Case Study #2 DKA

02/19/16
KNH 413
Gretchen Matuszak
Brooke Bryant

1. There are precipitating factors for diabetics ketoacidosis. List at least seven possible
factors.
Factors precipitating in diabetic ketoacidosis include illness, problems with insulin therapy
resulting in to little insulin, physical or emotional trauma, heart attack, alcohol or drug abuse,
certain medications such as corticosteroids and some diuretics, vomiting and excessive fluid loss
(Mayo Clinic, 2015).
2. Describe the Metabolic events leading up to the symptoms associated with DKA.
Metabolic acidosis occurs when the body produces too much acid, or when the kidneys are not
removing enough acid from the body. Diabetic ketoacidosis is caused by the buildup of ketones
throughout the body. This is a result of Type I diabetes not being controlled and monitored.
Hyperchloremic acidosis results from excessive loss of sodium bicarbonate from the body. This
can occur with severe diarrhea. The last type of acidosis is a result of lactic acid build up in the
body causing the acidity to increase in the blood (Medline, 2016).
3. Assess Susans physical examination. What is consistent with diabetic ketoacidosis? Give
the physiological rationale for each that you identified.
Susans physical symptoms that are consistent with diabetic ketoacidosis are as followed: sunken
contact lenses in both eyes, membranes dry within ears, dry mucous membranes within nose, dry
flushed skin, poor turgor, deep rapid Kussmauls respirations, tender with guarding decreased
bowel sounds in the abdomen, and Tachycardia within the heart. These are all symptoms that
Susan experienced that Nelms gives for symptoms related to ketoacidosis (Nelms, 506). Susan
also came into the ER complaining of fatigue , nausea, vomiting, and intense thirst which are all
symptoms of DKA.When adequate insulin is not available, glucose production via

gluconeogenesis and lipolysis are stimulated by counter-regulatory hormones in an effort to

avoid starvation. The by-product of lipolysis is ketones and as glucose and ketones accumulate in
the bloodstream, osmotic diuresis occurs, resulting in dehydration and electrolyte imbalances and
as the fluid is lost the blood becomes concentrated causing hyperglycemia. (Nelms, 505).
4. Examine Susans biochemical indices both in the chemistry section and in her ABG
report. Which are consistent with DKA? Why?
Susans biochemical and chemistry section and her ABG indicated that her Potassium, Chloride,
Osmoility, BUN, Creatine, CHOL, PO4 and HbA1c were all high and her total CO2 was low.
These values show that her kidneys are not excreting the proper amount of acid out of her body
making these levels high. The kidneys are not functioning correctly due to the lack of insulin to
maintain these levels. These levels also indicate that Susan is dehydrated which will lead to the
buildup of ketones within the body and complication to her ph. Susan also tested positive for
glucose and ketones in her urine which support the diagnosis of DKA. Another indication of
DKA presence is a glucose level reading above250 and Susans glucose reading was 475 (Nelms,
506-507).
5.If Susans symptoms were left untreated what would happen?
If DKA is left untreated the body would continue to build up ketones and it will continue to
cause Susans blood pH to stray from normal levels. This then can lead to brain swelling, coma,
severe dehydration and sometimes death. Other side effects of leaving DKA untreated are heart
and respiratory problems causing in trouble breathing. (Diabeticforecast, 2010).
6. Assuming Susans SMBG records are correct, what events seem to have precipitated the
development of DKA?

Based on Susans Blood glucose readings her readings were steady all the way up till the start of
her period. Once her period started her glucose began to rise steadily. While Susan was on her
period she had a volleyball tournament where her glucose reading remained high and then on her
Birthday and from that point on her glucose readings stayed in the upper 200s-300s. These
readings steadily increasing have to do with not having the right amount of insulin and the
buildup of ketones in the blood stream.
7. What, if anything could Susan have done to avoid DKA?
Susan could have avoided DKA by watching her glucose readings more carefully and when she
saw that they were increasing she could of adjusted the amount of insulin needed to get them to
the proper level. Susan could have also taken into consideration the amount of physical activity
she was doing and increased her insulin intake to account for the physical activity that she was
doing. Also normally on birthdays and for teenagers cake and other high carbohydrate foods like
pizza are consumed so she would of needed to account for the extra carbs and monitored her
glucose and adjusted insulin accordingly. Susan could also monitor her carb intake for her diet
each day when her glucose levels start to increase. It could of also been prevented by staying
hydrated throughout the day (Nelms,506).
8. While Susan is being stabilized, Tagamet is being given IV piggyback. What does IV
piggyback mean? What is Tagamet, and why has it been prescribed?
An IV piggyback is a secondary IV that is attached to the main port of the primary IV port. If a
patient is receiving continuous IV fluids and/or medication and in addition must receive a second
kind of intermittent infusion, or if a patients current IV infusion must be interrupted in order to
administer a second IV medication or fluid that is more pressing, there will need to be another

