Journal of Nursing Education

Educational Innovations 

Development of Simulation Scenarios for an Adolescent Patient with Diabetic Ketoacidosis

Patricia A. Schneider Sarver, MSN, RN, CPN; Elizabeth A. Senczakowicz, MSN, RN, CNOR; Bernadette Murphy Slovensky, MSN, RN, CEN

Abstract

Changes in health care delivery have shifted the care of pediatric patients primarily to the outpatient setting, with the exception of children and adolescents requiring complex, highly acute care. Thus, nurse educators are challenged to provide nursing students with pediatric learning experiences and are further confounded by the relative paucity of available clinical placements. Nurse educators are exploring the use of simulation to provide realistic alternatives to pediatric clinical experiences. The development of simulation scenarios focused on the care of an adolescent patient presenting with diabetic ketoacidosis is discussed. A review of the current literature addressing the use of simulation in nursing education and the advantages and challenges of designing, implementing, and evaluating simulation scenarios are also discussed.

Abstract

Changes in health care delivery have shifted the care of pediatric patients primarily to the outpatient setting, with the exception of children and adolescents requiring complex, highly acute care. Thus, nurse educators are challenged to provide nursing students with pediatric learning experiences and are further confounded by the relative paucity of available clinical placements. Nurse educators are exploring the use of simulation to provide realistic alternatives to pediatric clinical experiences. The development of simulation scenarios focused on the care of an adolescent patient presenting with diabetic ketoacidosis is discussed. A review of the current literature addressing the use of simulation in nursing education and the advantages and challenges of designing, implementing, and evaluating simulation scenarios are also discussed.

Ms. Schneider Sarver is Education Nurse Specialist, The Children’s Hospital of Philadelphia, Philadelphia, and Ms. Senczakowicz is Assistant Professor of Nursing, Misericordia University, Dallas, Pennsylvania. Ms. Murphy Slovensky is Clinical Care Manager, Peconic Bay Medical Center Emergency Department, Riverhead, and Adjunct Faculty, Suffolk County Community College School of Nursing, Ammerman Campus, Selden, New York.

The authors have no financial or proprietary interest in the materials presented herein.

The authors would like to acknowledge Drexel University and The College of Nursing & Health Professions, where they all completed graduate studies and had the opportunity to come together to develop this work. Specifically, they would like to thank Marylou McHugh, EdD, RN, CNE, Associate Professor of Nursing and Coordinator, Contemporary Nursing Faculty Track, for her guidance, support, and encouragement in pursuing the publication of this article.

Address correspondence to Patricia A. Schneider Sarver, MSN, RN, CPN, Education Nurse Specialist, The Children’s Hospital of Philadelphia, Department of Nursing Education, Room 8516, 34th Street & Civic Center Boulevard, Philadelphia, PA 19104; e-mail: sarver@email.chop.edu.

Received: June 09, 2009
Accepted: February 10, 2010
Posted Online: June 30, 2010

Over the past decade, the health care environment has shifted in such a way that the majority of acute and chronic care for pediatric patients is provided in outpatient settings, resulting in increased complexity and higher acuity among hospitalized children and adolescents (Baldwin, 2007; Broussard, Myers, & Lemoine, 2009; Hockenberry, Wilson, & Winkelstein, 2005). In light of this shift, nurse educators are challenged to provide adequate learning experiences in pediatric courses where high acuity and complexity are no longer the exception, but rather essentially the rule in the clinical learning environment. In an effort to meet these challenges, nurse educators are exploring the use of low-fidelity, intermediate-fidelity, and high-fidelity simulation to prepare students with the fundamental assessment, communication, critical thinking, and technical skills necessary to competently care for complex pediatric patients (Broussard et al., 2009; Todd, Manz, Hawkins, Parsons, & Hercinger, 2008).

The purpose of this article is to present the use of three variations of a high-fidelity simulation scenario developed to address the care of an adolescent patient experiencing diabetic ketoacidosis. This article presents a brief review of the literature addressing the use of simulation in nursing education and then discuss the development and implementation of the diabetic ketoacidosis simulation scenarios. The article concludes with a discussion of the advantages and challenges associated with the use of simulation in nursing education.

