# Situation: A 76-year-old woman with type 2 diabetes mellitus is brought from home after three days of increasing drowsiness and poor oral intake during a febrile illness. She weighs 60 kg. The provider diagnoses hyperosmolar hyperglycemic state (HHS). Her blood pressure is 92/50 mmHg, heart rate 118 beats/min, and serum potassium 4.6 mEq/L (normal 3.5–5.0 mEq/L). She has no history of heart or kidney failure. Which order should the nurse carry out FIRST?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 76-year-old woman with type 2 diabetes mellitus is brought from home after three days of increasing drowsiness and poor oral intake during a febrile illness. She weighs 60 kg. The provider diagnoses hyperosmolar hyperglycemic state (HHS).

Her blood pressure is 92/50 mmHg, heart rate 118 beats/min, and serum potassium 4.6 mEq/L (normal 3.5–5.0 mEq/L). She has no history of heart or kidney failure. Which order should the nurse carry out FIRST?

## 보기

1. Start the regular insulin infusion
2. Infuse 0.9% sodium chloride as ordered **✔ 정답**
3. Add potassium chloride to the intravenous (IV) fluid
4. Give sodium bicarbonate by intravenous (IV) push

**정답: 2**

## 해설

The first priority in HHS is fluid replacement, because severe dehydration is the main problem and fluids alone lower glucose. Insulin is started after fluids are running and potassium is confirmed adequate; starting insulin in a dehydrated client can worsen hypotension as glucose and water move into cells.

## 심화 해설

Why fluid replacement comes first in HHS

In hyperosmolar hyperglycemic state (HHS), the dominant pathophysiologic problem is profound intracellular and extracellular dehydration driven by sustained osmotic diuresis. The serum glucose rises high enough to overwhelm renal reabsorption, so glucose spills into the urine and drags water and electrolytes with it. Over several days, total body water deficits in HHS typically reach 100–200 mL/kg, which for this 60 kg patient represents roughly 6–12 L of fluid loss. This explains the hypotension (92/50 mmHg) and reflex tachycardia (118 beats/min) on presentation.

Restoring intravascular volume is the first and most urgent intervention because it improves tissue perfusion, supports blood pressure, and begins lowering serum glucose even before insulin is given. Fluid resuscitation alone reduces glucose through dilution and by improving renal perfusion, which enhances urinary glucose excretion. The initial fluid of choice is isotonic 0.9% sodium chloride, infused to expand the extracellular compartment and stabilize hemodynamics [1][2][3].

Watch out! Starting insulin before adequate fluid resuscitation can worsen hypotension. Insulin drives glucose and water from the extracellular space into cells, which may further reduce circulating volume in an already dehydrated patient. The consensus approach is to begin fluids first, confirm adequate blood pressure and urine output, and verify that serum potassium is not low before starting insulin [1][2].

Why the other options are not first

| Order | Why it is not the first action | When it becomes appropriate |
| --- | --- | --- |
| Regular insulin infusion | Insulin given before volume restoration can precipitate or worsen circulatory collapse by shifting glucose and water into cells; also, insulin lowers potassium and may unmask hypokalemia | After fluids are running and serum potassium is confirmed at or above 3.3 mEq/L; often started once blood pressure and urine output are adequate [1][2] |
| Potassium chloride in IV fluid | This patient’s potassium is 4.6 mEq/L, which is within normal range; adding potassium now is unnecessary and risks hyperkalemia | Only if potassium falls below 3.3 mEq/L or if insulin therapy causes potassium to drop; potassium is replaced once urine output is confirmed [1][3] |
| Sodium bicarbonate IV push | Bicarbonate is not indicated in HHS unless there is severe acidosis with pH below 6.9; HHS typically has only mild or no acidosis because enough insulin remains to suppress significant ketogenesis | Reserved for rare cases of severe metabolic acidosis or life-threatening hyperkalemia; routine use is not recommended [3] |

How the potassium value guides sequencing

The serum potassium of 4.6 mEq/L is deceptively reassuring. In HHS, total body potassium is usually depleted because osmotic diuresis causes large urinary potassium losses. However, the serum level may appear normal or even high at presentation because insulin deficiency and hyperosmolality shift potassium out of cells into the extracellular fluid [1][2].

Once insulin is started, potassium moves back into cells, and the serum potassium can fall rapidly. This is why potassium status must be assessed before insulin administration, but it does not make potassium replacement the first priority in this patient. The immediate threat is hypovolemic shock from dehydration, not hypokalemia. With a current potassium of 4.6 mEq/L and no ECG evidence of hypokalemia, the correct sequence is fluid first, then reassess potassium before insulin [1][3].

Key point! The order of priorities in HHS is: (1) restore intravascular volume with isotonic saline, (2) correct electrolyte deficits once urine output is established, and (3) begin insulin only after fluids are running and potassium is confirmed adequate. This sequence prevents both worsening shock from premature insulin and dangerous hypokalemia during insulin therapy [1][2][3].

Clinical application to this patient

This older adult with type 2 diabetes developed HHS during a febrile illness, which increased insensible fluid losses and reduced oral intake. The three-day history of drowsiness reflects progressive hyperosmolality causing neurologic depression. The hypotension and tachycardia indicate significant volume depletion requiring immediate intervention.

The nurse should first initiate the ordered 0.9% sodium chloride infusion, typically at an initial rate guided by hemodynamic status and the degree of dehydration. For a patient with hypotension, rapid infusion of isotonic saline is appropriate to restore perfusion. Monitoring includes hourly urine output, blood pressure, heart rate, and frequent glucose and electrolyte checks. Once the patient is hemodynamically stable and potassium is confirmed adequate, insulin therapy can be added according to protocol [1][2].References (research sources)

- [1]Hyperglycemic Crises in Adults With Diabetes: A Consensus Report.GuidelineUmpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. (2024) · DOI: 10.2337/dci24-0032

- [2]Hyperglycaemic crises in adults with diabetes: a consensus report.GuidelineUmpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. (2024) · DOI: 10.1007/s00125-024-06183-8

- [3]Treatment Challenges and Controversies in the Management of Critically Ill Diabetic Ketoacidosis (DKA) Patients in Intensive Care Units.Research articleDunn BK, Coore H, Bongu N, Brewer KL, Kumar D, Malur A (2024) · DOI: 10.7759/cureus.68785

## 임상 시나리오

HHS Initial Fluid ResuscitationPrioritizing isotonic fluids before insulin
In HHS, the dominant problem is profound dehydration from osmotic diuresis, with total body water deficits of 100–200 mL/kg. For a 60 kg patient, this equals 6–12 L. The first nursing action is to infuse 0.9% sodium chloride to restore intravascular volume, improve tissue perfusion, and support blood pressure.

Fluid resuscitation alone lowers serum glucose through dilution and improved renal perfusion, which enhances urinary glucose excretion. Insulin is initiated only after fluids are running, blood pressure and urine output are adequate, and serum potassium is confirmed not low.

CautionStarting insulin before adequate fluid resuscitation can worsen hypotension because insulin shifts glucose and water into cells, further reducing circulating volume in an already dehydrated patient.

## 핵심 개념

- **Hyperosmolar hyperglycemic state (HHS)** — A serious complication of diabetes characterized by extreme hyperglycemia, hyperosmolality, and severe dehydration without significant ketoacidosis.
- **Osmotic diuresis** — Increased urine output caused by excretion of osmotically active substances such as glucose, leading to water and electrolyte loss.
- **0.9% sodium chloride** — Isotonic crystalloid fluid used initially in HHS to expand extracellular volume and stabilize hemodynamics.
- **Total body water deficit** — In HHS, typically 100-200 mL/kg, representing 6-12 L for a 60 kg patient.
- **Insulin-induced hypovolemia** — Worsening of hypotension when insulin shifts glucose and water into cells before adequate fluid resuscitation.

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