DKA ER Assessment

Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬

University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬
Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
Student Name Turki Meshal Alshammri
Student ID
Date
Hospital
Instructor Name
Patients Data
Patient’s name (First & surname): Fahad Sultan Mohammad Alshammry
Healthcare Record Number (HRN):
Age: 47 years/old
Gender: Male
Patient has 3 days history of body weakness, fever, nausea,
Presenting Chief complaint: vomiting & painful left foot with foul smelling pus discharge from
ulcer on the sole.
Triage category: Immediate (Red)
Infection status: Unknown
Accompanied by: Patient’s daughter & son
Patient
Family or significant other
Source of data collection/gathering Caregiver
EMS personnel
Bystander
Use of translator
Medical Diagnosis: Diabetic Ketoacidosis (DKA)
Last oral intake: 2 hours ago
1

Summary of the Primary Assessment:
1. Response
a. Patient is alert but drowsy.
2. Airway & C-Spine
a. Subjective
 Patient has no history of airway problem.
 Patient has recent nausea & vomiting.
b. Objective
 Patient able to open mouth widely, and mouth is clear.
 Patient has equal rise and fall of chest with ventilations.
3. Breathing
a. Subjective
 Patient has no distress.
 Patient has no history of injury to head, chest, or abdomen.
b. Objective
 Patient oxygen saturation measured by pulse oximetry (SpO2) 94–98% (or patient’s
normal baseline).
 Kussmaul respirations: rapid & shallow breathing
4. Circulation
a. Subjective
 Patient has no history of disease or injury that could result in significant bleeding.
 Weak & thready peripheral pulse.
 Patient weak, lightheaded, nauseated, experiencing blurring of vision.
b. Objective
 Skin color, temperature, moisture: pink, warm, flushed, dry skin, & poor skin turgor
5. Disability
a. Subjective
 Patient has no history of neurologic trauma.
 Patient has no sudden onset of severe headache.
b. Objective
 Patient has Glasgow Coma Scale scores 15.
 Patient has the ability to respond to commands.
6. Exposure/Environmental controls
a. Subjective
 Patient has no history of unexposed injury.
 Complaint of extremity pain (Left foot ulcer pain)
b. Objective
 Patient has tachycardia.
 Patient has an elevated temperature.
 Observable extremity injury (left foot ulcer).
2

History of Present Illness/injury/chief complaint : (FEVER)
Palliative Factors Patient’s fever was relieved by paracetamol
Aggravated by ulceration of the left foot

Provocative Factors
Low-grade fever
Quality
Evidenced by oral temperature
Region
Low-grade fever to the whole parts of the body
Radiation
Low-grade fever (37.9℃)
Severity
3 days ago around 8pm, the patient was chilling
Timing: Onset
Unknown by the patient, but the patient was not feverish by the next day
Timing: Duration
Patient got a low-grade fever 3 days ago
Timing: Frequency
Treatment prior to Patient took paracetamol 1G tablet at 10pm 3 days ago
arrival
History of Present Illness/injury/chief complaint: (NAUSEA & VOMITING)
Palliative Factors Not relieved any food or fluid intake, no medication taken
Unknown provocative factors

Provocative Factors
Slightly projectile vomitous
Quality
Epigastric area
Region
Abdominal area
Radiation
Mild-moderate vomitous
Severity
Patient started to vomit 3 days ago and at 8am in this morning
Timing: Onset
Nauseated & vomited for almost 5 minutes
Timing: Duration
Patient vomited 5 times today
Timing: Frequency
3

Treatment prior to No treatment prior to the arrival, just drink orange juice & water
arrival
History of Present Illness/injury/chief complaint: (BODY WEAKNESS)
Palliative Factors Not treated with anything, no medication taken
Unknown provocative factors

Provocative Factors
Feeling of fatigue & whole body weakness
Quality
Whole parts of the body
Region
Whole parts of the body
Radiation
Severe body weakness
Severity
Body weakness since 3 days ago
Timing: Onset
Body weakness for 3 days already
Timing: Duration
Body weakness for 3 whole days
Timing: Frequency
Treatment prior to No treatment given, patient just want to rest & sleep
arrival
History of Present Illness/injury/chief complaint: (PAINFUL LEFT FOOT ULCER)