Literature Review

In preparing to develop the simulation scenario that involves an adolescent patient experiencing diabetic ketoacidosis, the authors performed a review of the current professional literature and found that the number of articles and publications that address the use of simulation in nursing education are abundant (Alinier, Hunt, Gordon, & Harwood, 2006; Baldwin, 2007; Brannan, White, & Bezanson, 2008; Broussard et al., 2009; Fanning & Gaba, 2007; Hovancsek, 2007; Jarzemsky & McGrath, 2008; Jeffries, 2007; Lasater, 2007; Long, 2005; Overstreet, 2008; Rauen, 2004; Todd et al., 2008).

However, the number of articles that specifically address the use of simulation in pediatric nursing education are far less numerous (Baldwin, 2007; Broussard et al., 2009). The following paragraphs summarize and synthesize the information amassed from the review of the literature.

Hovancsek (2007) clearly iterated one of the foremost themes evident in the literature addressing simulation when she wrote:

Students are able to learn from and correct their mistakes without the mistakes adversely affecting live patients and without teachers or clinical instructors needing to step in, correct, and control the situation.

Rauen (2004) noted that, when using simulation, mistakes can be permitted, low-frequency and high-acuity situations can be rehearsed, problem solving and critical thinking skills can be practiced, and learning can be self-paced.

Several research studies focused on assessing the efficacy of simulation found that students realized significant gains in both cognitive and psychomotor development as a result of participating in learning situations that employed low-fidelity (Moule, Wilford, Sales, & Lockyer, 2008), intermediate-fidelity (Alinier et al., 2006), and high-fidelity (Lasater, 2007) simulation experiences.

Broussard et al. (2009) specifically addressed the ways that simulation may be used to enhance learning of pediatric content for undergraduate students and novice nurses, stating that the use of simulation “may bring the nursing profession one step closer to bridging the gap between nursing school, unit orientation, and real clinical situations” (p. 11). Given the fact that nursing programs are often challenged to secure pediatric clinical placements due to the competing demands of baccalaureate, associate degree, and vocational nursing students, the use of simulation scenarios may provide students with opportunities for learning that simply may not arise during their often brief clinical rotations.

Compounding the difficulties associated with the relative brevity of pediatric clinical rotations is the trend toward higher acuity and greater complexity among the hospitalized pediatric patient population (Baldwin, 2007; Broussard et al., 2009). According to Baldwin (2007), “High acuity in client populations has placed increasing demands on novice nurses to apply concepts of clinical reasoning to nursing practice” (p. 24).

Advantages and Challenges of Simulation

Although the introduction of simulation at varying degrees of fidelity as a teaching-learning strategy in nursing education clearly has a multitude of strengths and advantages, it is not without several logistical challenges in terms of physical and human resources. As the range of simulation technologies broadens and more schools of nursing seek to develop formal simulation programs, it is important that both the advantages and challenges of simulation are explored. An overview of the advantages and challenges of simulation is presented in Table 1.

Advantages and Challenges of Simulation

Table 1: Advantages and Challenges of Simulation

On a positive note, in a study conducted to determine nurse faculty perceptions of the use of simulation in schools of nursing in Ontario, Canada, it was found that simulation was considered an important element in nursing education (Akhtar-Danesh, Baxter, Valaitis, Stanyon, & Sproul, 2009). As simulations are developed that closely resemble the realities of clinical practice environments, their use will likely expand to encompass all types and levels of complexity of nursing education (Hovancsek, 2007).

Although some faculty will likely enthusiastically adopt this teaching methodology, it is equally likely that simulation will not be as readily accepted by all. For example, a fair degree of computer literacy and technological savviness are required to develop simulations. Although there are many faculty who will embrace this opportunity to cultivate new skills, there may be others who will retreat from this requirement, perhaps being less experienced in computer and technological skills.

For those faculty members willing to embrace the opportunity of simulation, another challenge faced will be the time factor. It takes a large amount of faculty time to develop and implement simulation scenarios (Jarzemsky & McGrath, 2008). In addition, simulation implementations can be lengthy, especially with a thorough debriefing, and may take up time that otherwise would have been spent introducing new material (Rauen, 2004). Coupled with this, faculty will be challenged by the need to offer multiple simulation sessions because only small groups can participate effectively in any given scenario (Rauen, 2001).

Clearly, although the advantages are many, it is equally important for the challenges to be given serious consideration. Faculty will require administrative support to provide them with the time and money to further their education regarding how to develop and implement simulations. This administrative support will need to be further extended to ensure that faculty will have the time needed to properly execute simulations and to do so on multiple occasions.

