Management of Type 1 Diabetes Mellitus
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A nurse in the emergency department (ED) is admitting a client who has Type 1 Diabetes mellitus.
Nurses' Notes:
- Client reports increased glucose levels and "feeling really bad." States, "I think I may have given myself the wrong dose of insulin."
- Alerted to person, place, and time; appears lethargic.
- Skin is warm and moist. Decreased turgor. Dry mucous membranes.
- Pulse is rapid, $S_1S_2$ heard on auscultation.
- Respirations deep and rapid. Fruity odor noted to breath. Chest is clear on auscultation.
- Bowel sounds auscultated in 4 quadrants. Reports anorexia and abdominal pain.
- Reports frequent urination with no difficulty.
For each potential provider's prescription, click to specify if the prescription is anticipated, nonessential, or contraindicated.
1. Infuse $D_5$ 1/2 sodium chloride @ 100 mL/hr.
2. Obtain blood and urinalysis for ketones.
3. Obtain capillary blood glucose frequently
4. CT scan of the head
5. Repeat potassium level every 2 hr.
6. Chest x-ray
This question includes visual content: The image shows a digital assessment interface. On the left, a 'Nurses' Notes' section describes clinical assessment findings for a diabetes patient (lethargy, dry membranes, rapid pulse, fruity odor in breath). On the right, a table lists six medical orders: 'Infuse D5 1/2 sodium chloride @ 100 mL/hr.', 'Obtain blood and urinalysis for ketones.', 'Obtain capillary blood glucose frequently', 'CT scan of the head', 'Repeat potassium level every 2 hr.', and 'Chest x-ray'. Each row has checkboxes for 'Anticipated', 'Nonessential', and 'Contraindicated'.
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Let's work through this clinical prioritization task for a client with type 1 diabetes mellitus. We need to categorize these prescriptions based on the clinical signs presented in the nurses notes.
Clinical Prioritization: Diabetic Ketoacidosis (DKA)
First, let's look at the assessment data. The client reports high glucose, lethargy, warm and moist skin with decreased turgor, rapid pulse, and deep rapid respirations. Crucially, a fruity odor was noted on their breath.
These signs strongly suggest Diabetic Ketoacidosis, or D K A. This informs which treatments are essential or contraindicated.
Now, let's categorize the prescriptions one by one. Our first prescription is to infuse D 5 half sodium chloride at 100 milliliters per hour.
Action Categorization
| Prescription | Status |
|---|---|
| Infuse D5 1/2 NaCl @ 100 mL/hr | ... |
In D K A management, we typically start with isotonic saline to restore volume. However, the use of dextrose and half saline is often contraindicated during the initial resuscitation phase when blood glucose is very high, because we need to clear ketones and lower glucose first. Therefore, we mark this as contraindicated for this phase.
Next, obtaining blood and urinalysis for ketones. This is essential to confirm the D K A diagnosis and monitor progress, so we categorize this as anticipated.
| Prescription | Status |
|---|---|
| Infuse D5 1/2 NaCl @ 100 mL/hr | Contraindicated |
| Obtain blood/urine for ketones | Anticipated |
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