Mr. L is a 58-year-old man who is recovering in the orthopedicunit of the hospital from a right total knee replacement of twodays ago. Mr. L has type 1 diabetes and was diagnosed with thecondition at 12 years of age. He has been managing his illness withblood glucose checks 4 times a day: before meals and once atbedtime. He currently takes Humulin-R on a sliding scale based onhis glucose results. He weighs 315 lbs. and has developedosteoarthritis in both knees, requiring surgical replacement of theknee joint on the right side. The nurse caring for Mr.L. enters hisroom at 8:15 AM for a morning assessment. She finds Mr. L lying inhis bed awake, but his mental status is altered and there is afruity odor to his breath. His vital signs are: HR 100bpm, RR32/minute, BP 116/78 mm Hg. The nurse notes that his last bloodglucose level was 156 mg/dl the previous night before bed and hereceived 2 units of insulin at that time, but he has not receivedhis morning glucose check or any insulin yet today. A rapid bedsideglucose check reveals a blood glucose level of 468 mg/dl. The nursecontacts the physician and upon further examination, Mr. L isdiagnosed with diabetic ketoacidosis. The physician has givenorders to administer 0.9% Sodium Chloride IV at 500 mL/hour for 1hour, then 200mL/hour for the next 4 hours. The nurse is to start adrip of Regular insulin at 0>1mg/kg/hour. The physician has alsoadded orders for lab work, including a metabolic profile andarterial blood gases. The metabolic panel results are: Na 135mEq/L, K 3.2mEq/l, CL 95mmol/L, Ca 8.5mg/dl. The arterial bloodgases results are as follows: ph 7.31, pCO2 20 mmHg, pO2 95 mmHg,HCO3 12 mmol/L
What is the rationale for the IV fluids to be given at thisrate?
Explain why the patient’s potassium result is at the currentlevel?
Based on the metabolic profile results, what is the next stepthat the nurse would most likely need to perform?
Explain why DKA would most likely produce these types of bloodgas results.
An hour after the insulin was started, the nurse checks Mr. L.’sblood glucose levels and notes it has decreased to 208 mg/dl. Heappears more comfortable and his vital signs are: HR 92 bpm, RR 22/minute, BP 116/70mm Hg, O2 saturation 95% on 2L of oxygen.
What should the nurse do next?