Patient just drink paracetamol 1G for the pain & applied alcohol & betadine for
Palliative Factors
the foot ulceration.
Not healing left foot ulceration
Provocative Factors
The ulcer has a foul smelling pus discharge, small but deep ulceration
Quality
Sole of the left foot
Region
Left foot
Radiation
Mild-moderate pain on his left foot
Severity
Left foot pain since 3 days ago
Timing: Onset
Left foot pain for 3 days already
Timing: Duration
4

Painful left foot ulceration for 3 days already
Timing: Frequency
Treatment prior to Paracetamol 1G only for the pain & application of alcohol & betadine for the
arrival foot ulceration.
Pathophysiology of the Disease/ Patient condition/ Medical Diagnosis
Insulin
Utilization of the glucose Lyposis Proteolysis Glycogenolysis

Protein synthesis
FFA to the liver Gluconeogenesis
Ketosis
Hyperglycemia
Ketouria Ketoacidosis
Glycosuria Polyuria
Lactic acidosis
Dehydration/ Polydipsia
hypovolemia
Diabetic Ketoacidosis
5

Full Set of Vital Signs
Blood Pressure Temperature Central & Peripheral Pulse Pain
Time SpO2 GCS
Location Value MAP Route Value Location Rate Rhythm Quality Severity
1500 L arm 96/60 72 Oral 38℃ Radial 110 Weak Thready 94% 15 5/10
1600 L arm 100/75 83 Oral 37.9℃ Radial 105 Weak Thready 95% 15 5/10
1700 L arm 108/78 88 Oral 37.8℃ Radial 102 Weak Thready 97% 15 4/10
Oral 37.6℃ Radial 97 Slightly Slightly 98% 15 3/10
1800 L arm 110/76 87
Weak thready
1900 L arm 115/82 93 Oral 37.5℃ Radial 93 Regular Strong 96% 15 3/10
6

Diagnostic Examinations/Procedures:
Reference Value
Test/Procedure Patient Results Nursing Considerations
(Normal Results)
-Normalize the blood glucose.
-Inform the physician.
(-) Glucose
(+4) Glucose -IV fluid (isotonic solution)
(-) Ketones
Urinalysis (+3) Ketones infusion as ordered.
(-) Nitrate & Leucocytes
(-) Nitrite & Leucocyte -Administration of insulin/oral
hypoglycemic agent as ordered.

-IV fluid (isotonic solution)
infusion as ordered.
Blood Glucose (RBS) < 7.8 mmol/L 25 mmol/L
-Administration of insulin/oral
-Keep monitoring on blood
glucose level.
(Metabolic Acidosis)
pH = 7.35-7.45 pH = 7.06 -IV fluid (isotonic solution)
Arterial Blood Gas
pCO2 = 35-45 mmHg pCO2 = 17 mmHg infusion as ordered.
(ABG)
HCO3 = 22-26 mmol/L HCO3 = 5.6 mmol/L -Administration of insulin/oral
-Keep monitoring on blood
glucose level.
(Lactic Acidosis)
-Inform the physician right away.
-Normalize blood glucose level.
Blood Lactate 0.5 – 1.0 mmol/L 3.2 mmol/L
-IV fluid infusion as ordered
-Adequate hydration
-Administration of insulin
Renal Profile Urea- 2.5-6.4 mmol/L Urea- 7 mmol/L -Monitor vital signs
Sodium- 135-145 mmol/L Sodium-142 mmol/L -Adequate hydration, IVF infusion
Potassium- 3.5-5.1 Potassium- 5.0 mmol/L as ordered
mmol/L Chloride- 109 mmol/L -Administer insulin as ordered
Chloride- 102-109 Creatinine- 118 μmol/L -Insert indwelling catheter as
mmol/L indicated & monitor I & O.
7

