A Case Presentation on Diabetic Ketoacidosis

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Pediatric Ward

Date of Submission
 TABLE OF CONTENTS
I. _
LIST OF FIGURES
LIST OF TABLES
I. INTRODUCTION

Diabetic Ketoacidosis (DKA) in children is defined as a metabolic

derangement caused by the absolute or relative deficiency of the anabolic
hormone – insulin. It is a condition in which the common manifestation as
hyperglycemia (blood glucose level over 11mmol/L), venous pH below 7.3
or serum bicarbonate level below 15 mmol/L, and either the presence of
ketonemia or moderate to high ketonuria. Together with the major
complication of cerebral edema, it is the most important cause of mortality
and severe morbidity in children with diabetes.

The most common causes include newly diagnosed diabetes, an

illness, or a failure to comply with treatment. DKA is more common in type
1 diabetic patients, although it can also develop in patients with type 2
DM. Triggering factors may include, catabolic stress from acute disease
or injury, such as trauma, surgery or infections.

A. Definition of Terms
1. Diabetic Ketoacidosis- is an acute, major, life-threatening
complication of diabetes characterized by hyperglycemia,
ketoacidosis, and ketonuria.
2. Diabetes Mellitus-is a metabolic disease, involving
inappropriately elevated blood glucose levels.

B. Epidemiology
 Occurs primarily in adult patients with TYPE 1 DM. The incidence
is roughly 2 episodes per 100 patients per years of diabetes, with
about 3% of patients with TYPE 1 DM initially presenting with
DKA.
 Young children are more likely to have DKA as first presentation of
type 1 diabetes than older children. DKA is the first presentation of
diabetes in 30-40 % of Pediatric cases.
II. PATIENT’S HISTORY
Name: Patient T.E. Age: 16 years old Sex: Female
Residence: Calabanga, Camarines Sur
Religion: Roman Catholic

 Chief Complaint: Body Weakness

 History of Present Illness:
 Patient is known to have Diabetes Mellitus, on maintenance of
insulin injection and on multivitamins. Interim, patient is apparently
 well until few hours prior to admission, (+) abdominal pain and
body weakness. Hence consult and subsequently admitted.
Parent/ mother revealed patient was fond of eating junk food and
sweets
 Past Medical History: Diabetes Mellitus ( March 2022);
Admission (March 21-29,2023) due to DM
 Allergies: None
 Social History: Unremarkable
 Family History: Diabetes Mellitus on Maternal Side
 Immunization: BCG, OPV, DPT, MMR
 Medications: Novomix, Multivitamins with Iron

III. ASSESSMENT
 V/S:
o BP- 90/70
o CR- 118
o RR- 20
o T- 36.4C
o SPO2- 96%

 Wt: 24 kg Ht: 145cm

 AVPU: Alert (Awake, conscious, coherent, not in distress)
 GCS: E4V5M6 = 15
 ABCs:
o Airway- Clear
o Breathing- Regular, Normal depth & quality, (-)
dyspnea, (-) cyanosis
o Circulation- <2 sec
o Pulse- Strong
o Skin- warm

IV. THEORETICAL FRAMEWORK

V. ANATOMY AND PHYSIOLOGY

The pancreas performs two critical tasks:

 It produces digestive enzymes that help break down the food you
eat,
  it regulates your blood sugar by secreting insulin.

 Scattered throughout the pancreas, are little collections of cells

called Islets of Langerhans. These cells are responsible for the
other function of the pancreas, regulating insulin levels

CLINICAL MANIFESTATIONS:

VI. LABORATORIES & DIAGNOSTIC FINDINGS

Upon arrival in the Hospital, a child or young children with suspected DKA
should have immediate:

 Capillary Blood Glucose

 Capillary Blood Ketones, if near-patient testing is available, urine
ketones if not.
 Capillary or venous pH and Bicarbonate.
VII. PROCEDURES AND ITS NURSING RESPONSIBILITIES
A. Nursing Management
B. Treatment
 General resuscitation:
o IV ACCESS : PNSS Il + 40meqs KCL and insulin drip
 Precise patient weight is necessary for
calculating insulin and other medication
dosing.
o 1cc + 99cc PNSS = 100cc to run @ 2.4 cc/hr
 Potassium replacement
 o 40meqs KCL in PNSS
o KCL tab, 1 tab 3x a day for 3 doses
 Insulin injection
o Humulin R SC
o Novomix 30 SC
VIII. DRUG STUDY
MEDICATION INDICATION NURSING CONSIDERATION

NOVOMIX used to treat patients  The dose of NovoMix depends on the

who have diabetes and patient’s blood glucose levels, which
need insulin to keep should be tested regularly to find an
their blood glucose effective dose. The medicines are
(sugar) level controlled. normally given shortly before a meal,
but can be given just after a meal if
necessary.
POTASSIUM a mineral supplement  To prevent stomach upset, take each
CHLORIDE (KCL) used to treat or prevent dose with a meal and a full glass of
tablet low amounts of water
potassium in the blood  Do not lie down for at least 10
minutes after taking this medication.
 Do not crush, chew, or suck on the
tablets. Doing so can release all of
the drug at once, increasing the risk
of side effects

IX. NURSING CARE PLAN

X. DISCHARGE PLAN
Medications NOVOMIX 30 40 UNITS IN AM POST MEALS,
NOVOMIX 30 18 UNITS IN PM POST MEALS.

Exercise ENCOURAGED ADEQUATE EXERCISE AS TOLERATED.