Why Diabetic Ketoacidosis Was Selected for Simulation Development

Diabetic ketoacidosis is an example of a high-acuity, potentially life-threatening condition that is estimated to occur in “15% to 70% of all newly diagnosed infants and children with diabetes” (Wolfsdorf, Glaser, & Sperling, 2006, p. 1150). According to Hockenberry et al. (2005), diabetic ketoacidosis is classified as a pediatric emergency that requires prompt recognition and therapeutic intervention.

Because diabetes mellitus is the most commonly occurring endocrine disorder affecting the pediatric population (Ross, 2003, as cited in Hockenberry et al., 2005) and because prompt diagnosis and treatment of diabetic ketoacidosis is so critical (Wolfsdorf et al., 2006), the authors determined that the development of simulation scenarios for an adolescent patient in varying levels of diabetic ketoacidosis could provide a much-needed template or starting point for educators who desire to introduce simulation as a teaching-learning strategy in pediatric nursing courses, where clinical learning opportunities with actual clients may be limited or nearly nonexistent.

The next section of this article presents the essential elements associated with the development of the diabetic ketoacidosis simulation scenarios.

Preparing Students for the Simulation

Prior to the simulations of patients with diabetic ketoacidosis, a brief pre-conference must be conducted with the students to establish the “ground rules” for student conduct, use of resources, and safety (Horn & Carter, 2007). As noted by Jeffries (2007), it is important to review the objectives for the simulation and the expectations required of the learners before they actually begin to participate in the simulation. In preparing for this pre-conference, the guidelines offered by Jeffries (2007), O’Connor (2006), and Stokes and Kost (2005) were closely followed.

During the preconference, the overall goal of the diabetic ketoacidosis simulation and the learning objectives should be reviewed with the students. To help assuage any fears, the students are then offered the opportunity to review any of the psychomotor skills they will need to perform in the diabetic ketoacidosis simulation, such as obtaining capillary blood glucose via finger stick, performing ketone testing of urine, or connecting patient-monitoring devices.

The plan for how the diabetic ketoacidosis simulations will proceed is then discussed. Students are informed of the patient scenario and then of the various roles for which each will take responsibility and how to act out those roles if assigned to be the guardians, family members, or family liaison. Those performing the roles of the RN, licensed practical nurse, and certified nursing assistant are told to treat the situation as if it were real and to take whatever actions they would normally take if such a situation presented in the clinical setting. In addition, they are informed that they may interact with the patient and family by asking questions, giving information, and so forth. Before beginning the simulation, the students are given the opportunity to ask any questions they may have about the simulation.

Executing the Simulation Scenarios

In developing simulation scenarios, faculty must plan for the myriad logistical requirements and conditions that are associated with successful implementation. According to Horn and Carter (2007), considerations for implementation include “time constraints, availability of space, support resources, class schedules, and number of students participating” (p. 65). Horn and Carter (2007) further suggest that, to consistently implement simulations among repeated groups, it is necessary to construct two separate sets of written materials to compliment the scenarios: one directed at faculty and the other for student participants. Faculty information should include essential guidance in terms of the set-up and execution of the simulation. It is essential that students are provided with information that will help them understand how the simulation will support the stated learning objectives for the unit of study or overall course.

As previously stated, the authors developed three distinct scenarios for an adolescent patient experiencing diabetic ketoacidosis: mild, moderate, and severe levels of illness. Each level of illness is further divided into three alternative treatment pathways associated with the students’ level of assessment, diagnosis, and implementation of a treatment plan for the patient: non-recognition, no treatment; partial recognition, partial treatment; and full recognition, appropriate treatment. Table 2 includes a completed simulation template worksheet that details the many aspects involved with successfully executing a simulation scenario. Tables 3, 4, and 5 provide information regarding the pathways for the mild, moderate, and severe levels of illness, respectively, discussed above.