Creatinine- 62-115 -Administer medication as
μmol/L indicated.
-Administer antibiotic as
prescribed.
Leukocytes- 4.5-11
Leukocyte- 23 x 109/L -Normalize the blood glucose
x 109/L
CBC Predominant neutrophils, level.
Neutrophils- 40-60
Haematocrit- 55% -Aseptic technique when cleaning
Haematoctrit- 42-52%
the wounds.
-Adequate fluid hydration.
-Normal result of chest x-ray
Chest X-ray Unremarkable Unremarkable
-No significant finsings
-Normalize the blood glucose

level.
Diabetic foot with
-Administration of insulin/oral
X-ray (Left Foot) Unremarkable osteomyelitic changes of
1-3 metatarsals
-Regular aseptic wound dressing
to prevent infection & to
promote wound healing
Pain Assessment
Palliative Factors The pain does not subside by taking paracetamol.
The pain is aggravated by not healing left foot sole ulceration.
Provocative Factors
Quality The pain is sharp/ steady in nature with foul smelling pus discharge.
Region Left foot sole

Radiation Left foot
Severity* Pain scale: 5/10
Timing: Onset The pain started at night 3 days ago

The pain is still present since 3 days ago
Timing: Duration
Continuous abdominal pain that has started 3 days ago
Timing: Frequency
* Pain Scale used for severity assessment:
FACES pain rating scale for patients approximately 3 years of age and older
8

Visual analog scale for school-age children and adolescents
FLACC (Faces, Legs, Arms, Cry, Consolability) Scale for infants and preverbal children
Numeric rating scale for older school-age children and adolescents
Past Medical History

Patient’s definition of own health Unhealthy & a lot of disease person
Past medical history (PMH), to include With a long history of type 2
hospitalization/ surgeries: diabetes (> 5 years), dyslipidemia and hypertension
Respiratory disease Infectious disease
Cardiovascular disease; risk Hematologic disease
factors Immunosuppression
Current or preexisting
Neurologic disease Autoimmune disease
diseases/illness/injuries/surgeries
Endocrine disease Psychological disorders
Hepatic disease psychiatric or mental health
Others, Specify:
Medication—prescription, OTC
Food
Allergies Latex
Iodine
Environmental (dust)
Pneumococci
Immunization status Influenza
Tetanus
Childhood illnesses
Psychological/social/environmental factors
Smoking: Smoking history 5 years ago
Substance and/or alcohol Not using

use/abuse:
Possible/actual assault, abuse, or intimate partner violence
situations
Safety Use of seat belts
Texting while driving
Drinking and driving
Psychiatric history (personal or family No personal or family history
members):
Literacy (level of Education) College undergraduate
Behavior appropriate for age and Gradual decline of physical abilities and the awareness of mortality.
developmental stage:
9

Occupation/profession: Business man
Meaning of illness, injury, or event to Poor health condition
patient/family:
Patient’s/family’s expectations of care: High-standard/quality of care
Family structure
Significant others
Support system: Social agencies
Religious affiliation
Caregivers
Self
Responsibilities Family
Business
Community
Cultural beliefs and practices: Islamic culture
Spirituality: Muslim
House
Apartment
Living accommodations
Accessibility (e.g., stairs)
Homeless, shelters
Affordability and accessibility to care- Average
Socioeconomic status:
History of descriptive and non-descriptive medications:
Descriptive medications (Prescribed by physician/doctor):
Generic Name & /
Trade Name Dosage Frequency Route
Classification
Gliclazide Diamicron 80 mg BID Oral
Metformin Glucophage 500 mg BID Oral
Insulin NPH, Regular Mixtard 30 units BID Subcutaneous Injection
Amlodipine Norvasc 10 mg Once a day Oral
Losartan Cozaar 50mg Once a day Oral
Atorvastatin Lipitor 10mg Once a day Oral
Non-descriptive medications: Legal/ illegal, over the counter drugs (OTC):
Generic Name &
Trade Name Frequency Route Rationale
/Classification
Paracetamol/ Panadol BID Oral To relieve fever, headache or
Acetaminophen body pain
10

