Diabetic Ketoacidosis (DKA) Case Study

Diabetic Ketoacidosis (DKA) Diana Humphries, 45 years old Primary Concept Fluid and Electrolyte Balance Interrelated Concepts (In order of emphasis) 1. 2. 3. 4. 5. 6. 7. 8. Acid-Base Balance Glucose Regulation Infection Pain Clinical Judgment Patient Education Communication Collaboration Diabetic Ketoacidosis (DKA) History of Present Problem: Diana Humphries is a 45-year-old woman with chronic kidney disease stage III and diabetes mellitus type1 who checks her blood sugar daily, or whenever she feels like it. She has been feeling increasingly nauseated the past 12 hours. She has had a harsh, productive cough of yellow sputum the past three days. She checked her blood glucose before going to bed last night and it was 382, but then she fell asleep early and missed her bedtime dose of glargine (Lantus) insulin. When she awoke this morning, she had generalized abdominal pain and continued to feel nauseated and had a large emesis. Her glucometer was unable to read her blood glucose because it was too high. She took 10 units of lispro (Humalog) insulin this morning. Her nausea has increased all morning and she has been unable to eat or keep anything down despite having an increased thirst and appetite. She also has had increased frequency of urination. When her lunchtime glucometer gave no reading because it was too high and out of range, she called 9-1-1 to be evaluated in the emergency department (ED). Personal/Social History: Diana has been inconsistently compliant with her medical/diabetic regimen due to her struggles with anxiety and depression that have worsened since her mother died three months ago. She considers 200 a good blood sugar reading. She is divorced with no children and has been homeless and has lived in a shelter off and on the past month. She is on Social Security disability because of complications related to diabetes. At one point during the intake interview, she expressed to the nurse, “I’m going to die anyway, why does all this matter?” What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: ● CKD Stage III ● These are all risk factors and complications of diabetic ● Diabetes Mellitus Type 1 ketoacidosis. ● Harsh, productive cough with yellow sputum ● Blood Glucose: 382 ● Abdominal pain with large emesis ● Unable to keep food down, thirsty, hungry, and increased urination RELEVANT Data from Social History: ● Inconsistently compliant with her medical/diabetic regimen ● Anxiety and Depression from her mother’s death ● Divorced with no children ● Homeless ● Receives social security disability benefits Clinical Significance: ● Inability to comply with medications increases risk for complications. ● Lacks emotional support. ● Due to her current financial hardship, she is unable to comply with her medications/diabetes regimen. What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect) PMH: Home Meds: Pharm. Classification: Expected Outcome: ● Chronic Kidney disease 1. Aspirin 81mg PO daily ● Salicylates ● Aspirin will help with the stage III (diabetic 2 .Lisinopril 10 mg PO ● ACE inhibitors pain caused by her nephropathy) daily ● Benzodiazepine neuropathy . ● Anemia 3. Lorazepam 1mg PO bid ● Lisinopril will help manage ● Diabetes mellitus type 1 ● SSRI prn her hypertension and with since age 12 4. Citalopram 40 PO her kidney disease. ● Sedative mg daily ● Lorazepam will help calm ● Diabetic retinopathy 5. Zolpidem 10 mg PO at down the patient less ● Neuropathy in lower legs ● Analgesic adjunct HS prn anxiety. ● Hyperlipidemia 6. Gabapentin 300 mg ● Zolpidem will allow the ● Hypertension ● Beta Blocker PO bid patient to sleep better ● Coronary artery disease 7. Labetalol 200 mg PO causing less anxiety and ● Gastroesophageal reflux disease (GERD) bid may aid in decreasing ● Anxiety ● Antilipidemia 8. Omeprazole 20 mg depression. ● Depression ● Pancreatics PO daily ● Gabapentin will help with 9. Simvastatin 40 mg PO nerve pain caused by her ● Pancreatics HS neuropathy. ● Labetalol will help with her 10. Glargine insulin 50 hypertension and decrease units SQ at HS her heart rate lowering 11. Lispro insulin SQ stress on the heart. sliding scale AC and HS ● Omeprazole will decrease the stomach acid helping with her GERD. ● Simvastatin will help her cholesterol and lipids which will help with hyperlipidemia and coronary artery disease. ● Glargine is long acting insulin used to manage diabetes ● Lispro is rapid acting insulin used to manage diabetes What medications treat which conditions? Draw a line to identify what illness is being managed by what medication? (Refer to table) One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her