ACKNOWLEDGEMENT

It is indeed a matter of great pleasure to present the case study on the case of one of the medical problems which I had encountered during my 4 weeks posting in medicine ward which was made for partial fulfillment of the requirement for the third year B.Sc. Nursing Programme. Regarding this process, I would like to express our heartfelt gratitude to various personnel who made our work easier and helped in different ways. This case study has been possible with the patience, support and encouragement that I received from them. First and foremost, I want to express my thanks to our Nursing Director Miss Nani Maiya Shrestha, our Coordinator Mrs. Rameswori Shrestha. I am indebted to Madam Roshnanee Shrestha, Madam Diana Shakya and Madam Shrijana Pandey, our supervisor for her helpful guidance during Medicine Ward Practicum for showing path to complete our task providing us full support and inspiration and innovative ideas for presentation of this case study. I am also extremely obliged to all the teachers and staff of Medicine Unit for their good co-operation, guidance, ideas, and mutual co-ordination which aid in my case study. I cant help thanking the patient and the patient party. Without their coordination and adequate information, I wouldnt have been able to describe a detail history of this case study. Similarly, I would want to express gratitude of thanks to all the people who have direct and indirect involvement in this case study as well as cordial association are especially thanked.

CONTENTS
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Contents 1. Introduction Of The Case 2. Objective Of The Case Study 3. 4. 5. 6. History taking Physical Examination Anatomy And Physiology Of Pancreas Description Of The Disease

Page No: 3 4 5-6 7-9 10 11 12

7. Clinical Picture/Features Book Picture Patient Picture 8. Diagnostiic Evaluation Book Picture Patient Picture 9. Management Medical Management Nursing Management 10. Application Of Nursing Theory 11. Drug Used For The Case 12. Nursing Care Plan 13. Daily Progress Note 14. Health Teaching 15. Discharge Teaching To Patient And Family 16. Conclusion 17. References

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19-20 21 22-27 28-31 32 33 34 35

INTRODUCTION OF THE CASE

I hereby present a case of " Diabetic ketoacidosis with Type 1 Diabetes Mellitus in a 18 years old female named Urmila Ramtel from Sindhuli. She came to emergency ward of KMCTH and was admitted .She was admitted on 2068/10/16 and was discharged on 2068/10/23 with the final diagnosis of Diabetic ketoacidosis with Type 1 Diabetes Mellitus. Within this period, I got the chance to study about the disease condition properly with the correlation of book picture and patient picture which proved to be very fruitful to me. This case study includes a detailed history of the patient along with her physical examination, the full description of the disease condition and its comparisons to the book picture which has been useful to study about the case in more detailed and practical way.

OBJECTIVES OF CASE STUDY

GENERAL OBJECTIVES 1. To provide competent nursing care to the client according to their needs. 2. To utilize the nursing process in providing nursing care to the client. 3. To give medications confidently by using five rights and three checks.

SPECIFIC OBJECTIVES 1. To identify the physical and psychological problems of the client (patient). 2. To provide holistic nursing care to the patient with physical and psychological problem with application of nursing process. 3. To apply knowledge from the basic science nursing theories and other specific courses to plan and implement nursing care. 4. To demonstrate skills which provide comfort and recovery of the patient. 5. To help patient and family in promotion of health with available resource. 6. To select patient with medical or surgical problem and plan and intervene the nursing care in priority basis after making nursing diagnosis and evaluate the result of care. 7. To observe the impact of illness on the patient and family and their sociocultural influence. 8. To identify developmental task according to the age of the patient and compare with what of natural age group. 9. To provide health teaching according to the need of the patient. 10. To conduct case study and present it in the group.