Head-to-Toe Assessment (Review of Systems)
General appearance
-Tired & drowsy behavior due to body weakness
-Foul smelling pus discharge on the left foot ulceration
-Unsteady posture/gait/mobility due to ulceration of the left foot
-Mild-moderate discomfort due to left foot pain
-Gradual-onset of weight loss
Skin/mucous membranes/nail beds
-Skin color- pinkish
-Skin moisture- dry
-Skin temperature- warm & flushed
-Decreased skin turgor
-Mucous membranes- dry
-Integrity- ulceration on the sole of his left foot
Head and face
-Normal skin integrity
-No ecchymosis & facial edema
-Symmetrical facial feature
Eyes/ Ear/ Nose/ Mouth/ Neck
Eyes
-Slightly blurred vision
-Normal reaction to light (PERRLA)
Ears
-Normal ears symmetry
-No any ear drainage & hematoma
Nose
-No bleeding/discharge/swelling/deformity
-Normal symmetry of the nose
Mouth
-Normal inspection of gums/mucosa
-Normal tongue color/movement
-Sweet & fruity-smelling breath
Neck
-Normal tracheal position
-Normal neck veins
-No deformity along cervical spine
Chest
11

-Normal symmetry & integrity of the chest wall
-Kussmaul breathing (rapid & shallow breathing)
Abdomen/flanks
-Mild epigastric tenderness through palpation
-(-)Rebound tenderness
-Presence of bowel sounds in all the quadrants of the abdomen.
Pelvis/perineum
-Symmetrical pelvis
-Unsteady gait/posture due to left foot ulceration
Extremities
-Symmetrical extremities
-Skin integrity- Ulceration on the sole of left foot with adjacent cellulitis extending to the knee
-Left foot pain
-Weak & thready peripheral pulse
-Skin temperature: warm & dry to touch
Posterior Surfaces
-No potential for spinal injury
-No tenderness/deformity
Currently Described Medications

Generic Name
Trade Name/
(Dosage, Route, Adverse Reactions Nursing Responsibilities
Classification
Frequency)
Nausea, vomiting, - Stop taking the medication.
Metformin stomach upset, diarrhea, -Informed the physician right
Glucophage
(1000mg/Orally /BID) weakness, or a metallic away to change or to give
taste in the mouth. other prescribed medication.
- Stop taking the medication.
Stomach ache or
Gliclazide -Informed the physician right
Diamicron indigestion, nausea,
(80mg/Orally/BID) away to change or to give
vomiting, & diarrhea
other prescribed medication.
-Give 15-20 grams of fasting-
carbohydrates.
Insulin NPH, Regular Hypoglycemia
Mixtard -Informed the physician
(30 units/SQ/BID)
-Recheck blood sugar level
after 15 minutes.
Amoxicillin / Cluvalanic Nausea, vomiting, -Stop taking medication.
Augmentin
Acid (1G/Orally/BID) headache, diarrhea, -Informed the physician right
12

stomach pain, skin rash
or itching, white patches away to change or to give
in your mouth or throat, other prescribed medication.
& vaginal yeast infection. -Adequate fluid hydration.
-Slow administration of the
An allergic reaction, medication.
which can cause a rash -Stop the infusion if any
and swelling, flushing, adverse effect seen in the
Paracetamol 1G Q6hrs IV Paracetol low blood pressure and a patient.
fast heartbeat. -Inform the doctor right away
if you’ve seen any of this
adverse effect after taking the
medication.
Treatments/Therapeutic Regimens/Doctor Orders rather than Medications

(e.g. oxygenation, ventilation, intubation, cardioversion, IV therapy, etc.)
Infuse 0.9% normal saline drip-large bore cannula for the 1 st hour.
Infuse a fixed rate intravenous insulin infusion (0.1 unit/kg/hr) through infusion pump for the 1 st hour.
Assess & monitor the patient vital signs and laboratory investigations.
Look for precipitating causes & treat accordingly-infected foot ulcer.
Reassess the patient, monitor vital signs & response to treatment for the 2 nd -6th hour.
Additional measures: Fluid balance chart, urinary catheterization, NG tube, ABG, & ECG if indicated.
Reassess patient, monitor vital signs (reduce fluid; K balance; blood glucose < 14 mmol/l – D5% infusion)
for the 6th-12th hour.
Reassess cardiovascular status at 12 hours; further fluid may be required; Check for fluid overload.
Review biochemical and metabolic parameters: check for resolution of DKA; referral to diabetes team.
Reassess patient, monitor vital signs, review biochemical and metabolic parameters for the 12 th-24th hour.
13

