UNFOLDING Reasoning Simulation

Diabetes Mellitus Type I

Diabetic ketoacidosis
Part I: Developing Noticing and Interpreting Skills
1. Which findings from the present problem are most important and noticed by the nurse as clinically significant?
Most Important Findings Clinical Significance
9 years old boy came to ER his grandmother states he is more sleepy and DKA develops when your body does not have enough insulin to allow blood sugar into your
his breathig is not normal is deeper and faster. Pt was sick with respiratory
virus 2 week ago but his is recovered. pt started to complain of abdominal cells for use as energy. DKA usually develops slowly. Early symptoms include being very
pain, headache, muscle aches and consistently being hungry and thist , he is thirsty, urinating a lot more than usual. If untreated, more severe symptoms can appear
urinating more frecuently during the day and nigth quickly, such as: fast, deep breathing, dry skin and mouth, flushed face, fruity-smelling
breath, headache, muscle stiffness or aches, being very tired, nausea and vomiting and
stomach pain.

2. Which data from the social history is most important and noticed by the nurse as clinically significant?
Most Important Findings Clinical Significance
Pt lives with his grandmother and 2 siblings a Patiet has family support, Family and pt can learn about
younger sister four years old and a 12-yearold
brother. His mother passed away a year ago. Jack signs and symptoms about DKA. PT can be motivated to
is in the 4th grade he is a good student and loves keed excercising. Family can get social and emotional
play baseball support.

3. Which findings from the contextual factors are most important and noticed by the nurse as clinically significant?
Most Important Findings Clinical Significance
The new nurse in the er department at a busy urban Nurse has lack of experience with pediatric patients.
hospital. The nurse has been off orientation for 6 months.
She feel uncomfortable with the care of pediatric
patients’ population because clinical rotation was
shortened in nursing school due covid 19.

Patient Care Begins

4. Which vital sign findings are most important and noticed by the nurse as clinically significant?
Most Important Data Clinical Significance
T 38c oral Fever present is a sign of infection
P 136 Regular Tachycardia and thachyapenea are present, CO2 triggers the brain to
R 44 deep/ rapid
B/P 80/48 increase the rate and depth of respirations in an attempt to it get rid of it.
O2 sat 98% RA B/P hypotension is a sign of dehydatation due excessive urination

Current Assessment:
GENERAL SURVEY Lying on the bed with eyes closed, whimpers with touch, recognizes grandmother. Fruity
odor to the breath.
PAIN Continuous dull ache in abdomen. Rates 4/10
NEUROLOGICAL Lethargic, responding with one-word phrases. Occasionally slow to arouse and
intermittently confused to place and time; muscle strength 5/5 in both upper and lower
extremities bilaterally.

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 UNFOLDING Reasoning Simulation

HEAD Head normocephalic with symmetry of all facial features. PERRLA, sclera white
bilaterally, conjunctival sac pink bilaterally. Eyes appear "sunken," mucus membranes
dry, tacky mucosa, chapped lips.
RESPIRATORY Respirations are deep and rapid; lung sounds clear bilaterally.
CARDIAC Pink, warm & dry, no edema, heart sounds regular, pulses slightly weak/thready, equal
with palpation at radial/pedal/post-tibial landmarks, cap refill 2 seconds. Heart tones
audible and regular, no abnormal beats or murmurs.
ABDOMEN Abdomen round, soft, and tender to light palpation. BS active in all four quadrants,
feeling nauseated
GENITOURINARY Voiding large amounts of clear light-yellow urine
INTEGUMENTARY Skin warm, dry, itchy, flushed, intact, normal color for ethnicity. No clubbing of nails,
cap refill <3 seconds, Hair soft-distribution normal for age and gender. Skin integrity
intact, skin turgor nonelastic, tenting present.

5. What assessment data needs to be noticed as most important? Interpret its clinical significance.
Most Important Data Clinical Significance
fruity odor to the breath ketones are present that make his breath like fruity odor, fat is broken down
lethargy
eyes appear sunken, mocus membranes dry, tacky
as a surce of energy.
mucosa, chapped lips. when is not enoth insulin, the blood glucose can not get into the cells, so the
respirations deep and rapid cell not get the enough energy that they need.
pulses slightly weak/theady signs and symptoms of dehytratation
feeling nauseated
skin warm, dry tenting present
polyuria
voidding large amounts of clear ligth yellow urine

6. Using the data from this scenario, determine the weight for age percentile for Jackson using the CDC growth
chart.
Percentile Clinical Significance
64 lb / 29.1 kilos in range for his age

Auscultate Breath Sounds

Place a circle on the chest where the nurse would place the stethoscope to
auscultate the left lower lobe.