life? ● Circle what PMH problem started FIRST - Diabetes ● Underline what PMH problem(s) FOLLOWED as dominoes - Hypertension, heart disease, kidney disease, anxiety, and depression. Patient Care Begins Current VS: T: 101.6 F/38.7 C (oral) P: 114 (regular) R: 24 (regular/deep) BP: 102/66 O2 sat : 90% Room air P-Q-R-S-T Pain Assessment (5th VS): P rovoking/Palliative Coughing and deep breathing/Not coughing Sharp Q uality: R egion/Radiation: Right chest 5/10 S everity: Intermittent T iming: What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: ● T: 101.6 F/38.7 C ● Fever may indicate dehydration in DKA patient or underlying infection ● P: 114 ● Increased pulse is a compensatory mechanism ● R: 24 ● Patient should be monitored for Kussmaul’s respirations and acetone breath ● BP : 102/66 ● A decreased blood pressure indicates a decreased blood volume ● O2 sat: 90% RA ● O2 sat should be kept above 92% ● Pain: 5/10 ● Pain can increase the heart rate and respirations of the patient Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Appears anxious and uncomfortable, body tense, occasional grimacing Breath sounds clear with coarse crackles in RLL , nonlabored respiratory effort, harsh productive cough with thick yellow phlegm visualized Pink, warm & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants, nausea is persistent Frequency of urination, urine clear in color, denies painful or burning when voids Skin integrity intact, lips dry, oral mucosa dry–tacky What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: ● Appears anxious and ● Appears to be in discomfort because of lack of support and symptoms uncomfortable, body tense, she’s been feeling. occasional grimacing ● Causing decreased oxygen saturation; impaired oxygenation. ● Breath sounds clear with coarse crackles in RLL , unlabored respiratory effort, harsh productive cough with thick yellow phlegm visualized ● Indication of dehydration. ● Skin integrity intact, lips dry, oral mucosa dry–tacky ● Urine clear in color 12 Lead EKG: Interpretation: Peaked T’s sinus rhythm Clinical Significance: Narrow and tall peaked T waves is usually an indication of hyperkalemia. We will monitor potassium levels and take necessary interventions to have potassium levels WNL. Radiology Reports: Chest x-ray What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: ● Right lower lobe infiltrate. ● Pneumonia. Pt has productive cough with yellow sputum Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Complete Blood Count (CBC): WBC (4.5–11.0 mm 3) Hgb (12–16 g/dL) Platelets (150–450x 103/µl) Neutrophil % (42–72) Band forms (3–5%) Current: 15.2 11.8 155 92 3 High/Low/WNL? High Low WNL High WNL Prior: 9.8 11.2 162 70 1 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: ● ● ● WBC: 15.2 Hgb: 11.8 Neutrophil:92 ● ● ● Basic Metabolic Panel (BMP): Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) CO2 (Bicarb) (21–31 mmol/L) Glucose (70–110 mg/dL) BUN (7–25 mg/dl) Creatinine (0.6–1.2 mg/dL) GFR (>60 mL/min) Misc. Labs: Lactate (0.5–2.2 mmol/L) Elevated WBC indicates Infections Low Hgb can indicate that the client is hypovolemic A high Neutrophil count indicate that the client has a bacterial infection Current: 122 6.4 11 729 56 2.4 20 2.8 High/Low/WNL? Low High Low High High High Low High Improve/Worsening/Stable: ● Worsening Prior: 138 4.2 25 168 42 1.9 38 n/a What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: ● ● Potassium Sodium ● ● ● CO2 ● ● ● ● Glucose BUN, Cr GFR Lactate ● ● ● ● ● Urine Analysis (UA): Color (yellow) Clarity (clear) Specific Gravity (1.015–1.030) Protein (neg) Glucose (neg) Ketones (neg) Bilirubin (neg) Blood (neg) Nitrite (neg) LET (Leukocyte Esterase) (neg) MICRO RBCs (<5) WBCs (<5) Bacteria (neg) Epithelial (neg) Can cause cardiac dysrhythmias Can lead to seizures, coma, or death when too low Low CO2 can indicate metabolic acidosis Glucose is severely high at 729 Elevated BUN can indicate dehydration and kidney dysfunction GFR indicates how well the kidney is functioning Elevated lactate indicates anaerobic metabolism Current: Clear Cloudy 1.005 Positive >1000 Large Negative Negative Negative Negative 1 2 Negative Negative WNL/Abnormal? Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal WNL WNL WNL WNL WNL WNL WNL WNL ● Everything is worsening What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): ● Clinical Significance: Urinalysis: color , clarity, specific gravity, protein, glucose, and ketones ● The abnormal color, clarity, specific gravity, and protein in the urine can be an indication for kidney disease. The glucose and ketones present in the urine is an indication for DKA. Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Creatinine Value: 2.4 Normal Value: Critical Value: > 1.2 Lab: Normal Value: Potassium 3.5 - 5.0 Value: Critical Value: >5.5 6.4 Clinical Significance: Nursing Assessments/Interventions Required: ● signifies impaired ● Frequent skin assessment for signs of skin kidney function or breakdown (pt may complain of itching kidney disease skin) ● cause of CKD, ● assess pt cognitive and physical dehydration capabilities- fall risk due to muscle weakness and fatigue ● monitor I&Os, possible fluid restriction depending on BUN 0.6 - 1.2 Clinical Significance: ● can cause a heart attack or death ● cause of CKD, dehydration, diabetes, beta blockers, medications Nursing Assessments/Interventions Required: ● EKG monitoring, ● frequent cardiac assessment, monitor labs closely ● Give Kayexalate Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? ● The primary problem the patient is presenting with is diabetic ketoacidosis (DKA). 2. What is the underlying cause/pathophysiology of this primary problem? ● DKA is caused by a deficiency in available insulin resulting in the disordered metabolism of fats, carbohydrates, and proteins. This causes dehydration, hyperglycemia, ketosis, and electrolyte imbalances. Collaborative Care: Medical Management Care Provider Orders: Blood glucose stat Rationale: Expected Outcome: ● To monitor the blood glucose level if ● 120- 200mg/dL since the client claims it falls in an acceptable range that her normal level is 200mg/dL 12 lead EKG ● EKG is to define Dysrhythmias ● Normal EKG should present a heart rate of 60-100 beats/ min Place on cardiac monitor ● To monitor is there is a cardiac defect ● No cardiac defects Establish IV and initiate NS 0.9% bolus of 1000 mL ● 0.9% Normal saline is for fluid resuscitation to replenish the fluid lost ● ● Increase blood sodium, Increase BP, Patient will have decreased level of pain Ondansetron 4 mg IV push every 4 hours for nausea ● Ondansetron is an antiemetic that will limit the feeling of nausea Hydromorphone 0.5 mg every 4 hours for pain ● hydromorphone is a pain killer , use to provide comfort to the patient PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: 1. Blood glucose stat 2. 12 lead EKG 3. Place on cardiac monitor 4. Establish IV and initiate NS 0.9% bolus of 1000 mL 5. Ondansetron 4 mg IV push 6. Hydromorphone 0.5 prn every 4 hours for pain Order of Priority: Rationale: ● Blood glucose level ● Establish baseline glucose level ● Establish IV and ● Priority action should be to restore the circulatory initiate NS 0.9% bolus fluid volume deficit of 1000 mL ● The patient should be put on a 12 lead EKG and ● 12 lead EKG cardiac monitoring because electrolyte imbalances ● Cardiac monitoring that may cause cardiac dysrhythmias ● Ondansetron 4 mg IV ● Patient should be given something for nausea push ● Patient should be given something for pain ● Hydromorphone 0.5 prn every 4 hours for pain The physician has just noted the concerning labs of: ● ● ● ● ● Potassium: 6.4 Glucose: 729 UA: + ketones CO2: 11 Chest x-ray consistent with pneumonia (RLL infiltrate) and orders the following: Care Provider Orders: Regular insulin 10 units IV push stat Rationale: ● Insulin is necessary to control glucose in a diabetes pt Expected Outcome: ● Normal blood glucose level Sodium Bicarbonate (50 mL)1 amp IV push stat ● Antacid used to relieve heartburn and acid indigestion ● No acid indigestion Calcium Chloride 1 gm IV ● Used in cardiac resuscitation, arrhythmias, CCB overdose, beta-blocker overdose; treatment of hypocalcemic tetany/ muscle spasms ● Patient will be free of spasms. No Beta-blockers overdose. Regular insulin IV drip rate per DKA protocol ● IV drip gets into body more quickly to bring down high blood sugars ● Blood glucose WNR will be achieved sooner ● Antibiotic used for bacterial infections ● Patient will be free of infection Ciprofloxacin 400mg/250 mL IVPB after blood/urine/sputum cultures obtained Medication Dosage Calculation: Medication/Dose: Ondansetron 4 mg IV push (4mg/2 mL vial) Medication/Dose: Ciprofloxacin 400mg/250 mL IVPB Mechanism of Action: Serotonin antagonist, meaning it blocks the serotonin receptors in the chemoreceptor trigger zone and at the vagal nerve terminals in the intestine. This reduces N/V by preventing the serotonin release in the small intestine and by blocking signals to the CNS. Mechanism of Action: Bacterial antibiotic of the fluoroquinolone class. It inhibits DNA replication by inhibiting the bacterial DNA topoisomerase and DNA-gyrase. Volume/time frame to Safely Administer: IV Push: Volume