NURSING CARE PLAN
Priority Nursing
Assessment Planning Nursing intervention Rationale Evaluation
Diagnosis
Subjective Data: Deficient knowledge After 8 hours of 1. Establish rapport and - Create an After 8 hours of
“I don’t know that my related to unfamiliarity nursing intervention trust. environment where nursing intervention
blood sugar is high with the risk factors, the patient will: trust and good rapport the patient:
already.”– as verbalized treatment, and facilitates good
by the patient. prevention of the Short Term Goal relationship in the Short Term Goal
disease as evidenced -Verbalize learning process. - Verbalized
by inaccurate follow- understanding of the understanding of the
through of instructions, disease condition and 2. Explain the signs and -Symptoms of disease condition and
Objective Data:
development of potential symptoms of diabetic hyperglycemia include potential
- Inaccurate follow-
preventable complication. ketoacidosis. polyuria, polydipsia, complication.
through of instructions,
complications. -Correctly perform polyphagia, flushed -Correctly performed
development of
necessary procedures skin, and body malaise. necessary procedures
preventable
and explain rationale and explain rationale
complications.
on each action. 3. Discuss the following - Baseline knowledge on each action.
-Demonstrate with the client; normal enables the client to -Demonstrated
V/S as follows:
lifestyle changes and blood glucose level, risk make informed lifestyle changes and
-T- 37.6℃
participate in factors, type of diabetes, lifestyle choices. participate in
-BP- 110/72 mmHg
treatment regimen. & the relationship treatment regimen.
-PR- 88 bpm
between elevated
-RR- 21cpm
Long Term Goal glucose level and insulin Long Term Goal
-SpO2- 94%
-Maintain lifestyle deficiency. -Maintain lifestyle
modification to modification to
normalize his blood 4. Demonstrate proper - Monitoring blood normalize his blood
14

glucose level. blood glucose testing glucose 3-4 times a day glucose level.
using the glucometer. is an essential part of
managing diabetes to -Goal partially met
avoid further
complications.
5. Teach signs of - These are signs of

hypoglycemia; dizziness, excessive insulin
sweating, hunger, pallor, dosage, resulting in
diaphoresis, hypoglycemia.
nervousness, & tremors.
6. Teach client that - These are signs of

polyuria, polydipsia, and insufficient insulin
polyphagia are signs of dosage and
hyperglycemia which hyperglycemia which
requires increased may lead to coma and
dosage of insulin. death if untreated.
7. Explain the - Medical nutrition

importance of having a therapy is important in
dietary plan; managing diabetes and
limit intake of simple preventing the rate of
sugar, fat, salt and development of
alcohol & increase intake diabetes complications.
of whole grains, fruits,
15
Priority Nursing
Diagnosis
Subjective Data: Risk for infection After 8 hours of 1. Assess for signs of - Infection is a common After 8 hours of
“My wound is not related to high glucose nursing intervention infection and cause of DKA. Signs of nursing intervention
healing for 2 weeks levels & decreased the patient will: inflammation. infection includes the patient:
already.”-as verbalized leukocytes function. fever, chills, dysuria,
by the patient Short term goals: and increased WBC Short term goals:
-Identify count. -Identified
interventions to interventions to
prevent reduce risk 2. Observe client’s feet -Due to impaired prevent reduce risk
of infection. for ulcers, infected circulation in diabetes, of infection.
-Demonstrate toenails, or other foot injuries are -Demonstrated
techniques, lifestyle medical problems. predisposed to poor techniques, lifestyle
Objective Data: changes to prevent wound healing. changes to prevent
-Flushed skin appearance the development of the development of
-Wound drainage infection. 3. Observe aseptic -Elevated blood sugar infection.
-Open wound technique during IV weakens the immune
-Hyperglycemia Long term goals: insertion and medication system thus clients are Long term goals:
(RBS: >500 mg/dL) -Maintain healthy administration. more prone to -Maintained healthy
lifestyle for the infection. lifestyle for the
V/S as follows: normalization of normalization of
-T- 37.6℃ blood glucose & to 4. Provide skin care. -An intact skin protects blood glucose & to
-BP- 110/72 mmHg prevent development against infection. prevent development
-PR- 88 bpm of infection. of infection.
-RR- 21cpm 5. Encourage proper -To avoid the risk of
-SpO2- 94% handwashing technique. cross-contamination. -Goal partially met.
6. Encourage adequate -Reduces susceptibility
oral fluid intake (2-3 to infection.
liters a day unless
contraindicated).
7. Encourage deep -Helps in mobilizing