Click this link to listen. Identify what type of breath sounds are heard and
interpret their clinical significance.
Breath Sounds Clinical Significance
Clear breath sound are clear and equal on inspiration
and expiration. repirations are deep and rapid.

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 UNFOLDING Reasoning Simulation

Auscultate Heart Sounds

Place a circle on the chest where the nurse would place the stethoscope to
auscultate the apical pulse.

Click this link to hear heart sounds. Identify what type of heart sounds are
heard and interpret their clinical significance.
Heart Sounds Clinical Significance
heart tone regular not abnormal beats or murmurs.

Lab Results:
Hematology: Complete Blood Count (CBC)
WBC HGB PLTS % Neuts % Lymphs % Monos % Eosin Bands

Which diagnostic findings are most important and noticed by the nurse as clinically significant?
Most Important Data Clinical Significance TREND
Improved/Declined/No Change
WBC 6.9 WBC count can detect infectionin the body. not infection no change
normal 5-10 pressent.
HGB 16.1 HGB transport oxigen to the body's organs ans tissues.
normal 11-13 HGB is high due dehytratation declined
PLT 252
normal 250-450
Help to coaulation and wound heal
Neuts. 62 type of WBC that help heal damage tissues and infections. no change
normal 55-70 Bands are cells from of neutrophis that are essential for
Bands 0 fighting during an infection. no change
normal <10%
no change

Metabolic Panel
Na K Cl CO2 AG Gluc Ca BUN Creat GFR

Which diagnostic findings are most important and noticed by the nurse as clinically significant?
Most Important Data Clinical Significance TREND
Improved/Declined/No Change
sodium 132 hyponatremia may be the cause of nausea declined
normal 135-145
potassium 5.7
normal 3.5-5 hyperkalemia may make the heart beat irregularly declined
glucose 598 hyperglycemia cause increase hunger, fatige and thirst.
normal 64-110 high creatinine levels indicate that kidneys are no working decline
creatinine 1.4mg/dl
normal 0.8-1.2
properly decline
CO2 15 co2 high may be the cause of abdominal pain due decline
normal 16-22 depletion of bicarbonate buffer

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 UNFOLDING Reasoning Simulation

Misc.
Mg Phosphorus Beta- Hgb A1C Lactate (Ven)
hydroxybutyrate

Which diagnostic findings are most important and noticed by the nurse as clinically significant?
Most Important Data Clinical Significance
magnesium 2.4 mEq/l high levels indicate renal failure
normal 1.4-1.7
phosphorus 2.8mg/dl
when phosphate level in blood becomes very low, muscle weakness are present.
betahydroxybutyrate positive
normal negative metabolic substrate use disorders, insulin deficiency,

Urinalysis
Color Clarity Sp Grav pH Protein Glucose Ketones Bili Blood Nitrate LET

Which diagnostic findings are most important and noticed by the nurse as clinically significant?
Most Important Data Clinical Significance
specific gravity 1.014 kidneys are funtioning properly
normal 1.010- 1.030
glucose 4+
normal 0 glucose should be not present in the urine, may be a sign of diabetes.
ketone 4+ sugar protein ketones should not be present in urine
normal 0

Lab Planning Activity

Lab Name Physiologic Significance Priority Nursing Assessments/Interventions
Sodium 132 mEq/L Sodium is the major cation of Monitor respiratory rate and depth.
extracellular fluid, which includes Monitor blood pressure.
Normal Range blood plasma and interstitial Assess skin turgor, color, temperature, and
135-145
fluid. Responsibility for mucous membrane moisture.
Critical Value
maintaining the composition of ncreased oral intake, and other salt-replacing
below 135 extracellular fluid with respect to medications.
constituents other than oxygen
and carbon dioxide resides
largely with the kidneys

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
 UNFOLDING Reasoning Simulation

Part II: Developing Responding Skills

1. Interpreting clinical data collected, list at least two problems that are possible for this patient? Which
problem is the priority?
Possible Problems Priority Problem Pathophysiology of Priority Problem
DKA Glucose regulation DKA type 1, the body does not produce insuline. Lack of
insuline in the body is causing the body metabolize free
fatty acids and proteins for energy.This starts from ketone
bodies, which results in diabetic ketoacidosis. this is a life
threatening disease that must be treated at soon is posible.

