A nurse in the emergency department is caring for a 28-year-… | 마이메르시 MyMerci
Adult Health
문제

A nurse in the emergency department is caring for a 28-year-old client with type 1 diabetes mellitus who presents with nausea, vomiting, abdominal pain, severe dehydration, and rapid, deep respirations. Recognizing these as signs of diabetic ketoacidosis (DKA), which intervention should the nurse implement first?

해설
In DKA, severe dehydration occurs due to osmotic diuresis, making fluid resuscitation the immediate priority to restore circulating volume and prevent shock.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests the priority nursing intervention for a patient in Diabetic Ketoacidosis (DKA). DKA is a life-threatening complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis. The pathophysiological cascade begins with insulin deficiency, leading to hyperglycemia, which causes severe osmotic diuresis and profound fluid and electrolyte loss. This results in hypovolemic shock as the primary immediate threat to life. The rapid, deep respirations (Kussmaul respirations) are the body's attempt to compensate for the metabolic acidosis by blowing off carbon dioxide.

Answer Rationale: Key Point! The nurse's first action must be to establish IV access and begin fluid resuscitation. This is based on the ABCs (Airway, Breathing, Circulation) of emergency care. Severe dehydration compromises circulation, leading to poor tissue perfusion, organ failure, and shock. Restoring intravascular volume with IV fluids (typically 0.9% Normal Saline initially) is the foundational treatment that stabilizes the patient, improves tissue perfusion to vital organs, and also helps lower blood glucose by dilution and improved renal function.

Distractor Analysis:
  • Option 1 (Administer insulin): While insulin is a definitive treatment for DKA to stop ketogenesis and lower blood glucose, it is not the first intervention. Administering insulin to a severely hypovolemic patient can be dangerous, as it can precipitate a rapid shift of potassium into cells, causing severe hypokalemia and cardiac arrhythmias. Fluid resuscitation must precede or accompany insulin therapy.
  • Option 3 (Monitor blood glucose): Frequent monitoring (e.g., every hour) is essential but is an assessment activity, not the first intervention. You must first act to stabilize the patient's condition.
  • Option 4 (Assess neurological status): Neurological assessment (for signs of cerebral edema or altered consciousness) is crucial, especially as treatment progresses. However, it is not the immediate priority over addressing the life-threatening circulatory collapse caused by dehydration.
Related Concepts: The management of DKA follows a specific sequence: Fluids → Electrolytes (especially Potassium) → Insulin. Understanding this order is critical for safe and effective care. The body's compensatory mechanism (Kussmaul respirations) is a key assessment finding that confirms the presence of metabolic acidosis.

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the triage nurse in the ED. A young adult is brought in by family. They are lethargic, skin is dry and tenting, breath has a fruity odor (acetone), and they are taking rapid, deep breaths. Their heart rate is 120 bpm, BP 90/60, and a point-of-care glucose reads "HI" (over 600 mg/dL).

Nursing Intervention Strategy:
  1. Immediate Action (First 5 minutes): Call for help. Place patient on a cardiac monitor. Establish two large-bore IV lines (18-gauge or larger). Initiate a rapid infusion of 0.9% NS as ordered (e.g., 1-2 liters in the first hour). Obtain STAT labs: Blood glucose, Basic Metabolic Panel (BMP), Venous Blood Gas (VBG), and serum ketones.
  2. Ongoing Management (First Hour): After fluids are running, initiate a continuous IV insulin infusion (regular insulin) via an infusion pump, as prescribed. Watch out for confusion! The insulin infusion is typically started after or concurrently with potassium replacement if the serum potassium is low/normal, as insulin drives potassium into cells.
  3. Monitoring & Evaluation: Monitor vital signs every 15-30 minutes initially. Check blood glucose hourly. Strictly monitor intake and output (I&O). Assess for signs of improving perfusion (decreased HR, increased BP, improved urine output) and resolving acidosis (slowing of respiratory rate).
Patient Safety and Precautions:
  • Hypoglycemia/Hypokalemia Risk: The greatest danger during DKA treatment is a rapid drop in blood glucose or potassium. Never administer a bolus of IV insulin. Always use a continuous infusion.
  • Cerebral Edema: This is a rare but devastating complication, often seen in children and young adults as treatment progresses. Report any headache, change in mental status, or neurological signs immediately.
  • Fluid Overload: Monitor for crackles in lungs, especially in older adults or those with cardiac history, once large-volume resuscitation is underway.
Nursing Procedure & Medication Flow DKA Protocol Sequence: 1. FLUIDS: 0.9% NS 1-2 L over first 1-2 hours → switch to 0.45% NS when serum sodium normalizes and BP stabilizes. 2. POTASSIUM: Add KCl to IV fluids once serum K+ is

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