breathing exercise; secretions. And
Maintain client in semi- expanding the lung.
Fowler’s position.
8. Obtain sample for -Identifies the

culture and sensitivity as bacteria/fungus that
indicated. causes an infection and
the appropriate drug
for it.
9. Administer antibiotics -Early initiation of

as indicated. antibiotic may help to
prevent sepsis.
Priority Nursing
Diagnosis
Subjective Data: Risk for fluid volume After 8 hours of 1. Assess precipitating - These will provide After 8 hours of
“I’m so tired today, had deficit related to nursing intervention factors such as other baseline data for nursing intervention
vomited 3x today excessive gastric losses the patient will: illnesses, new- education once with the patient:
already, peed a lot & I’m due to nausea and onset diabetes, or poor resolved
so thirsty lately.”-as vomiting & Short term goals: compliance with hyperglycemia. Short term goals:
verbalized by the patient. hyperglycemia-induced treatment regimen.
osmotic diuresis. -Remain -Remained
normovolemic as 2. Assess skin turgor, -Skin turgor will normovolemic as
Objective Data: evidenced by urinary mucous membranes, and decrease and tenting evidenced by urinary
-Nausea & vomiting output >30 ml/hr, thirst. may occur. The oral output >30 ml/hr,
-Poor skin turgor normal skin turgor, mucous membranes normal skin turgor,
-Sudden weight loss good capillary refill, will become dry, and good capillary refill,
-Body weakness/fatigue normal blood the client may normal blood
-Frequent urination pressure, palpable experience extreme pressure, palpable
-Fruity-scented breath peripheral pulses, & thirst. peripheral pulses, &
-Hyperglycemia blood glucose levels blood glucose levels
(RBS: >500 mg/dL) between 70-200 3. Monitor hourly intake -Oliguria or anuria between 70-200
-(+3) urine ketone levels mg/dl. and output. results from reduced mg/dl.
-Kussmaul respirations glomerular filtration
-ABG: Metabolic acidosis and renal blood flow. -Goal met.
V/S as follows: 4. Monitor respirations, -Acetone breath is due

-T- 37.6℃ acetone breath, to the breakdown of
-BP- 110/72 mmHg Kussmaul’s respirations. acetoacetic acid.
-PR- 88 bpm Kussmaul’s respiration
-RR- 21cpm (rapid and shallow
-SpO2- 94% breathing) the
respiratory buffering
system to raise arterial
pH by exhaling more
carbon dioxide.
5. Monitor BP especially -Decreased blood

for orthostatic volume may be
hypotension. manifested by a drop
in systolic blood
pressure and
orthostatic
hypotension.
6. Monitor temperature. -Fever with flushed,

dry skin may indicate
dehydration.
7. Assess neurological -Decreased level of

status every two (2) consciousness results
hours. from blood volume
depletion, elevated or
decreased glucose
level, hypoxia or
electrolyte imbalances.
8. Weigh client daily. -Provides baseline data

of current fluid status
and adequacy of fluid
replacement. A weight
loss of 2.2 lbs over 24
hours indicates a 1 liter
of fluid loss.
9. Monitor laboratory -Any alterations or

studies; blood glucose elevations in these
level, serum ketones, K, laboratory results
Na, blood urea nitrogen indicate of DKA, HHNS
& creatinine. and acute renal failure.
10. Insert indwelling -To provide accurate

