NURS13141- Acute Alterations in Health in Complex Care Environment

First Nursing Intervention: Monitor and manage blood glucose levels closely through frequent capillary blood glucose testing and appropriate insulin administration.

Rationale:

Peter has high blood sugar (26.4 mmol/L) and elevated ketones in his blood and urine, suggesting poor glycaemic control and likely DKA (diabetic ketoacidosis). His metabolic acidosis (pH 7.2, bicarbonate low) provides additional evidence for this diagnosis. OS is associated with rapid deterioration of hyperglycaemic patients due to osmotic diuresis, dehydration, electrolyte disturbances, and cellular dysfunction in the absence of control over hyperglycaemia. Frequent monitoring of blood glucose is critical for insulin therapy adjustment and to avoid complications such as cerebral oedema or cardiac arrhythmias. Insulin has the effects of reducing blood glucose by promoting glucose intake into cells, suppressing ketone formation.

Evidence:

According to the American Diabetes Association (2023), regular glucose control and immediate insulin treatment are essential in the treatment of hyperglycaemia and in preventing the development of DKA. The Nursing and Midwifery Board of Australia (2020) point out that insulin dosing and monitoring should be tailored for the patient and the specific metabolic abnormalities. In addition, as shown in peer-reviewed papers (Maharjan et al., 2024), intensive glucose monitoring decreases the duration of hospitalisation and enhances the recovery prognosis of diabetic emergencies. This treatment treats the pathophysiological derangements and is directed towards the aetiology of Peter’s acute deterioration.

Second Nursing Intervention: Assess and support respiratory function by monitoring respiratory rate, oxygen saturation, and providing supplemental oxygen as needed.

Rationale:

Peter has a rapid respiratory rate of 26/min with deep Kussmaul breathing (respiratory compensation for metabolic acidosis due to DKA). On an arterial blood gas, the pH is low (7.2) and the bicarbonate is low (14 mEq/L), consistent with a metabolic acidosis. The body tries to counteract with Kussmaul respiration (deep, rapid breaths) in order to blow off CO₂ and increase the pH of the blood. Hypoxia and respiratory fatigue must be recognised and treated. Peter is a borderline patient because of his SpO₂ (94%) and may need to be on supplementary oxygen to ensure his tissues are all oxygenated properly. Indifference may further result in respiratory failure or cardiac sequelae.

Evidence:

American Thoracic Society (2022) guidelines suggest that continuous monitoring of respiration be performed in all patients with metabolic acidosis as an early warning sign of respiratory depression. Nursing guidelines (NMBA, 2020) highlight the significance of oxygen therapy for patients who have hypoxia and are due to metabolic waste. A study by Perez Ruiz de Garibay et al. (2019) demonstrated that early respiratory support in DKA patients leads to reduced admissions to the intensive care and better outcomes. This medical intervention also helped maintain Peter’s failing oxygenation status and minimised potential complications of deranged acid-base balance, like inadequate oxygen supply and respiratory fatigue.

Third Nursing Intervention: Initiate and maintain adequate fluid resuscitation with intravenous (IV) fluids to correct dehydration and electrolyte imbalances.

Rationale:

Peter’s hyperglycaemic and ketonuric state demonstrates DKA, which activates severe dehydration secondary to osmotic diuresis. Hyperglycaemia leads to diuresis with loss of fluids and electrolytes. Dehydration can decrease perfusion to tissues, cause hypotension, and lead to organ failure. The restoration of circulating volume, improved renal perfusion, and enhanced removal of glucose and ketones are the probable mechanisms underlying the use of IV fluids. This also corrects electrolyte concentrations that are out of balance when someone has a low potassium which is commonly seen with DKA, which if not corrected can lead to heart arrhythmias. Careful attention to fluid balance and electrolyte supplementation is needed to avoid fluid expanders or osmotic shifts associated with gravity.

Evidence:

The American diabetes Association Clinical Practice Guideline (2023) advises that isotonic saline IV fluids are commenced in DKA at once to correct the deficit and/or treat shock. The Nursing and Midwifery Board of Australia (2020) emphasises the importance of monitoring fluid and electrolyte status to guide empiric, safe intervention. Research by Li et al. (2025) proposes that aggressive fluid resuscitation in the early phase reduces the mortality and morbidity in patients with DKA. It is aimed at correcting the pathophysiologic consequences of dehydration and deranged electrolytes in Peter’s acute illness, to stabilise him and allow recovery.

Fourth Nursing Intervention: Perform comprehensive cardiovascular monitoring, including heart rate, rhythm, blood pressure, and signs of ischemia or arrhythmia.

Rationale:

Peter has unstable angina, for which he has had a past medical history of hypertension and hyperlipidaemia; he would be at high risk of acute coronary events and cardiac morbidity. His hyperglycemia and metabolic acidosis may increase myocardial oxygen demand and possibly lead to depression of myocardial contractility and conduction. Early arrhythmia, ischemia, or hemodynamic instability can be recognised by closely watching vital signs and cardiac rhythm. It is important to identify such patients in a timely fashion to avoid progression to myocardial infarction, development of heart failure or sudden cardiac death. A kept in ECG observation and repeated blood pressure measurements are required to control possible cardiovascular bad changes.

Evidence:

The Australian and New Zealand Cardiovascular Nursing Journal (2022) highlights the need for cardiac monitoring for unstable angina with metabolic disturbance (Abrahams & Chew, 2025). Nursing practice standards (NMBA, 2020) stipulate that a comprehensive cardiac assessment is necessary to direct intervention and appropriate escalation of care. Research by Giannitsis et al. (2019) has shown that the use of ECMO treatment and early recognition of cardiac dysfunction with utilisation ratios correlates with a good outcome, with the patients being less likely to end up in the ICU. This form of management holds the advantage of acknowledging that Peter’s acute cardiac and metabolic condition is complex, that a spectrum of clinical symptoms related to his ischaemic heart disease is possible, and that the nurse is able to practice preventive care to reduce risk and stabilise the heart condition.

Collaborative Intervention: Consult the Endocrinology Specialist Team for comprehensive management of Peter’s diabetic ketoacidosis (DKA) and complex glycaemic control.

Considering Peter’s DKA, unstable angina, and other comorbidities, consult an endocrinologist. The endocrinologists have expertise in the management of acute and chronic metabolic complications of diabetes. They can offer expertise in manipulating insulin regimens, correcting electrolytes and in metabolic monitoring to avoid relapse, and to maximise long-term control. Their participation means personalised, evidence-based care for Peter’s immediate and historical pattern of poor glucose management.

I would order the endocrinology consult to optimise Peter’s insulin dosing regimen to supervise his fluid and electrolyte management, and provide Wyatt with some inpatient education to enhance his follow-up compliance. Such a partnership helps ensure we can deliver safe, optimal care by combining specialists with nursing on the front line.

Evidence:

According to the Australian Diabetes Society (2023), involving an endocrinologist early in DKA reduces complications and the length of stay in hospital. Collaborative practice to optimise care outcomes is highlighted in many nursing and multidisciplinary guidelines (NMBA, 2020). Research (Nurchis et al., 2022) shows that interdisciplinary intervention better manages glycemia and reduces patient readmissions among those with diabetes and acute illness.