Case Presentation Kevin Harney

Case Presentation

Kevin Harney, age 14 years, did not appear for breakfast when his mother called him. “That is unusual,” she thought, “He has been so hungry lately, and he is so skinny, he really needs the food!” She found Kevin lying on his bed, breathing rapidly and deeply. He responded slowly with one or two words at a time to her increasingly frantic questions. Some of his answers did not make sense. Kevin’s parents took him to the nearest emergency department, where his laboratory tests showed arterial blood pH 7.20, PaCO2 21 mm Hg (2.8 kPa), serum HCO3 – concentration 8 mEq/L (8 mmol/L), and glucose concentration 450 mg/dL (25 mmol/L). Kevin was diagnosed with DKA arising from previously undiagnosed type 1 diabetes. During Kevin’s hospitalization, interventions focused initially on intensive collaborative management of his disrupted acid–base balance with insulin and IV fluid to treat the diabetes. As a safety intervention, Kevin was positioned on his side to prevent aspiration if he vomited. During this phase of management, aention also was given to supporting his parents, explaining that Kevin’s unusual breathing paern actually was beneficial to him, and coaching his mother to assume the task of protecting Kevin’s lips by keeping them lubricated. Careful monitoring of blood values and physical assessment parameters was used to follow his progress and to modify therapy when his condition changed. As Kevin began to be more responsive and stable, the focus of nursing interventions expanded to teaching Kevin and his parents about type 1 diabetes: how to manage it, and how to recognize the signs of hyperglycemia. Although not directed specifically at the acid–base balance, this teaching helped to prevent future episodes of DKA through disease management.

Case Analysis Questions

 1. Review Fig. 9.1. Based on the information presented in the case, where does Kevin fall on the continuum?

 2. Review Box 9.1, examining the three categories that can cause metabolic acidosis. In which category does Kevin’s situation definitely fall? Explain the mechanisms by which this occurs in undiagnosed type 1 diabetes. Is there an additional category that also may have played a part?

3. Explain the mechanisms that caused Kevin’s decreased PaCO2 and decreased HCO3 – concentration.