urinary catheter as measurement of
indicated. urinary output.
11. Administer fluid as -Initial goal of therapy

indicated: Isotonic is to correct circulatory
solution (0.9% NaCl). fluid volume deficit.
12. Administer an IV -Regular insulin has a

bolus dose of regular rapid onset and
insulin, followed by a therefore immediately
continuous infusion of helps move glucose
regular insulin. intracellularly.
13. Administer IV -Potaasium is added to

potassium and other the IV once serum
electrolytes as indicated. potassium drops below
5.5 mEq/L to prevent
hypokalemia.
14. Administer -This is given in clients

bicarbonate as indicated. with a severe
hyperkalemia and
severe acidosis with pH
of less than 7.1.
15. Add dextrose to IV -Dextrose is added to
fluid when serum blood prevent the occurrence
glucose level is less than of hypoglycemia and
250 mg/dL in DKA or less an excessive decline in
than 300 mg/dL in HHNS. plasma osmolality.
References
1. https://www.ncbi.nlm.nih.gov/books/NBK279146/#:~:text=Insulin%20deficiency%2C%20increased%20insulin%20
counter,underlie%20the%20pathophysiology%20of%20DKA.
2. http://www.pathophys.org/hyperglycemic-emergencies-diabetic-ketoacidosis-and-hyperosmolar-hyperglycemia-
state/

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Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Education ‫وزارة التعليم‬

Emergency Nursing Care I Practical (NURS 516)

Healthcare Record Number (HRN):

Last oral intake: 2 hours ago

Emergency Nursing Care I Practical (NURS 516)

Emergency Nursing Care I Practical (NURS 516)

Palliative Factors Patient’s fever was relieved by paracetamol

Aggravated by ulceration of the left foot

History of Present Illness/injury/chief complaint: (NAUSEA & VOMITING)

Unknown provocative factors

Emergency Nursing Care I Practical (NURS 516)

History of Present Illness/injury/chief complaint: (BODY WEAKNESS)

Palliative Factors Not treated with anything, no medication taken

Unknown provocative factors

History of Present Illness/injury/chief complaint: (PAINFUL LEFT FOOT ULCER)

Emergency Nursing Care I Practical (NURS 516)

Pathophysiology of the Disease/ Patient condition/ Medical Diagnosis

Utilization of the glucose Lyposis Proteolysis Glycogenolysis

FFA to the liver Gluconeogenesis

Emergency Nursing Care I Practical (NURS 516)

Emergency Nursing Care I Practical (NURS 516)

-Normalize the blood glucose.

Emergency Nursing Care I Practical (NURS 516)

-Normalize the blood glucose

Region Left foot sole

Timing: Onset The pain started at night 3 days ago

Emergency Nursing Care I Practical (NURS 516)

Past Medical History

Substance and/or alcohol Not using

Emergency Nursing Care I Practical (NURS 516)

Emergency Nursing Care I Practical (NURS 516)

Emergency Nursing Care I Practical (NURS 516)

Currently Described Medications

Emergency Nursing Care I Practical (NURS 516)

Treatments/Therapeutic Regimens/Doctor Orders rather than Medications

Look for precipitating causes & treat accordingly-infected foot ulcer.

Emergency Nursing Care I Practical (NURS 516)

Emergency Nursing Care I Practical (NURS 516)

5. Teach signs of - These are signs of

6. Teach client that - These are signs of

7. Explain the - Medical nutrition

7. Encourage deep -Helps in mobilizing

8. Obtain sample for -Identifies the

9. Administer antibiotics -Early initiation of

V/S as follows: 4. Monitor respirations, -Acetone breath is due

5. Monitor BP especially -Decreased blood

6. Monitor temperature. -Fever with flushed,

7. Assess neurological -Decreased level of

8. Weigh client daily. -Provides baseline data

9. Monitor laboratory -Any alterations or

10. Insert indwelling -To provide accurate

11. Administer fluid as -Initial goal of therapy

12. Administer an IV -Regular insulin has a

13. Administer IV -Potaasium is added to

14. Administer -This is given in clients

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