HISTORY TAKING
BIODEMOGRAPHIC DATA Name: Urmila Ramtel Age: 18years Sex: Female Temporary Address: Kapan Permanent Address: Sindhuli Bed no: 138 Hospital no.: 09875C Ward: Medicine Occupation: Student Religion: Hindu Date of admission: 2068/10/16 Date of discharge: 2068/10/23

DIAGNOSIS: Diabetic ketoacidosis with Type 1 Diabetes Mellitus CHIEF COMPLAINTS: On the day of admission: Vomiting 3 days On the day of assessment: Vomiting Constipation 4 days Decreased appetite HISTORY OF PRESENT ILLNESS According to the patient, she was called of Type 1 Diabetes Mellitus under insulin for 3-4years (30U morning and 20U evening). She complained of vomiting since 3 days, multiple episodes, firstly contained undigested food particles then contained watery content which was yellowish colour and sour in taste. She also complained of abdominal pain which was around umbilical region, burning sensation, non- radiating. She has not passed stool and flatus since 3 days. No history of fever, chest pain, shortness of breath, burning micturation. HISTORY OF PAST ILLNES Called of DM type 1 since 3-4 years under insulin No history of TB, Hypertension, Asthma PERSONAL HISTORY Appetite: Decreased Urination: Decreased Bowel: constipated Sleep: Disturbed.

FAMILY HISTORY Family includes patient herself, her father, her mother, her one brother and one sister Total family members: 5 Type of family: Nuclear Family tree INDEX: MALE: FEMALE:

PATIENT MARRIAGE: FOLIATION: There is no any history of chronic diseases such as HTN, DM, TB, and Asthma in the family. DIETARY HISTORY: She is non-vegetarian. She does not consume alcohol and does not smoke. SOCIO- ECONOMIC STATUS She lives in clean and good environment. She has cemented house with proper ventilated rooms for the family members. She drinks water directly from tap. The management of the wastes is done by door to door collection.

PHYSICAL EXAMINATION
1. GENERAL EXAMINATION State of consciousness: Drowsy, oriented and responsive Gait: Balanced Facial expression: sad Hygienic state: Not maintained 2. MEASUREMENT Height: 5 feet 2inch Weight: 48kg Body temperature: 98.8F Pulse: 110 beats/min Respiration: 20 breaths/min Blood pressure: 100/60mmHg 3. INTEGUMENTARY EXAMINATION Colour of skin: Pale Inflammattion : Not present Rashes/ lesions: Not present 4. JALCyCOD Jaundice: Not Present Anemia: Not Present Lymphadenopathy: Not present Cyanosis: Not present Clubbing: Not present Oedema: Not Present Dehydration: Present

5. EXAMINATION OF HEAD, FACE AND NECK: Inspect Head for: Color and texture of hair: black and oily hair Cleanliness: not maintained Pediculosis: not present Abrasions/ Injuries/ Other: not present Inspect face for: a) Eye: Symmetrical, sunken eyes Swelling of eyelids/ Discharges: not present Color of sclera/ conjunctiva: pale Reaction to light: present Vision problem: not present b) Ear: Appearance: normal Discharge: not present 7

 Wax/ lesion/ Polyp: not present Hearing problem: not present c) Nose: Discharge/ Bleeding: not present Blockage: not present Deviated nasal septum: not present Sensation of smell: present d) Neck: Mobility: normal Lymph node: normal Thyroid gland: normal Enlarged neck vein: not present e) Mouth: Color of lips: pink Cracked lips: present Bleeding/pain of gums: not present Dental caries: not present Tongue: Dry Oral hygiene: not maintained 6. 7. 8. EXAMINATION OF BREAST: Inspection of the breast: Symmetry: normal Condition of nipples: normal Discharges form nipples: not present Palpate breast for abnormal lump: not present EXAMINATION OF CHEST Inspection of the chest: Shape of the chest: normal Equal movement of chest during breathing: present Difficulty in breathing: not present Auscultation of chest: Breathing sounds: normal Heart sounds: normal Chest percussion: Resonance sound(normal) EXAMINATION OF ABDOMEN Auscultation: Bowel sounds: 1-2 times/min Abdominal palpation: Hepatomegaly: not present Spleenomegaly: not present Tenderness: mild tenderness over umbilical region Abnormal masses: not present Percussion Shifting dullness/ Fluid thrill: Not present 8

