain and steps taken to relieve pain • All interventions time, date, and outcome • Note time and date physician was contacted and any new orders given • Document consultations and the outcome of those consultations • Documenting that discharge teaching was provided along with resources for patient and family to take home. Appropriate Documentation for This Patient in an Emergent Situation.

21. Patient was d/c home on day 3 with diabetic teaching information, medication administration, when to check blood pressure and glucose, diet and when to contact the physician/hospital. • Patient stated that he was starting to get use to the finger sticks and that he is happy to be going home. • The family will be staying with the father’s brother who lives 10 miles away, close to Ryan’s school. They hope to find a new home in the next month or so. They also plan to find a new family pet with Ryan as soon as his health is back to being stable. Outcomes

22. 1) Clinical manifestations associated with a diagnosis of type 1 DM include all of the following except: • a. Hypoglycemia • b. Hyponatremia • c. Ketonuria • d. Polyphagia • 2) A nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the priority nursing action is to prepare to: • A. Correct the acidosis • B. Administer 5% dextrose intravenously • C. Administer regular insulin intravenously • D. Apply a monitor for an electrocardiogram Questions

23. Bangstad, H., Danne, T., Deeb, L., Jarosz-Chobot, P., Urakami, T., & Hanas, R. (2009). Insulin treatment in children and adolescents with diabetes. Pediatric Diabetes, 10, 82-99. Retrieved from http://www.ispad.org/sites/default/files/resources/files/ispad_guidelines_2009_-_insulin_treatment.pdf • Fröhlich-Reiterer, E. E., Ong, K. K., Regan, F. F., Salzano, G. G., Acerini, C. L., & Dunger, D. B. (2007). A randomized cross-over trial to identify the optimal use of insulin glargine in prepubertal children using a three-times daily insulin regimen. Diabetic Medicine, 24(12), 1406-1411. Retrieved from https://webmail.health.usf.edu/owa/attachment.ashx?attach=1&id=RgAAAADdNv2wg0cGTLgOLCy3Ie%2blBwD6p5nXpbIXTYnodiiC%2bDfnAAAAT3i9AAD6p5nXpbIXTYnodiiC%2bDfnAAAVfTeXAAAJ&attid0=BAAAAAAA&attcnt=1 • Lamb, W., Corden T., Cantell, P., Barry, E., Windle, M. (2013). Pediatric Diabetic Ketoacidosis Treatment & Management. Retrieved from http://emedicine.medscape.com/article/907111-treatment • Mcfarlane, K. (2011). An overview of diabetic ketoacidosis in children. Pediatric Care, 23(1), 14-19. • Silverstein, J., Holzmeister, L. A., Clark, N., Anderson, B., Grey, M., Deeb, L., et al. (2005). Care of children and adolescents with type 1 diabetes: A statement of the americandiabetes association. Diabetes Care, 28(1), 186-212. Retrieved from http://care.diabetesjournals.org/content/28/1/186.full.pdf+html References