bag to hang a secondary IV for the patient (cwlaids,2012). Tagamet is used as a H2 blocker or a
histamine blocker. It works by blocking the release of histamine that produces acid within the
stomach. Tagamet is used to treat gastrointestinal bleeding, ulcer, inflammation of the GI tract,
and GERD (Tagamet, 2015). Susans doctors most likely prescribed this to get her pH back to
normal since her pH is lower due to the DKA. This would help stabilize her pH and help her
body get rid of the excess ketones and glucose that is in her system.
9. The Diabetes Control and Complication Trial was a landmark multicenter trial designed
to test the proposition that complications of diabetes mellitus are related to elevation of
plasma glucose. It is the longest and largest prospective study showing that lowering blood
glucose concentration slows or prevents development of complications common to the
individuals with diabetes. The trial compared intensive insulin therapy (tight control)
with conventional insulin therapy. Define intensive insulin therapy. Define
Conventional insulin therapy.

Intensive insulin therapy is best defined as a comprehensive system of diabetes

management with the patient and management team as partners. The system is directed at
improvement of glycaemia and patient well-being. Glycemic targets should be
individually defined. The patient is given multiple bolus injections throughout the day

and basal insulin twice a day (Hirsch,1990).

Conventional therapy usually involves one to three daily injections that are the same
every day. The types of insulin that you take and the number of injections and dose
sizes are determined based on how much food you eat, when you eat, how much
activity you have in a typical day and other factors (Diabeteslearningservices,2014).

10. List the microvascular and neurologic complications associated with type I diabetes.

Complications associated with type I diabetes are Cardiovascular disease, Nephropathy,

Retinopathy, and nervous system diseases. Cardiovascular lesions are the most common cause
for premature death in individuals with type I diabetes. About 65% of deaths occur due to heart
disease-related and is two times higher in people with diabetes. Hyperglycemia makes all
blood vessels prone to endothelial damage, leading to thickening and changes in the intimal
layer. This causes problems in blood pressure and how the blood vessels and valves function
(Nelms, 507).
Nephropathy occurs in 20%-40% of individuals with diabetes and is the single leading
cause of chronic kidney disease. Hyperglycemia results in changes in the structure of the blood
vessels of the glomerulus, the functioning unit of the kidney which is comprised of tuft
capillaries. Changes in these capillaries results in lack of filtration and increase of ketones and
toxins within the body, this in return leads to dialysis to be able to filtrate out toxins in the
body. Retinopathy is the most frequent cause of blindness in adults and prevalence of
retinopathy is strongly associated with diabetes. This is related to the hyperglycemia and the
damage to the blood vessels and lack of oxygen being transported throughout the body. Other
nervous system disease causes pain and loss of sensation in hands and feet. Because of the lack
of feeling consequences include not noticing injuries that lead to ulcerations, infection and
even amputations (Nelms,508).
11. What are the advantages of intensive insulin therapy?
Intensive insulin therapy can slow and prevent complications of long-term diabetes
complications. It can reduce the risk of eye damage by 75%. It can reduce the risk of nerve
damage by 60% and it can prevent and slow the progression of kidney disease by 50%.

Intensive insulin therapy keeps tight blood sugar levels and it can provide people with more
energy throughout the day (Mayoclinic,2014).
12. What are the risks of intensive insulin therapy (tight control)?
The risks of intensive insulin therapy are that if you suffer from low blood sugar levels it can
cause you to go too low. If a patient is not use to eating frequent meals or if they have a
tendency to work out can cause a person to go low. Also when you use insulin to lower your
blood sugar, the sugar in your bloodstream enters cells in your body instead of being excreted in
your urine. Your body converts the sugar your cells don't use for energy into fat, which can lead
to weight gain. This can cause problems with the cardiovascular system in return
(Mayoclinic,2014).
13. Dr. Green consults with you, and the two of you decide that Susan would benefit from
insulin pump therapy combined with CHO counting for intensive insulin therapy. This will
give Susan better glycemic control and more flexibility. What are some of the key
characteristics of candidates for intensive insulin therapy?
Some key characteristics of candidates for intensive insulin therapy include they are not at any
particular disease state such as chronic kidney disease, cardiovascular disease, and no other sever
complications. Patients that understand how to carb count and keep a food diary are candidates
for intensive insulin therapy because they are able to keep their sugar levels at the level they
need to be and this is crucial to intensive insulin therapy due to the tight control can cause insulin
to drop to low levels that are unsafe. Since Susan keeps a log of her glucose readings this helps
in monitoring and controlling her glucose at different times of the month for example during her

