High School

Mr. L is a 58-year-old man recovering in the orthopedic unit from a right total knee replacement performed two days ago. He has type 1 diabetes, diagnosed at 12 years old, and manages his condition with blood glucose checks four times daily: before meals and at bedtime. He uses Humulin-R insulin on a sliding scale based on his glucose results. Mr. L weighs 315 lbs and has osteoarthritis in both knees, necessitating surgical replacement of the right knee joint.

At 8:15 AM, the nurse enters Mr. L's room for a morning assessment. She finds him awake but with an altered mental status and a fruity odor on his breath. His vital signs are: HR 100 bpm, RR 32/minute, BP 116/78 mm Hg. His last blood glucose level was 156 mg/dl the previous night, and he received 2 units of insulin but has not had a morning glucose check or insulin dose. A rapid bedside glucose check shows 468 mg/dl. The nurse contacts the physician, and Mr. L is diagnosed with diabetic ketoacidosis (DKA).

1. **Describe how diabetic ketoacidosis could develop in a patient who has undergone surgery.**

2. Mr. L has an elevated respiratory rate, identified as Kussmaul respirations. **Explain this respiratory pattern.**

3. Mr. L reports excessive thirst and sudden blurry vision. The nurse observes a large amount of clear urine in his catheter bag, which tests positive for ketone bodies.
**How does the body release ketone bodies into the urine during DKA?**
**Explain why Mr. L has increased urinary output, blurred vision, and increased thirst.**

4. The physician orders 0.9% Sodium Chloride IV at 500 mL/hour for 1 hour, then 200 mL/hour for 4 hours. Regular insulin is to be administered at 0.1 mg/kg/hour. Lab work, including a metabolic profile and arterial blood gases, is ordered. Results are:
- Na: 135 mEq/L
- K: 3.2 mEq/L
- Cl: 95 mmol/L
- Ca: 8.5 mg/dl
- Arterial Blood Gases: pH 7.31, pCO2 20 mmHg, pO2 95 mmHg, HCO3 12 mmol/L

**What is the rationale for administering IV fluids at this rate?**
**Explain why the patient’s potassium result is at this current level.**
**Based on the metabolic profile results, what is the next step the nurse should most likely take?**
**Explain why DKA likely produces these types of blood gas results.**

5. An hour after starting the insulin, the nurse checks Mr. L's blood glucose levels, noting a decrease to 208 mg/dl. He appears more comfortable, and his vital signs are: HR 92 bpm, RR 22/minute, BP 116/70 mm Hg, O2 saturation 95% on 2L of oxygen.
**What should the nurse do next?**

Answer :

The nurse should advice the patient to get admitted in the hospital one or two days prior to any operation so that he may be put under surveillance before the surgery.

For such patients, it is advised to wait a few days before their scheduled surgery. When possible, even urgent surgery should be postponed to give patients with diabetic crises time to stabilize. The physiologic stressor known as surgery can cause ketoacidosis. Insulin resistance increases as a result of the postoperative upregulation of regulatory hormones such glucagon, growth hormone, and cortisol.

Increased postoperative morbidity and mortality as well as an increased need for surgical operations are all related to diabetes. Perioperative ketoacidosis or hyperosmolar syndrome can arise from the stress response to surgery and the ensuing hyperglycemia, osmotic diuresis, and hypoinsulinemia.

To know more about diabetes, refer to the following link:

https://brainly.com/question/28096487

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