every 15 sec? Adults and children age 12 or older: 4mg undiluted as a single dose over 2-5 minutes. Hourly Rate IVPB: Nursing Assessment/Considerations: Assess for: CNS : agitation, drowsiness, dizziness CV : arrhythmias, hypotension, prolonged QT Interval. EENT: altered taste, blurred vision, dry mouth, laryngeal edema GI: flatulence, abd. pain, indigestion Resp : SOB, bronchospasm Skin: rash, flushing Other: s/s anaphylaxis, IV site for redness or pain. Nursing Assessment/Considerations : ● Hourly rate IVPB: IVPB 400 mg every 8-12 hours 30 ml/hr ● ● Assessment of VS, obtain specimens for cultures, WBC, UA (freq/urgency of urination; cloudy or foul-smelling urine). Observe signs for anaphylaxis Monitor bowel function- diarrhea, cramping Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) ● Provide Insulin to regulate the Blood sugar ● Infuse The client with 0.9% NS for fluid restoration ● Give Antibiotics for Infections ● Provide an antiemetic to limit nausea.( ondansetron) 4. What interventions will you initiate based on this priority? Nursing Priority: Nursing Interventions: Rationale: ● 5. Blood glucose stabilization to normal baseline (120-200mg/dL) ● ● Provide insulin as required Monitor blood glucose for hypoglycemia ● ● Insulin is the drug of choice to reduce the blood glucose To much insulin can result in hypoglycemia Expected Outcome: ● ● Blood glucose returns to normal level 120-200 mg/dL Patient does not have cerebral damage due to rapid hypoglycemia What body system(s) will you assess most thoroughly based on the primary/priority concern? ● Respiratory ● Renal 6. What is the worst possible/most likely complication to anticipate? ● Diabetic coma ● Respiratory failure 7. What nursing assessments will identify this complication EARLY if it develops? ● Regular vital signs and glucose monitoring will help catch if the patient is worsening in condition ● Signs of respiratory distress or worsening of symptoms 8. What nursing interventions will you initiate if this complication develops? ● Make sure patient is receiving IV insulin to prevent the DKA from progressing ● Monitor blood glucose levels for complications ● Give fluids to fix the dehydration ● Monitor and administer supplements to help maintain and restore lab values 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? ● Social workers and case management may need to be involved because this patient is homeless and is struggling with controlling her diabetes. ● Patient may benefit from psychosocial assistance because she is showing signs of depression and lack of hope by stating “I’m going to die anyway, why does all this matter?”. 10. How can the nurse address these psychosocial needs? ● The nurse can address these needs by listening to the patient and making her feel heard and validated. The patient may feel hopeless due to her health issues. She should be educated that if she controls her diabetes she will feel overall better. ● A social worker may need to be involved in helping the patient find a safe place to live where she can feel confident in taking care of herself. ● Patient might benefit from therapy to help her with her depression and anxiety, as well as to cope with her mother’s passing. Evaluation: Two Hours Later… All primary care provider orders have been administered by the nurse. The regular insulin IV drip rate is currently at 3.4 units/hour. The physician orders a repeat BMP and 12 lead EKG. The following clinical data is included in your most recent evaluation: Basic Metabolic Panel (BMP:) Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) Chloride (95–105 mEq/L) CO2 (Bicarb) (21–31 mmol/L) Glucose (70–110 mg/dL) Calcium (8.4–10.2 mg/dL) BUN (7– 25 mg/dl) Creatinine (0.6–1.2 mg/dL) GFR (>60 mL/min) Current: 125 5.1 106 18 578 8.6 50 2.2 24 High/Low/WNL? Low High High Low High WNL High High Low Prior: 122 6.4 98 11 729 8.4 56 2.4 20 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: ● ● ● ● ● ● ● ● Sodium: 125 Potassium: 5.1 Chloride: 106 CO2: 18 Glucose: 578 BUN: 50 Cr: 2.2 GFR: 24 ● Hyponatremia and hyperkalemia due to dehydration. ● Acidosis and BG above 400 are indications of DKA. Elevated BUN & Cr and low GFR due to impaired kidney function from CKD Stage 3. ● ● ● ● ● ● ● ● ● Worsening Improving Worsening Improving Improving Improving Improving Improving 12 Lead EKG: Interpretation: Sinus rhythm Clinical Significance: Alterations in potassium can lead to cardiac dysrhythmias. The patient is on an insulin drip, which causes potassium to go back into the cell, so we will continue to monitor cardiac function. Current VS: Most Recent: Current WILDA: T: T: W ords: 100.2 F/37.9 C (oral) P: 88 ( regular) R: 20 (regular) BP: 124/70 O2 sat: 94% 2 liters n/c 101.6 F/38.7 C (oral) P: 114 ( regular) R 24 (regular) BP: 102/66 O2 sat: 95% 2 liters n/c I L D A A ntensity: ocation: uration: ggravate: lleviate: sharp 2/10 Right chest Intermittent Coughing and deep breathing Not coughing and breathing shallow Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Resting comfortably, appears in no acute distress Breath sounds clear coarse crackles RLL, nonlabored respiratory effort Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants, no nausea or abdominal pain Urine clear and yellow. 