Medical Management of Care

2. Identify the rationale for each provider order and its expected outcome.
Care Provider Orders: Rationale: Expected Outcome:
Establish two large bore peripheral IVs geting as much fluid in the patient iv in place
Admit to the Pediatric ICU close monitoring needed nurse had to
monitor pt closely
NPO
food can alter glucose levels blood glucose
stablilization
Vital signs every 30 minutes with neurological checks
every for detecting any changes v/s in normal
hour ranges
monotor for any disrhytmias cause no arrhythmias
Continuous cardiac monitor for electrolyte imbalances presents

STAT finger stick for blood glucose then every one hour For check blood sugar levels levels in normal
ranges
Administer 0.9% NS 20 mL/kg IV BOLUS (over one for pt hydratation
hour) levels back to
then begin ½ NS with 20 mEq KCL at maintenance rate normal due
(1,000 mL for first 10 kg + 500 mL for next 10 kg over rehytratation
24 hours) insuline needed for regulate blood
sugale levels blood sugar will
After fluid bolus start IV Regular insulin infusion not drop
0.05 unit/kg/hour

Once blood glucose level is less than 300 mg/dL or

the blood glucose fall is more than 100 mg/dL,
change IV fluids above to Dextrose 5% in 0.45 NaCl
with 20 mEq KCL
monitor daily weight no changes in
Strict I &O and daily weight
weigth
Ondansetron 2 mg/mL IV push prn every 4 hours nausea to helps with nausea pt with no nausea
experience
Acetaminophen suppository per rectum 350 mg PRN to help to reduce fever pt no experience
every 4 hours comfort or temp > 38.5 C (>101.3 F) fever

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 UNFOLDING Reasoning Simulation

Nursing Management of Care

3. After interpreting clinical data collected, identify the current nursing priority and which action(s) the nurse should
take. List appropriate interventions, rationale, and expected outcome.
Nursing Priority

Priority Intervention(s) Rationale Expected Outcome

vital signs every hour vital signa can be unestables in pat with DKA stable v/s

administrer fluids. pt's leves of

pt need hydratation hytratation will be
stable
cardiac monitoring monitor for cardiac arrhytmias due K
imbalances pt with no
arrhytmias
monitor i&o check for fluid imbalances
i&o will match

4. Based on the social history findings noted as most important, what is the psychosocial/holistic care priority? List
appropriate interventions, rationale, and expected outcomes.
Psychosocial Nursing Priority
Priority Interventions Rationale Expected Outcome
stress management the management of pt's stress can help to Keep pt
improve the pt's health. comfortable
encourage pt and family to
express emotions pt and family will be able to express, pt and family will
frustations, doubs. cope and will able
to help with the
plan care.

Education/Discharge Planning
5. What educational topics need to be included in a teaching plan to prevent complications and prepare this patient
for discharge?
Priority Topics Rationale
administration of insulin check glucose leves before administration
injection site
proper aplication and dosage to administrate
educate about the proper sites of administration and alternate
signs and simtoms sites as needed.
diet educate pt and family to idenfy signs and simtoms of DKA
exercise
get a banlance between diet and exercise

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 UNFOLDING Reasoning Simulation

Part III: Developing Evaluation Skills

Jackson has been transferred from the ED to pediatric ICU two hours
ago. His blood glucose is now 442 (this is an appropriate value based on
the average of 50-75 mg/dL/hour correction). His insulin infusion is
infusing at 1.5 units/hour. You just collected the following clinical data:
6. The nurse has implemented the medical and nursing plan of care. Sixty minutes later, you collect the following
assessment data below.
For each finding, make a clinical judgment by placing an "x" in the appropriate column if the patient's
condition has improved, has not changed, or has declined.
Assessment Finding Improved No Change Declined
T: 98.9 F/37.2 C (oral) x
P: 92 (reg) x
R: 24 (reg) x
BP: 100/60 x
O2 sat: 98% on RA x
Blood Glucose: 442 x
2/10 dull and aching abdominal pain x

Write a concise nurse's note to document what was most important in the medical record at the end of your
shift.
pt vital signs are stable. insuline infusion at 1.5units/hour. keep monitoring for any changes.

Nurse Reflection
To strengthen your clinical judgment skills, reflect on your knowledge and the decisions made caring for this patient by
answering the reflection questions below.
Reflection Question Nurse Reflection
As you worked through this I feel that is very important to know about or family medical history.
simulation, how did it make you We can develop genetic diseases.
feel?
What did you already know and I used that what I learn in class to be able to completed this
do well on this simulation? simulation

What areas do you need to memorized labs values

develop/improve?

What did you learn? How will I learned more abour DKA, like signs and symptoms, so I will able
you apply what was learned to to provide a better patient care.
improve patient care?

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
 UNFOLDING Reasoning Simulation

© 2023 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN