Michael is a 14-year-old male brought into a small ER by his mother. They were driving a long distance after he competed in a wrestling tournament. He had not felt well on the bus ride with the team so his mother decided he should ride with her. His mother denies a history of chronic illness but did say he had “like a cold but with a stomachache” about 3 months ago.

She also says that he has been very thirsty, and they had to stop several times for him to urinate. She is also worried because he almost missed his wrestling “weight class” parameters because he was significantly lighter this past weekend than he has been in the past. And that is even with him eating more than usual. In triage, the nurse obtains a point-of-care blood glucose (BG) level and the machine gives no value. Instead, an error message indicating “hi” displays on the machine. Michael is AAO x 4. He complains of a “stomachache” and reports he has nausea and experienced vomiting shortly before arrival. His skin is warm and dry, but his face is flushed. When asked about pain, he says he has a headache, and his vision is blurry. The nurse notices a fruity odor on his breath when obtaining vital signs.

BP 90/54 mmHg SpO2 98% on Room Air

HR 122 bpm and regular

RR 26 bpm at rest

Temp 37°C

The patient and his mother are placed into an exam room immediately and the triage nurse verbally reports this to the accepting nurse. The provider orders stat labs, urinalysis and ABGs then examines the patient. The provider tells Michael and his mother that he suspects diabetic ketoacidosis which is not uncommon for new type I diabetics. He plans to transfer Michael to a nearby city via helicopter for a higher level of care. The patient’s mother asks why he has to be transferred. The flight team arrives and assesses the patient. The ER completes a report using SBAR format at the bedside. The patient and his mother are given the chance to ask questions. Upon arrival to the higher level of care, Michael is admitted to the ICU overnight. By the morning he is transferred to a pediatric floor for further observation. His mother remains at his bedside. They plan to return to their home after discharge.

o Based on Clinical Scenario: Complete a nursing care plan with:

▪ 2 nursing diagnoses

▪ one short-term SMART goal with two nursing interventions

▪ one long-term SMART goal with two nursing interventions

▪ May not “use at risk for” for your nursing diagnoses

▪ Must prioritize your nursing diagnoses

. Let’s assume the patient will be discharged home with the following orders:

▪ Insulin (type doesn’t matter, but what side effects should the patient watch for?)

▪ Blood sugar checks at least 3 times a day. When do you recommend testing outside of the 3xs/day?

▪ He’ll follow up with an endo in 3 days

▪ Anything else you want them to understand?

ANSWER

Nursing Care Plan for Michael with Diabetic Ketoacidosis

Nursing Diagnoses

Impaired Tissue Perfusion related to decreased oxygen delivery secondary to diabetic ketoacidosis.
Deficient Knowledge related to newly diagnosed diabetes and self-care management.

Short-Term SMART Goal

Within the next 24 hours, the patient’s tissue perfusion will improve as evidenced by stable vital signs, normal capillary refill time, and absence of abnormal skin color changes.

Nursing Interventions

1. Administer IV fluids as ordered to improve circulating volume and oxygen delivery.
2. Monitor vital signs and capillary refill time every 2 hours to assess for improvement in tissue perfusion.

Long-Term SMART Goal

By the time of discharge, the patient and his mother will demonstrate understanding of diabetes management and insulin administration, as evidenced by correct self-administration of insulin, appropriate blood glucose monitoring, and verbalization of potential side effects and complications.

Nursing Interventions

1. Provide thorough diabetes education to the patient and his mother, including insulin administration techniques, blood glucose monitoring, and signs of hypoglycemia.
2. Collaborate with the diabetes education team to ensure the patient and his mother receive comprehensive information on self-management and lifestyle modifications.

Discharge Instructions

Insulin Administration Side Effects: Instruct the patient to watch for signs of hypoglycemia, including shakiness, sweating, palpitations, and confusion. Also, inform him about the potential for insulin allergy or skin reactions at the injection site.
Blood Glucose Monitoring: Recommend testing blood sugar levels before meals, at bedtime, and whenever feeling unwell. Additionally, advise checking blood sugar levels before and after strenuous physical activity.
Follow-Up with Endocrinologist: Emphasize the importance of attending the follow-up appointment with the endocrinologist in 3 days to review progress, adjust insulin regimen if needed, and receive ongoing diabetes management guidance.
Lifestyle Modifications: Educate the patient and his mother about the significance of maintaining a balanced diet, staying hydrated, and engaging in regular physical activity. Encourage them to keep a record of meals, insulin doses, and blood glucose readings.

By addressing tissue perfusion and knowledge deficits, providing appropriate interventions and education, and ensuring effective transition to home care, the nursing care plan aims to facilitate Michael’s recovery from diabetic ketoacidosis and empower him and his mother to manage his diabetes effectively.