9. EXAMINATION OF LIMBS Joint mobility: normal Tenderness/ Swelling: not present Texture of skin: normal Varicose vein: not present 10. EXAMINATION OF BACK Position of spine: normal Condition of skin: normal 11. EXAMINATION OF FEMALE GENITALIA Swelling of labia: not present Perineal hygiene: Maintained 12. REFLEXES: Gag reflex: Present Biceps reflex: Present Triceps reflex Present Knee jerk: Present Plantar reflex: Present SUMMARY OF POSITIVE FINDINGS Poor hygiene of the body. Body is pale. Patient is drowsy Oral hygiene is not maintained. Skin and tongue is dry. Mild abdominal tenderness over umbilical region Bowel sound present but sluggish Dehydration: Present

ANATOMY AND PHYSIOLOGY OF PANCREAS

The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small intestine). The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail). The pancreas is made up of two types of glands:

Exocrine: The portion of pancreas which secretes pancreatic juice is called the exocrine part. It is made up of acini or alveoli each acinus has a single layer of acinar with a lumen in the center cells which contain zymogen granules. A small duct arises from lumen of each alveolus which unite to form the main duct of pancreas called Wirsuns duct. Wirsungs duct joins common bile duct to form Ampulla of Vater which opens into duodenum. The enzymes secretions include amylase, trypsin and lipase. Endocrine The islet of Langerhans, the endocrine part of the pancreas, are collections of cells embedded in the pancreatic tissue. They are composed of alpha, beta and delta cells. These cells secrete hormones. Alpha cells secrete glucagon hormone, beta cells secrete insulin hormone and delta cells secrete somatostation hormone.

Functions of Pancreas: The secretions of exocrine pancreas are digestive enzymes which are very alkaline because of their high concentration of sodium bicarbonate, are capable of neutralizing the highly acid gastric juice that enters the duodenum Amylase aids in the digestion of carbohydrates, trypsin aids in digestion of proteins and lipase in the digestion of fats. A major action of insulin is to lower blood glucose by permitting entry of glucose into the cells of liver, muscles and other tissues 10

Insulin also promotes the storage of fat in adipose tissue and the synthesis of proteins in various body tissues Glucagon raises the blood glucose by converting glycogen to glucose in the liver Somatostatin exerts hypoglycemic effect by interfering with release of growth hormone from the pituitary and glucagon from the pancreas, both of which tend to raise blood glucose levels

INTRODUCTION TO DIABETIC KETOACIDOSIS

Diabetes mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action or both It is mainly classified into 3 types: a) Type 1 Diabetes Mellitus b) Type 2 Diabetes Mellitus c) Gestational Diabetes Type 1 Diabetes Mellitus: In type 1 diabetes mellitus, the insulin- producing pancreatic beta cells are destroyed by an autoimmune process. As a result, patients produce little or no insulin and require insulin injections to control their blood glucose levels. It is characterized by an acute onset, usually before 30 years of age. Diabetic Ketoacidosis is one of the acute complications of type 1 diabetes mellitus DIABETIC KETOACIDOSIS: DKA is a potentially life-threatening complication in patients with diabetes mellitus.
It happens predominantly in those with type 1 diabetes, but it can occur in those with type 2 diabetes under certain circumstances. DKA results from a shortage of insulin; in response the body switches to burning fatty acids and producing acidic ketone bodies that cause most of the symptoms and complications. Pathophysiology: Without insulin, the amount of glucose entering the cells is reduced, and production and release of glucose by the liver is increased. Both factors lead to hyperglycemia. In an attempt to rid the body of the excess glucose, the kidneys excrete the glucose along with water and electrolytes (Eg: Sodium and Potassium). This osmotic dieresis, which is characterized by polyuria, leads to dehydration and marked electrolyte loss. Patients with severe DKA may lose upto 6.5L of water and up to 400 to 500meq each of sodium, potassium and chloride over 24 hour period. Another effect of insulin deficiency or deficit is the breakdown of fat (lipolysis) into free fatty acids and glycerol. The free fatty acids are converted into ketone bodies by the liver. In DKA, there is excessive production of ketone bodies because of the lack of insulin. Ketone bodies are acids; their accumulation in the circulation leads to metabolic acidosis. Three main causes of DKA are decreased or missed dose of insulin, illness or infection, and undiagnosed and untreated diabetes. An insulin deficit may result from an insufficient dose of insulin prescribed or from insufficient insulin being administered by the patient. Illness especially infections can cause increased blood glucose levels, patient does not need to decrease the insulin dose to compensate for decreased food intake when ill. Other potential causes of decreased insulin include patient error in drawing up or injecting insulin, intentional skipping of insulin doses. In response to physical and emotional stressors, there is an increase in the level of stress hormones- glucagon, epinephrine,

