Simulation class

• Discussed the clinical viva, division of groups and

Clinical Workshop

Tutorial class

• Ice-breaking

• Introductory quiz for next week

What?

Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration.

It is a life-threatening complication of diabetes and is usually seen in patients with type-1 diabetes mellitus.

Causes and treatment

Diabetic ketoacidosis usually happens after:

• An illness. An infection or other illness can cause the body to make higher levels of certain hormones, such as adrenaline or cortisol.

• A problem with insulin therapy. Missed insulin treatments can leave too little insulin in the body. Not enough insulin therapy or an insulin pump that doesn't work right also can leave too little insulin in the body.

Other things that can lead to diabetic ketoacidosis include:

• Physical or emotional trauma

• Heart attack or stroke

• Pancreatitis

• Pregnancy

• Alcohol or drug misuse, particularly cocaine

• Certain medicines,

  Symptoms might include:

• Being very thirsty

• Urinating often

• Feeling a need to throw up and throwing up

• Having stomach pain

• Being weak or tired

• Being short of breath

• Having fruity-scented breath

• Being confused

More certain signs of diabetic ketoacidosis — which can show up in home blood and urine test kits — include:

• High blood sugar level

• High ketone levels in urine

Treatment

• Fluids. Fluids replace those lost through too much urinating.

• Electrolyte replacement. Electrolytes are minerals in the blood, such as sodium, potassium and chloride, that carry an electric charge.

• Insulin therapy. Insulin reverses diabetic ketoacidosis.

Case study- 17-year-old female with Diabetic symptoms.

Anxious and needs mother to make medical decisions. Based on the assessment, the patient has low blood glucose. Require insulin infusion and IV Infusion.

Clinical workshop

• ISBAR

• Drug Calculation

• Administration of Insulin therapy and

• Intravenous fluid resuscitation

  
  

  
  

  
  

By the end of the module, I was glad to understand the different symptoms of DKA and the different assessments required to screen DKA.

I also need to revise the IV infusion drug calculation for kids.

Read on cancer and blood disorder cancer.

Started the placement with one patient load.

Met CLN and did the following;

-Discussed on the nursing standards from 1-7.

-Did ISBAR for one patient

-Continue reading about common complications in cancer treatment.

Continued to read about hematological care plans, education and blood report reading.

Met CLN and did a learning cycle about two medications, the pathophysiology behind and the nursing standard.

Completed the ANSAT assessment and end of clinical placement.

Draft a time management schedule for each patient to keep track of task and prioritize the task.

Continue working towards taking leadership and working independently.

-Early recognition of the deteriorating patient including implementation of guidelines for escalation of care.

-Naloxone

Understanding about Naloxone. is an opioid antagonist medication used to block or reverse the effects of opioid drugs, particularly within the setting of drug overdoses which are rapidly becoming a leading cause of death worldwide.

• Do A-G assessment- prioritize the first concern

• Refer to clinical notes if available

• Critically analyse why intervention is required

White privileges.

DKA can present symptoms such as hyperglycemia, ketosis, acidosis, dehydration, and electrolyte imbalance which can be investigated by assessments such as biochemistry, ABG, ECG, Urine analysis, and BGL.

Administration of Naloxone for drug overdose-

why- as an opioid antagonist.

can be administered via different routes (nasal spray, IV injections, infusion, and sub cut).

Management of burn wound

-Cool the burn for 20 minutes under cool running water (to prevent burns in surrounding tissues).

-Avoid hypothermia

Similarly, we discussed trauma-informed care and the team involved in trauma-informed care.

Fundamental principles of Trauma-Informed Care include:

1. Safety: Ensuring the patient feels physically and emotionally safe.

2. Trustworthiness and Transparency: Building trust through transparency in actions and decision-making processes.

3. Collaboration and Mutuality: Emphasizing partnership between providers and patients, leveling power differences.

4. Empowerment, Voice, and Choice: Promoting Pt strength and autonomy by involving them in their care decisions.

5. Cultural, Historical, and Gender Issues: Recognizing and addressing the cultural and societal contexts that impact Pt's experience of trauma.

Trauma-informed care involves being sensitive to the possibility that a patient has a history of trauma and avoiding practices that could unintentionally trigger traumatic responses.

Sam Green,

who has fallen and biba to ED

Chest wall fractures and head injury,

bruising,

deteriorating,

vitals are unstable.

1. Practice Primary survey (A-G)

2. Secondary Survey (head to toe, neuro, abdominal, and pain assessment)

3. Chili Challenge

Workplace injury

-intervention and assessments

• Primary Survey (A-G):

• Pain Assessment:

• Immobilization:

• Control Bleeding:

• Wound Care:

• Fracture Management:

• Referral for Specialist Care:

• Support for Stress or Trauma:

Diabetic ketoacidosis (DKA) occurs when there is a severe insulin deficiency, leading to hyperglycemia, ketosis, and metabolic acidosis.

The following assessment are required to be carried out for DKA.

A-G assessment, which includes of Vital Signs: To assess hemodynamic status. Tachycardia, hypotension, and Kussmaul respirations (deep, labored breathing) may indicate the severity of DKA.

Neurological assessment: Perform regular neurological assessments (e.g., Glasgow Coma Scale to detect signs of altered mental status or cerebral edema, a rare but serious complication of DKA.

Blood Glucose Monitoring: Continuously monitor blood glucose levels (typically every hour or more frequently in severe cases) to track the effectiveness of insulin therapy and avoid rapid changes in glucose levels, which can lead to complications.

Urine Ketones and Blood Gases analysis: Check for ketonuria or ketonemia, and monitor blood gases (e.g., arterial blood gas [ABG] analysis) to assess the degree of metabolic acidosis. A low pH, low bicarbonate, and elevated anion gap indicate acidosis.

Electrolytes and Renal Function: Monitor serum electrolytes (particularly potassium, sodium, and chloride), as DKA can lead to electrolyte imbalances. Hypokalemia can occur as insulin therapy begins. Renal function (BUN, creatinine) should also be evaluated.

Management of DKA

Immediate Fluid Resuscitation

• Fluid Replacement: Initiate fluid resuscitation immediately to restore circulating volume and correct dehydration.

•  

• Ongoing Monitoring: Monitor fluid status by FB Chart to assess urine output, skin turgor, mucous membranes, blood pressure, and heart rate. Patients are often severely dehydrated in DKA, so fluid balance is crucial.

Insulin Therapy: IV Insulin Administration: Begin continuous intravenous insulin infusion to reduce blood glucose levels and suppress ketogenesis.

Electrolyte Monitoring and Replacement: Potassium: Close monitoring of potassium levels is crucial, as insulin therapy and rehydration can cause a rapid shift of potassium into cells, leading to hypokalemia.

Acidosis Management: Bicarbonate Therapy: Bicarbonate therapy is generally not indicated for mild to moderate DKA but may be considered in severe acidosis (pH < 6.9) to prevent cardiovascular collapse. If used, it must be administered carefully with close monitoring of blood gases.

Patient Education and Discharge Planning: Education on DKA Prevention:

Nurses are pivotal in identifying subtle changes in patient conditions and initiating timely interventions. Check the policy and guidelines of the concerned agency or facility about the escalation of care for deteriorating patients.

Some key points to note while noting deteriorating patients.

Early recognition of changes in vitals during A-G assessments or any other assessments (e.g., altered vital signs, confusion, reduced urine output) allows for prompt interventions before the patient’s condition worsens, e.g., changes in the Modified Early Warning Score (MEWS).

Timely Interventions: Initiating interventions such as administering oxygen, fluids, medications, or escalating care to a higher level can reverse or stabilize the patient’s condition.

Escalation of care to senior nurses, physicians, or specialized teams (e.g., rapid response teams or critical care outreach teams) to provide immediate assessment and treatment of deteriorating patients, reducing the time to definitive care.

Timely Communication: Nurses are at the bedside and are often the first to notice subtle signs of deterioration. Early communication of concerns to the healthcare team is vital in ensuring prompt escalation. Clear, concise, and assertive communication using frameworks like ISBAR- to hand over the key and priority issue instead of all the details about the patient.

The clinical rationale is essential for any intervention and for prioritizing nursing care plans as and when they observe changes that may not align with normal parameters but are significant for that patient (e.g., a deviation from baseline trends).

Frequent Reassessments: Continuous reassessment after interventions is crucial in determining whether the patient is improving or if further escalation is required.

Providing information and seeking consent from the patient is key. Nurses are patient advocates, and if a patient’s condition is deteriorating, they must ensure that appropriate care is provided, even if this means escalating the situation to higher levels of authority or medical staff.

Collaborative Decision-Making: While providing care, any clinical decision has to be consented to by the patient, and all care plans with rationale have to be informed to the patient to provide patient safety and autonomy.

• Good communication skills are the key to settling, resolving, and de-escalating a situation.

• Staying calm; anger may be a sign that the person is in distress, experiencing fear or frustration.

• Listen to what the issue is and the person's concerns.

• Offer reflective comments to show that you have heard what their concerns are.

• Wait until the person has released their frustration and explained their feelings.

• Look and maintain appropriate eye contact to connect with the person.

• Incline your head slightly to show you are listening and give you a non-threatening posture.

• Nod to confirm that you are listening and have understood.

• Express empathy to show you have understood.

Heat — The depth of the thermal injury is related to contact temperature, duration of contact with the external heat source, and the thickness of the skin.

Electrical discharge —The magnitude of the injury depends on the pathway of the current, the resistance to the current flow through the tissues, and the strength and duration of the current flow.

Friction — Injury from friction can occur due to a combination of mechanical disruption of tissues and heat generated by friction.

Chemicals — A wide range of caustic reactions, including alteration of pH, disruption of cellular membranes, and direct toxic effects on metabolic processes, causes injury. In addition to the duration of exposure, the nature of the agent will determine injury severity. Contact with acid causes coagulation necrosis of the tissue, while alkaline burns generate liquefaction necrosis.

Radiation — Radiofrequency energy or ionizing radiation can cause damage to skin and tissues. The most common type of radiation burn is sunburn.

Classification by dept

Superficial — Superficial or epidermal burns involve only the epidermal layer of skin. They do not blister but are painful, dry, red, and blanch with pressure.

Over the next two to three days the pain and erythema subside, and by approximately day 4, the injured epithelium peels away from the newly healed epidermis. Such injuries are generally healed in six days without scarring. This process is commonly seen with sunburns.

Partial-thickness — Partial-thickness burns involve the epidermis and portions of the dermis. They are characterized as either superficial or deep.

●Superficial partial thickness – These burns characteristically form blisters within 24 hours between the epidermis and dermis. They are painful, red, weep, and blanch with pressure. Burns that initially appear to be only epidermal in depth may be determined to be partial thickness 12 to 24 hours later. These burns generally heal in 7 to 21 days; scarring is unusual, although pigment changes may occur. A layer of fibrinous exudates and necrotic debris may accumulate on the surface, which may predispose the burn wound to heavy bacterial colonization and delayed healing. These burns typically heal without functional impairment or hypertrophic scarring.

●Deep partial thickness – These burns extend into the deeper dermis and are characteristically different from superficial partial-thickness burns. Deep burns damage hair follicles and glandular tissue. They are painful to pressure only, almost always blister (easily unroofed), are wet or waxy dry, and have variable mottled colorization from patchy cheesy white to red. rBlanching with pressure may be sluggish. If infection is prevented and wounds are allowed to heal spontaneously without grafting, they will heal in two to nine weeks. These burns invariably cause hypertrophic scarring. If they involve a joint, joint dysfunction is expected even with aggressive physical therapy. A deep partial-thickness burn that fails to heal in two weeks is functionally and cosmetically equivalent to a full-thickness burn. Differentiation from full-thickness burns is often difficult.

Full-thickness — These burns extend through and destroy all layers of the dermis and often injure the underlying subcutaneous tissue. Burn eschar, the dead and denatured dermis, is usually intact. The eschar can compromise the viability of a limb or torso if circumferential.

Full-thickness burns are usually anesthetic or hypo-aesthetic. Skin appearance can vary from waxy white to leathery gray to charred and black. The skin is dry and inelastic and does not blanch with pressure (picture 4). Hairs can easily be pulled from hair follicles. Vesicles and blisters do not develop.

Pale full-thickness burns may simulate normal skin except that the skin does not blanch with pressure. Features that differentiate partial-thickness from full-thickness burns may take some time to develop.

The eschar eventually separates from the underlying tissue and reveals an unhealed bed of granulation tissue. Without surgery, these wounds heal by wound contracture with epithelialization around the wound edges. Scarring is severe with contractures; complete spontaneous healing is not possible.

Extension to deep tissues — Fourth-degree burns are deep and potentially life-threatening injuries that extend through the skin into underlying soft tissue and can involve muscle and/or bone.

Assessment for Burn injury.

• Burn Depth: Superficial, partial-thickness, or full-thickness burns.

• Burn Area: Use the Rule of Nines or Lund and Browder Chart to estimate the percentage of the body affected by burns.

• Vital Signs: Monitor for signs of shock (e.g., tachycardia, hypotension) in severe burns.

• Fluid Balance: Assess for signs of dehydration or fluid overload.

• Pain Assessment: Use pain scales to evaluate pain intensity regularly.

• Psychosocial: Assess the patient’s emotional response, including anxiety, depression, or post-traumatic stress.

Nursing care plan

Impaired Skin Integrity

Perform daily wound care using aseptic technique.

Proper wound care prevents infection and promotes healing

Use appropriate dressings (e.g., hydrocolloid, alginate) based on the wound stage.

Dressings help manage exudate and protect the wound from contamination.

Acute Pain

Administer analgesics

Pain control improves patient comfort and facilitates participation in care.

Risk for Infection

Maintain a clean, sterile environment during wound care and dressing changes.

Infection control practices reduce the risk of wound contamination.

Deficient Fluid Volume

Administer IV fluids based on the patient's fluid loss (using formulas

Fluid resuscitation replaces lost fluids, preventing hypovolemia and shock.

Monitor urine output hourly (target > 0.5 mL/kg/hr for adults).

Urine output is a crucial indicator of adequate fluid resuscitation.

Monitor electrolytes and replace them as needed (e.g., potassium, sodium).

Burns can cause electrolyte imbalances, which must be corrected to maintain physiological stability.

Impaired Physical Mobility

Encourage passive and active range-of-motion exercises when possible.

Maintaining mobility prevents contractures and muscle atrophy.

Collaborate with physical and occupational therapists for rehabilitation planning.

Early rehabilitation promotes mobility and prevents long-term disability.

Impaired Gas Exchange (if applicable for severe burns)

Assess for signs of inhalation injury (e.g., soot around the mouth, singed nasal hair, hoarseness).

Maintain adequate oxygenation and ventilation.

Disturbed Body Image

Provide emotional support and encourage verbalization of feelings regarding changes in appearance.

Support emotional adjustment to body changes.

Anxiety

Provide clear explanations about procedures and expected outcomes

Reduce anxiety and promote coping mechanisms.

https://www-sciencedirect-com.ezproxy.canberra.edu.au/science/article/pii/S1751722217300902?via%3Dihub

https://www-sciencedirect-com.ezproxy.canberra.edu.au/science/article/pii/S0020748918301895?via%3Dihub

Practiced

• Identifying prioritisation of care for the patients based on A-G assessment.

• Infection precaution and safety control

• ISBAR

• NG tube insertion

• Escalation of care

Case Study:

Lucas- 10 yr old type 1 diabetic

ed

symptoms: increasing fatigue,frequent urination, excessive thirst, more irritability, feeling nauseated.

fruit smell, breathing rapidly. BGL-15mmol/L missed a dose or two in school.

Assessment at ED

Kussmal respirations

Pain 6/10

Tachycardia, mildly hypotensive, cap refill 4 secs,

Finger BGL 22 mmol/L,

Urine dipstick is positive for ketones

While providing care plan, it is essential to refer for NFR of patients or the agency's policy about escalating the care plan.

It is essential to refer to the Agency's policy and guidelines regarding infection outbreaks while providing care plans, such as the Agency's policy about gastro outbreaks in aged care.

Clinical viva rubric review

Critical thinking is needed to determine a nursing care plan ( providing a rationale for why it is required and why not, pathophysiological understanding of signs and symptoms, and associating with evidence).

-Complex medication management

How, why, what, safety orders, and side effects.

-Prioritisation of care

Able to identify the prioritisation of care based on AG assessment.

Provide rationale.