Health Teaching ADVISED TO CONTINUE CBG MONITORING EVERY

MORNING PRE-BREAKFAST AND PRE DINNER.

Out-patient FOLLOW UP AT ENDOCRINOLOGY CLINIC AFTER 1

MONTH WITH LATEST URINALYSIS RESULT.

Diet ENCOURAGED FEEDING (DIABETIC DIET) AND

ADEQUATE FLUID INTAKE

Sexuality or ENCOURAGED TO CONTINUE HER RELIGIOUS

Spirituality ACTIVITIES

XI. CARE PATHWAY

 MAY 16, 2023 DOCTOR’S ORDER

11:40 AM MAY FEED WITH STRICT ASPIRATION PRECAUTION.

REFER TO DIETARY SERVICE FOR NUTRITIONAL BUILD-UP.
LATEST CBG: CBG MONITORING NOW THEN EVERY 2 HOURS, RECORD
372 mg/dl AND INFORM PROD.
IVF:PNSS 1L + 40 MEQ KCL@ 26 GTTS/MIN

INSULIN DRIP:
PNSS 99cc
INSULIN: 1cc
100 cc @ 2.4cc/hour via infusion pump.
SECURE NOVOMIX 30, INFORM PROD ONCE AVAILABLE.

CONTINUE VITAL SIGNS MONITORING EVERY 4 HOURS

WITH BP AND O2SAT. STRICT INPUT AND OUTPUT
MONITORING EVERY SHIFT.

REFER FOR HYPERGLYCEMIA, DOB, CHANGE IN

SENSORIUM OR ANY UNTOWARD S/SX.

MAY 19, 2023 DOCTOR’S ORDER

10:45 AM CONTINUE DIABETIC DIET AS ORDERED.

LATEST CBG: CBG MONITORING PRE-MEALS.
230 mg/dl
K+:3.3 IVF TO CONSUME THEN HEPLOCK
DISCONTINUE INSULIN DRIP
CONTINUE PRESENT MEDICATIONS AS ORDERED.
CONTINUE VITAL SIGNS MONITORING EVERY 4 HOURS WITH
BP AND O2 SAT.
STRICT INPUT AND OUTPUT MONITORING EVERY SHIFT.

REFER FOR HYPERGLYCEMIA, DOB, CHANGE IN SENSORIUM

OR ANY UNTOWARD S/SX.

MAY 20, 2023 DOCTOR’S ORDER

10:23 AM CONTINUE DIABETIC DIET AS ORDERED.

LATEST CBG: CONTINUE CBG MONITORING PRE-MEALS.
263 mg/dl GIVE NOVOMIX 30, 36 UNITS SUBCUTANEOUS
IVF : HEPLOCK
 CONTINUE PRESENT MEDICATIONS AS ORDERED.
CONTINUE VITAL SIGNS MONITORING EVERY 4 HOURS WITH
BP AND O2 SAT.
STRICT INPUT AND OUTPUT MONITORING EVERY SHIFT.
REFER FOR HYPERGLYCEMIA, DOB, CHANGE IN SENSORIUM
OR ANY UNTOWARD S/SX.

MAY 21, 2023 DOCTOR’S ORDER

09:45 AM MAY GO HOME.

LATEST CBG: FOR DAILY CBG MONITORING, PLEASE SECURE BOOKLET OR
218 mg/dl DIARY.
FOR URINALYSIS UPON FOLLOW-UP AT ENDOCRINOLOGY
CLINIC AFTER 1 MONTH.
CONTINUE NOVOMIX 30, GIVE 40 UNITS IN AM POST MEALS
THEN, NOVOMIX 30 18 UNITS IN PM POST MEALS.

XII. REFERENCES

• American Diabetes Association: "DKA (Ketoacidosis) & Ketones,"

"Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)."
• Mayo Clinic: "Diabetic Ketoacidosis."
• Beth Israel Lahey Health Winchester Hospital: “Diabetic Ketoacidosis.”
• American Association for Clinical Chemistry: “Comprehensive Metabolic
Panel (CMP).”
• El-Mohandes, N. (2023b, February 9). Pediatric Diabetic Ketoacidosis.
StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK470282/
• Diabetic Ketoacidosis. (2021, March 25). Centers for Disease Control and
Prevention. https://www.cdc.gov/diabetes/basics/diabetic-
ketoacidosis.html#:~:text=Diabetic%20ketoacidosis%20(DKA)%20is
%20a,cells%20for%20use%20as%20energy.
• https://www.olivelab.org/the-pancreas-overview.html
• https://www.webmd.com/drugs/2/drug-676-7058/potassium-chloride-oral/
potassium-extended-release-dispersible-tablet-oral/details