period when the levels can decrease or elevate and also when she is doing high activity levels
like playing volleyball (Nelms 503-507).
14. Explain how an insulin pump works. Is Susan a candidate for an insulin pump?
Basal insulin is delivered continuously over 24 hours, and keeps your blood glucose levels in
range between meals and overnight. Often, you program different amounts of insulin at different
times of the day and night. When you eat, you use buttons on the insulin pump to give
additional insulin called a bolus. Insulin pumps are inserted with a port and tube and there are
directions and on how to use and when to give extra insulin. There is also education on the
different types of insulin released through the insulin pump. Susan is a candidate for the pump
and it would be a good recommendation for her because she would be able to check her levels
and it would help maintain her insulin levels instead of her having to inject insulin every time
she was to get low. The regular injections arent as convenient for her seeing as she is a teenager
and might be playing a volleyball game and not realize she is going low midgame and a pump
would help this from happening. Proper education would be given to Susan and her family on
how the pump works and how it can be used.
15. How would you describe CHO counting to Susan and her family?
How I would describe CHO counting to Susan and her family is that it is a way to monitor the
amount of carbohydrates in her diet. She would keep a food journal that she records all the foods
she has ate throughout the day and how many carbs are in each one of them. Then I will explain
to her and her family about how carbohydrates increase glucose in the blood which in return
raises blood sugar. I would explain to the family that setting a goal each day of how many carbs
she can have and at certain meals will help her know when her blood sugar increases or

decreases so she can better monitor her glucose levels to help prevent DKA again and to help
monitor and maintain her diabetic health. I would also make up a list of common foods that
Susan eats and the amount of carbs they have in them and teach her and her family how to
recognize and make an estimate on how many carbs are in foods that dont have labels for
example when they go out to eat they will be able to make an estimate on just how many carbs
are in Susans dish (ADA, 2015).
16. How is CHO counting used with intensive insulin therapy?
Carb counting is used with intensive insulin therapy because the patient must know how many
carbs they are taking in per meal to know how much insulin they need to take to keep an
adequate blood glucose level. If to many carbohydrates are taken in then using intensive insulin
therapy more insulin must be given to account for the extra carbohydrates. Carb counting is also
used with intensive insulin therapy to be able to figure out how much basal insulin is needed
between meals to keep blood glucose levels in a healthy range (AAFP foundation, 2007).
17. Estimate Susans daily energy needs using the Harris-Benedict equation
655 + (9.56 x weight) + (1.85 x height) (4.68 x age)
655 + (9.56 x 57.2) + (1.85 x 160.02) (4.68 x 16)
655 + (546.832) + (296.037) (74.88)
= 1,422.989 kcal x 2.0 = 2,845.978 kcal
Kcal needed 2,800-2,900 per day

A 2.0 activity was used for Susan due to her activity level involving volleyball practice three
times a week and games/ tourneys two days out of the week. She is also recovering from DKA.
18. Using 1-week food diary from Susan, calculate the average amount of CHO usually
consumed each meal and snack.
100 grams of carbohydrate for breakfast
90 grams of carbohydrate for lunch
30 grams of carbohydrate for snack
90 grams of carbohydrate for dinner
17 grams of carbohydrate HS
19. After you have calculated Susans usual CHO intake from her food record, develop a
CHO-counting meal plan that she could use. Include menu ideas.
Daily Total:

Protein: 2,800-2,900kcal x .20= 560-580kcal of protein 4kcal/g=390-400grams of

protein.
Carbohydrates: 2,800-2,900 x .55= 1,549-1,595kcal of

carbohydrates/4kcal/g=390-400grams of carbohydrate
2,800-2,900 x .25=700-725kcal of Fat/ 9kcal/g=78-80grams of Fat.

Each Serving below of carbohydrate in the menu Ideas and options are in one serving so they can
be paired to make more than one carbohydrate choice so Susan can make the decision instead of

having to have one serving of something multiple times. Each serving of starch or grain is worth
15grams of carbohydrates, each serving of vegetable are worth 5 grams carbohydrate, each fruit
serving is worth 15grams and each milk containing item is worth 12 grams of carbohydrate
Time
7:30-8:00a.m

CHO Choice or Grams of CHO

CHO: 100grams or 6 choices of Carbs.