250 mL the past 8 hours Skin integrity intact, lips dry, but oral mucosa is moist 1. What clinical data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: ● T: 100.2 F/37.9 C (oral) All vital signs are showing improvement ● P : 88 ● R : 20 ● BP : 124/70 ● O2 Sat : 94% via 2L NC RELEVANT Assessment Data: Clinical Significance: ● Resting comfortably with no acute ● Indicates improvement distress ● Indicates fluid excess in lungs probably due to pneumonia ● Clear coarse crackles ● UO is WNL ● UO 250mL in last 8 hours 2. Has the status improved or not as expected to this point? ● The most recent assessment data identifies improvement of the patient status. 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? ● We will continue to monitor patient status ● Priorities remain the same 4. Based on your current evaluation, what are your nursing priorities and plan of care? ● Current nursing priorities are to monitor the patient for any changes in status. ● Continue medications and treatments as prescribed ● Watch labs closely for improving or worsening trend Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient in ICU: S ituation: Name/age: Diana Humphries, 45-year-old female BRIEF summary of primary problem: Day of admission/post-op #: Patient presented to the ED due to highly elevated blood glucose. Day 1 B ackground: Primary problem/diagnosis: DKA RELEVANT past medical history: RELEVANT background data: CKD Stage III and Diabetes Mellitus Type I Homeless, receives social security benefits, divorced and no children A ssessment: Current vital signs: T: 100.2 F/37.9 C (oral), P : 88, R : 20, BP : 124/70 , and O2 Sat : 94% via 2L NC RELEVANT body system nursing assessment data: RESP: Breath sounds clear coarse crackles RLL, non-labored respiratory effort RELEVANT lab values: Sodium: 125, Potassium: 5.1, Chloride: 106, CO2: 18, Glucose: 578, BUN: 50, Cr: 2.2, GFR: 24 TREND of any abnormal clinical data (stable-increasing/decreasing): Stable How have you advanced the plan of? Patient response: Administered fluid replacement and insulin. Patients blood glucose is going down vital signs and vital signs and normalizing INTERPRETATION of current clinical status (stable/unstable/worsening): R Stable ecommendation: Suggestions to advance plan of care: Monitor blood glucose, LOC, vital signs and strict I&Os. Monitor acid-base balance. Educate client how to prevent DKA. Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with her medical condition to prevent future readmission with the same problem? ● ● Monitor blood sugar and take insulin as prescribed. Finish full course of antibiotics to treat pneumonia infection and prevent abx resistance. 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? ● Have the patient summarize the teachings you provided. ● Ask questions to see if the patient understood teachings. Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? ● The patient’s mother recently passed away, she is divorced and has no children so she might feel alone. She might feel as though she has no motivation or nothing to look forward to. 2. What can you do to engage yourself with this patient’s experience and show that he/she matters to you as a person? ● Build a connection with the patient by conversing with her, asking her about things she likes and maybe find similar interests. We can regularly check up on the patient to see if there is anything she needs or something that we can do for her. We can also provide physical touch to demonstrate that we care about her and provide comfort. Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? ● Dehydration, infection, inadequate insulin dose, and stress can all cause diabetic ketoacidosis 2. How can I use what has been learned from this scenario to improve patient care in the future? ● This will help in the future clinical setting by being able to identify those at risk of developing DKA. For those presenting with diabetes and dehydration or infection it will be more of a priority to monitor blood glucose levels