# A nurse is assessing a patient with type 1 diabetes mellitus who was brought to the emergency department. Which assessment finding would be the priority concern indicating diabetic ketoacidosis?

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## 문제

A nurse is assessing a patient with type 1 diabetes mellitus who was brought to the emergency department. Which assessment finding would be the priority concern indicating diabetic ketoacidosis?

A 28-year-old patient with type 1 diabetes mellitus presents to the emergency department with a 2-day history of nausea, vomiting, and abdominal pain. The patient reports missing several insulin doses due to illness.

## 보기

1. Blood glucose level of 180 mg/dL
2. Mild dehydration with decreased skin turgor
3. Complaint of increased urination and thirst
4. Fruity odor on breath with deep, rapid respirations **✔ 정답**

**정답: 4**

## 해설

The fruity odor on breath (acetone breath) combined with deep, rapid respirations (Kussmaul respirations) are classic signs of diabetic ketoacidosis and indicate severe metabolic acidosis requiring immediate intervention.

Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes that requires immediate recognition and intervention. This condition occurs when insulin is deficient and is characterized by hyperglycemia, ketosis, and metabolic acidosis.

The priority assessment finding indicating DKA is a fruity odor on the breath along with deep, rapid breathing (Kussmaul respirations). The fruity or acetone odor is caused by the presence of ketones, particularly acetone, which are volatile compounds produced during fat metabolism when glucose cannot be used effectively. Kussmaul respirations represent the body's compensatory mechanism to eliminate excess carbon dioxide and reduce acidosis through respiratory alkalosis.

The pathophysiology of DKA involves three main components: hyperglycemia (usually >250 mg/dL), ketosis, and metabolic acidosis (pH

## 심화 해설

Understanding the Priority in DKA Assessment

When a patient with type 1 diabetes mellitus presents with missed insulin doses and gastrointestinal symptoms, the nurse must rapidly identify findings that signal a life-threatening emergency. Diabetic ketoacidosis (DKA) is the most frequent hyperglycemic emergency and a leading cause of death in this population [1]. The priority concern is always the assessment finding that indicates a failure of physiological compensation and an immediate threat to the airway or breathing. In DKA, this is the combination of a fruity odor on breath and Kussmaul respirations (deep, rapid respirations).

Pathophysiology of the Priority Finding

The biochemical triad of DKA includes hyperglycemia, ketonemia, and acidemia [3]. A lack of insulin forces the body to break down free fatty acids for energy, producing acidic ketone bodies. As metabolic acidosis worsens, the respiratory system initiates a compensatory mechanism to blow off carbon dioxide (CO2) and raise the blood pH. This manifests clinically as deep, rapid breathing. The fruity odor on the breath is a direct consequence of exhaled acetone, a type of ketone body. This finding is a critical and late sign of severe acid-base disturbance, making it the highest priority because it directly reflects a failing compensatory mechanism that can lead to respiratory failure if not immediately treated.

Analysis of the Options

*   Option 1: Blood glucose level of 180 mg/dL

While DKA involves hyperglycemia, a value of 180 mg/dL is only mildly elevated and not specific to DKA. DKA can sometimes present with euglycemia. The core problem is not the glucose level itself but the production of ketones and resulting acidosis [1]. This finding is not the priority.

*   Option 2: Mild dehydration with decreased skin turgor

Dehydration is a common clinical symptom of DKA, resulting from osmotic diuresis driven by hyperglycemia [3]. However, "mild" dehydration indicates a fluid volume deficit that, while requiring treatment, does not pose the same immediate threat to airway, breathing, and circulation as an uncompensated acidotic state. It is a secondary concern to respiratory status.

*   Option 3: Complaint of increased urination and thirst

Polyuria and polydipsia are classic, early symptoms of hyperglycemia and precede the development of full-blown DKA [3]. The patient’s 2-day history of nausea and vomiting indicates a progression beyond this initial stage. This finding reflects the precipitating osmotic diuresis but is not the most critical indicator of the current, acute emergency.

*   Option 4: Fruity odor on breath with deep, rapid respirations

This is the correct answer. The fruity odor is a sign of significant ketone body accumulation, and the deep, rapid respirations (Kussmaul breathing) are a direct compensatory response to severe metabolic acidosis. This finding signals that the body's buffer systems are overwhelmed and the patient is at high risk for clinical deterioration, including altered consciousness and respiratory failure [3]. DKA is always lethal if misdiagnosed or improperly treated, and recognizing this respiratory pattern is key to prompt diagnosis and life-saving intervention [1].References (research sources)

- [1]Comprehensive review of diabetic ketoacidosis: an update.Research articleElendu C, David JA, Udoyen AO, Egbunu EO, Ogbuiyi-Chima IC, Unakalamba LO, Temitope AI, Ibhiedu JO, Ibhiedu AO, Nwosu PU, Koroyin MO, Eze C, Boluwatife AI, Alabi O, Okabekwa OS, Fatoye JO, Ramon-Yusuf HI. (2023) · DOI: 10.1097/ms9.0000000000000894

- [3]Diabetic Ketoacidosis in Children and Adolescents; Diagnostic and Therapeutic Pitfalls.Research articleKostopoulou E, Sinopidis X, Fouzas S, Gkentzi D, Dassios T, Roupakias S, Dimitriou G. (2023) · DOI: 10.3390/diagnostics13152602

## 임상 시나리오

Clinical Priority: Recognizing Decompensation in DKA

Kussmaul respirations with a fruity breath odor represent a critical turning point in diabetic ketoacidosis. This finding indicates that the body's respiratory compensation for severe metabolic acidosis is failing, placing the patient at immediate risk for respiratory arrest. Assessment and intervention must focus on airway and breathing.

Immediate Nursing Actions

- **Assess ABCs:** Evaluate airway patency, depth/rate of respirations, and oxygen saturation continuously.

- **Prepare for Support:** Have bag-valve-mask and intubation equipment ready if respiratory failure develops.

- **Notify Provider:** Immediately report this late sign of decompensation and anticipate orders for arterial blood gas analysis.

Pathophysiology of the Priority Sign

- **Acidosis Trigger:** Insulin deficiency leads to ketone body (acetoacetate, beta-hydroxybutyrate, acetone) accumulation.

- **Respiratory Drive:** Falling blood pH stimulates the medullary respiratory center to increase rate and depth to blow off CO2.

- **Acetone Exhalation:** Unmetabolized acetone is excreted via the lungs, producing the characteristic fruity odor.

**Clinical Pearl:** A patient with DKA who develops slow or shallow respirations after a period of Kussmaul breathing is not improving; they are likely in severe, uncompensated acidosis and approaching respiratory failure.

## 핵심 개념

- **Kussmaul Respirations** — Deep, rapid, labored breathing pattern characteristic of severe metabolic acidosis as the lungs attempt to excrete excess CO2.
- **Diabetic Ketoacidosis (DKA)** — A life-threatening complication of diabetes caused by a severe lack of insulin, leading to hyperglycemia, ketone body production, and metabolic acidosis.
- **Acetone** — A volatile ketone body produced during fat metabolism in DKA, excreted via the lungs and responsible for the characteristic fruity breath odor.
- **Metabolic Acidosis** — A condition where the blood pH is low due to increased acid production or bicarbonate loss, triggering compensatory respiratory alkalosis.
- **Priority Assessment** — The nursing process of identifying the most life-threatening patient problem using the ABC (Airway, Breathing, Circulation) framework.

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