Menu Ideas and Options

1oz bread

Breakfast

Protein:35grams

1/4cup dry cereal

Fat:25grams

(unsweetened)
cup oatmeal
1 cup fruit of choice
5 peanut butter crackers.
1/2cup Cream of wheat
1whole fruit of choice
Granola bar
1 cup yogurt
1 cup milk

Lunch

CHO:100grams or 6 Carb choices

cup fruit juice

1/2cup pasta (Mac and

Protein: 35grams

cheese)

Fat:25grams

1/3 cup rice

1 cup of soup (Ex: Chicken
noodle)
1/3 cup lentials or beans
Half of a sandwhich
6 crackers with cheese or

peanut butter
1 cup fresh veggies
Protein bar
1cup milk
cup fruit juice
Dinner

CHO:150grams or 10 choices of Carb

1cup yogurt
1 cup milk

Protein:35grams

cup fruit juice

Fat:25gram

cup pasta
cup mashed potatoes
1/3 cup rice
1 cup fresh vegetables
1 cup fresh fruit
1/3 cup stuffing

Snack

CHO: 50 grams or 3 choices of carb

1/3 cup beans

3Cups popcorn

Protein:35gram

5-6 snack crackers

Fat:grams

1 serving of pretzels
1 small bag of chips
Gronola bar
1 cup yogurt
1 cup milk
cup fruit juice

20. Just before Susan is discharged, her mother asks you, My friend who owns a health
food store told me that Susan should use stevia instead of artificial sweeteners or sugar.
What do you think? What will you tell Susan and her mother?
I would begin by showing Susan and her mother the chart for safe low-calorie sweeteners that
the American diabetes association has provided below.

Sweetener Name

Brand Names
Found in Stores

Acesulfame Potassium

Sunett
Sweet One

Aspartame

Nutrasweet
Equal

Neotame

N/A

Saccharin

Sweet 'N Low

Sweet Twin
Sugar Twin

Sucralose

Splenda

Stevia/Rebaudioside A

A Sweet Leaf
Sun Crystals
Steviva
Truvia
PureVia

Then I would go into depth about hat stevia is and how it is approved by the FDA as a safe
sweetener for diabetics to use. Stevia is also referred to as Redaudioside and it is a highly
purified product that comes from the stevia plant and tastes several hundred times sweeter than a

normal sugar. According to Food and drug administration has approved it as a safe sweetener in
moderate amounts. Although stevia may be used for Susan it needs to be used in moderate
amounts and all diabetics are different and if used her blood sugar should be monitored to see
how it affects her blood glucose levels to ensure it is a good sweetener for her (ADA,2014).

Works Cited
Diabetes. (2014, February 11). Retrieved February 17, 2016, from
http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensive-insulin-therapy/art20043866?pg=2
Diabetic Ketoacidosis. (2010, April). Retrieved February 15, 2016, from
http://www.diabetesforecast.org/2010/apr/diabetic- ketoacidosis.html?
referrer=https://www.google.com/

Diabetic ketoacidosis. (2015, August 21). Retrieved February 15, 2016, from
http://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/basics/causes/con20026470
Hirsch, I., & Skyler, J. (1990, December 13). Result Filters. Retrieved February 18, 2016, from
http://www.ncbi.nlm.nih.gov/pubmed/2276310
How Do Insulin Pumps Work? (2015, July 9). Retrieved February 17, 2016, from
http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/how-doinsulin-pumps-work.html?referrer=https://www.google.com/
Intensive Insulin Therapy. (2007, September 17). Retrieved February 17, 2016, from
http://www.aafpfoundation.org/hepp_files/files/intensive102104.pdf
Lecture 6: Introduction to IVs. (2012, February 10). Retrieved February 15, 2016, from
http://www.cwladis.com/math104/lecture6.php
Low-Calorie Sweeteners. (2014, December 16). Retrieved February 17, 2016, from
http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understandingcarbohydrates/artificial-sweeteners/?referrer=https://www.google.com/
Metabolic acidosis: MedlinePlus Medical Encyclopedia. (2016, February 02). Retrieved
February 15, 2016, from https://www.nlm.nih.gov/medlineplus/ency/article/000335.htm
Tagamet: Indications, Side Effects, Warnings - Drugs.com. (2015, March 21). Retrieved
February 16, 2016, from http://www.drugs.com/cdi/tagamet.html