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norepinephrine, cortisol and growth hormone. These hormones promote glucose production by the liver and interfere with glucose utilization by muscle and fat tissue, counteracting the effect of insulin.

CLINICAL FEATURES
The three main clinical features of DKA are Hyperglycemia, dehydration and electrolyte loss and acidosis

Book Picture Polyuria and polydipsia General weakness Blurred vision Shortness of breath Dry skin and mouth Vomiting Abdominal pain Anorexia Tachycardia because of volume depletion Air hunger (Kussmaul breathing) Hypotension Smell of acetone Confusion , drowsiness

Patient Picture Polyuria and polydipsia present General weakness present Blurred vision absent Shortness of breath absent Dry skin and mouth present Vomiting present Abdominal pain present Anorexia present Tachycardia present Air hunger (Kussmaul breathing) absent Hypotension present Smell of acetone present Confusion absent but drowsiness present

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DIAGNOSTIC EVALUATION
-

Book picture History taking and physical examination Blood glucose levels( may vary between 300 and 800 mg/dl) Monitoring urea and electrolytes Perform arterial blood gases to assess the severity of acidosis Urinalysis for ketones Full blood count

Patient picture History taking and physical examination Blood glucose level was monitored

Urea, creatinine, sodium and potassium was monitored Arterial blood gases was performed Urinalysis done to detect ketones Total blood count,differential blood count, ESR and Haemoglobin level was done Blood and urine culture was performed Stool was also examined

Infection screen : blood and urine culture

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LABORATORY INVESTIGATIONS
Report on blood test S. N 1. 2. 3. 4. Date/ Invesigations Hemoglobin WBC Platelets Differential count 10/16 14.9gm% 31200/mm3 569000/mm3 Polymorph: 94% Lymphocyte: 06% 10/17 12.2gm% 10,900/mm3 P: 78% L: 20% Erythrocyte: 02% 20 mm/1st hour( Wintrobe) 10/18 11.9gm% 8400/mm3 P: 56% L:40% Monocyte:02 % E: 02% Normal value 12- 16 gm/dl 4000-11000/mm3 200000400000/mm3 Polymorph: 5070% Lymphocyte: 2040% Erythrocyte1-4% Monocyte : 2-6% less than 20mm/ hr Remarks Decreased Normal Elevated P: Normal L: Normal E: Normal M: Normal Normal

5.

ESR

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S. N 1 2

Investigation s SugarRandom Blood Urea

10/16 277 mg/dl 69mg/dl

10/17 -

10/18 242 mg/dl 24.0mg/dl

10/19 -

10/20 310mg /dl -

Normal 60140mg/dl 1545mg/dl 0.51.4mg/dl 2.57mg/dl 8-11mg/dl 2.5-4.9 mg/dl 136145meq/l 3.85meq/l <220 U/L 68.3gm/dl

Remarks Elevated 10/16: elevated 10/18: Normal Normal Normal Normal Normal Normal

3 4 5 6 7

Creatinine Uric Acid Calcium Phosphorous Sodium

1.1mg/dl 4.9 mg/dl 8.3mg/dl 3.9 mg/dl 141.0 meq/l, 133meq/l 5.2meq/l, 3.3meq/l 112.0U/L 5.9g/dl

138 meq/l, 134 meq/l , 135 meq/l 4.2 meq/l,4.0 meq/l ,4.5 meq/l -

0.7 mg/dl 141.0 meq/l, 139 meq/l, 136 meq/l 4 meq/l, 3.8 meq/l, 4.5 meq/l

141 meq/l, 129.0 meq/l 4.1 meq/l, 4.9 meq/l

135 meq/l, 138 meq/l 4.2 meq/l, 4 meq/l

Potassium

Normal

9 10

Amylase Protein

Normal Low

Report on Biochemistry test S.N Date 1 2068/10/17 Investigations Total cholesterol HDL Cholesterol Triglyceride LDL Patient value 190 mg/dl 43mg/dl 220mg/dl 103mg/dl Normal <200 mg/dl >60mg/dl <150mg/dl 100-129mg/dl Remarks Normal Decreased Elevated Normal

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Report on urine RME S. N A. Investigations Physical examination Color Transparency Chemical examination Reaction Albumin Acetone RBC Pus cells Epicells 10/16 10/17 10/18 10/19 10/20 Normal Remarks

Light yellow Clear Acidic Trace +++ Nil 12/HPF 24/HPF

Light yellow Clear Acidic Nil Trace Nil 1-3/HPF 2-4/HPF

Yellow Clear Acidic Nil Nil Nil Nil 12/HPF

Normal Normal Normal Normal 10/16 to 10/18: High Normal High High

B.

+++ -

Negativ e

Negati ve -

Report on ABG Date S.N Investigations 2068/10/16 1 PH 2 PCO2 3 PO2 4 HCO3 5 Sodium 6 Potassium Report on Stool RME S.N A. Investigations Physical examination Color Consistency Blood Mucus Microscopic examination RBC Pus cells Protozoal Parasites Helminthic Parasites Yeast cells

Patients value 6.976 9.7mmHg 141.2mmHg 2.3mmol/L 133.1mmol/L 4.59mmol/L

Normal range 7.34-7.44 35-45mmHg 75 -100mmHg 20-28mmol/l 136-145mmol/l 3.8-5mmol/l

Remarks Acidosis Low High Low Normal Normal

10/16 Brown Solid Nil Nil Nil/HPF Nil/HPF Not found seen Undigested food particle seen

B.

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Report on blood and urine culture Date: 2068/10/16 Blood culture: No growth after 48 hrs incubation at 37 degree centrigrade Urine culture: No growth after 24 hrs

MEDICAL MANAGEMENT
In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss and acidosis A. Rehydration: In dehydrated patients, rehydration is important for maintaining tissue perfusion. Fluid replacement enhances the excretion of excessive glucose by the kidneys. The patient may need 6 to 10 L of IV fluid to replace fluid losses by polyuria, hyperventilation, diarrhoea and vomiting. Initially, 0.9% sodium chloride solution is administered at a rapid rate, usually 0.5 to1 L/hour for 2 to3 hours. After the first few hours, half-strength normal saline solution is the fluid of choice for continued rehydration; provided the blood pressure is 17

stable and the sodium level is not low. When the blood glucose level reaches 300mg/dl or less, the IV solution may be changed to dextrose 5% in water to prevent a precipitous decline in the blood glucose level Monitor fluid volume status which includes monitoring vital signs, intake and output. Monitoring fluid overload is especially important for patients who are older, have renal impairment or are at risk for heart failure. B. Restoring electrolytes: The major electrolyte concerned is potassium. Although the initial plasma concentration of potassium may be low, normal or even high, there is a major loss of potassium from body stores and an intracellular to extracellular shift of potassium. Furthermore, the serum level of potassium decreases as it renter the cells, therefore, the serum potassium level must be monitored frequently. Some of the factors related to treating DKA that reduce the serum potassium concentration include: - Rehydration, which leads to increased plasma volume and subsequent decreases in the concentration of serum potassium. Rehydration also leads to increased urinary excretion of potassium. - Insulin administration, which enhances the movement of potassium from the extracellular fluid into the cells. Frequent (every 2 to 4 hours) initially laboratory measurements of potassium are necessary during the first 8 hours of treatment. Potassium replacement is withheld only if hyperkalemia is present or if the patient is not urinating. C. Reversing acidosis Ketone bodies accumulate as a result of fat breakdown. The acidosis is reversed with insulin, which inhibits fat breakdown, thereby stopping acid buildup. Insulin is usually infused intravenously at a slow, continuous rate (Eg. 5 units/hour). Hourly blood glucose values must be monitored .Normal saline solutions are administered when blood glucose levels reach 250to 300 g/dL. Insulin must be infused continuously until subcutaneous administration of insulin can be resumed. Even if blood glucose level is decreasing, insulin drip must not be stopped until subcutaneous insulin therapy has been started. IV insulin may be continued for 12 to 24 hours until the serum bicarbonate level improves (at least 15 to 18 mEq/l) and until the patient can eat. Continuous insulin infusion is usually sufficient for reversal of DKA.

NURSING MANAGEMENT
Monitoring fluid, electrolyte and hydration status as well as blood glucose levels Vital signs (especially blood pressure and pulse), breath sounds and mental status are assessed every hour Administering fluids, insulin and other medications Preventing other complications such as fluid overload Urine output is to be monitored to ensure adequate renal function before potassium is administered to prevent hyperkalemia As DKA resolves and the potassium replacement rate is decreased, following things are to be taken in care: 18

There are no signs of hyperkalemia on the ECG ( tall, peaked or tented T waves) Laboratory values of potassium are normal or approaching to normal The patient is urinating (i.e. no renal shutdown) As the patient recovers, factors that may have led to DKA should be reassessed

Prognosis: Diabetic ketoacidosis if untreated may lead to coma and death.Improved therapy for young diabetics has decreased the death rate associated with this condition. However, it remains a major risk in the elderly and in people who fall into profound coma when treatment is not applied in time.

APPLICATION OF NURSING THEORY

VIRGINIA HENDERSONS THEORY In 1955, Virginia Hendersons definition of the unique function of nursing was a major stepping stone in the emergence of nursing as a discipline separate from medicine. Basic to her definition, there are various assumptions about the individuals that the individuals
Need to maintain physiologic and emotional balance. Requires assistance to achieve health and independence or a peaceful death. Needs the necessary strength will, or knowledge achieve or maintain health. These needs give direction to the nurses role. Henderson conceptualizes the nurses role as assisting sick or healthy individuals to gain independence in meeting 14 fundamental needs in 1996 to augment her definition. The components are as follow:

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Nursing process Nursing assessment

Hendersons 14 components and definition of nursing Assess needs of human being based on the 14 component of basic nursing care:

Patient Profile

Breathe normally Eat and drink adequately Eliminate body wastes Move and maintain desirable postures Sleep and rest Select suitable clothes-dress and undress Maintain the body temperature within the normal range by adjusting the clothing and modifying the environment Keep the body clean and well groomed and protect the integuments. Communicate with others in expressing emotions, needs, fears and opinions Worship according to ones faith Work in such a way that there is a sense of accomplishment Play or participate in various forms of recreation Learn, discover or satisfy the curiosity that leads to normal development and health and use the available health facilities.
Analysis: compare the data to knowledge base of health and disease

Breathe normally Loss of appetite Unable to eliminate body wastes Experiencing problem in moving because of weakness Disturbed sleep Able to dress and undress Normal body temperature

Hygiene not maintained and skin dry Well communicates with his family members and staffs Patient worships according to his own faith Unable to participate in recreation due to fatigue. Take part actively to learn about diseased condition and co operative with health facilities

So in order to provide nursing care to my patient with a diagnosis of Diabetic Ketoacidosis with Type 1 Diabetes Mellitus, I made an assessment to find out which of the component as described by Henderson were met and which of them have remained unmet.

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