Simulation Design: Diabetic Ketoacidosis (Mild, Moderate, and Severe)Simulation Design: Diabetic Ketoacidosis (Mild, Moderate, and Severe)

Table 2: Simulation Design: Diabetic Ketoacidosis (Mild, Moderate, and Severe)

Simulation Scenarios: Mild Diabetic Ketoacidosis Progressiona

Table 3: Simulation Scenarios: Mild Diabetic Ketoacidosis Progression

Simulation Scenarios: Moderate Diabetic Ketoacidosis Progressiona

Table 4: Simulation Scenarios: Moderate Diabetic Ketoacidosis Progression

Simulation Scenarios: Severe Diabetic Ketoacidosis Progressiona

Table 5: Simulation Scenarios: Severe Diabetic Ketoacidosis Progression

Debriefing with the Students Postsimulation

Guided reflection, as defined by Dewey (1933) and Jeffries (2007), is considered essential in helping students reflect on their experience, how they performed, what they learned, and how to apply this new-found knowledge to future practice. In setting up for the postsimulation debriefing, it is important for the instructors to establish a climate that is supportive, confidential, trusting, encouraging, engaging, and challenging (Jeffries, 2007). On the basis of this knowledge, the authors suggest incorporating those factors into the debriefing session and encourage taking time at the beginning of the debriefing to review this with the students so they are aware that these principles will be followed by the faculty, as well as to ensure that the students understand that they will also be expected to follow these principles.

Debriefing Questions

The following “standard” guided reflection questions offered by Jeffries (2007, pp. 30, 58) are suggested for use during the postsimulation de-briefing with students:

  • How did you feel throughout the simulation experience?
  • Describe the objectives you were able to achieve.
  • Which objectives were you unable to achieve (if any) and why?
  • Did you have the knowledge and skills to meet the objectives?
  • Were you satisfied with your ability to work through the simulation?
  • To observers: Could the students have handled any aspects of the simulation differently?
  • If you were able to do this again, how could you have handled the situation differently?
  • What did the group do well?
  • What did the team feel was the primary nursing diagnosis?
  • What were the key assessments and interventions?
  • Is there anything else you would like to discuss?

The following additional questions are not part of the standard list offered by Jeffries (2007) but are identified as critical to this simulation scenario given the specific topic, the age of the patient, and the desire to incorporate family-centered care into the scenario:

  • Did you find it helpful to have had the opportunity to care for the simulated patient who was experiencing the three levels of severity of diabetic ketoacidosis, rather than just one level?
  • In working with the patient’s guardians, and then family when they arrived, what were some of your concerns?
  • How comfortable were you eliciting health information about the patient from the guardians and parents?
  • How did the family’s interactions affect the care you provided?
  • What other resources could you have used to help meet the family’s needs?

It is believed that the students will be able to actively engage in reflecting on their experience and further extend their knowledge and ability in caring for patients exhibiting symptoms similar to those encountered during the simulation in the future through the setup of this supportive environment and the use of these de-briefing questions. Furthermore, the instructors will be able to identify areas in which the simulation and de-briefing process can be fine-tuned and improved for use with future groups of students.

Conclusion

As the health care environment and climate in which nurses are educated continues to evolve in the twenty-first century, it is evident that new approaches and strategies for teaching critical thinking, assessment, communication, and technical skills will be required to meet the demands of the new roles and responsibilities faced by nurse educators and their students (Nagle, McHale, Alexander, & French, 2009; Warner, 2005). Nurse educators are currently challenged to provide adequate learning experiences in pediatric courses, where high-acuity and complexity of care are standard fare in clinical learning environments, which are rapidly becoming less available to students. To address the learning needs of students, nurse educators are exploring the use of low-fidelity, intermediate-fidelity, and high-fidelity simulations to provide students with the skills necessary to competently care for complex pediatric patients (Broussard et al., 2009; Todd et al., 2008).

The purpose of this article was to present the use of three variations of a high-fidelity simulation scenario developed to address the care of an adolescent patient experiencing diabetic ketoacidosis. The article also offered a brief review of the literature, a discussion of the advantages and challenges associated with the use of simulation in nursing education, and a discussion of the development of the diabetic ketoacidosis simulation scenarios and how to implement them, and concluded with a discussion regarding the importance of debriefing with students postsimulation.

References

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Advantages and Challenges of Simulation

AdvantagesChallenges
Teaches clinical reasoning skills in an environment that is not clinically based (Baldwin, 2007).Can be lengthy, especially with a thorough debriefing and may take up time that would have otherwise been spent introducing new material (Rauen, 2004).
Helps students identify cues based on clinical presentation that form pattern recognition in a safe environment (Baldwin, 2007).Several classrooms are required for large groups (Baldwin, 2007).
Can recreate emotional involvement for the learner (Baldwin, 2007).A valid and reliable tool for assessment must be developed for each simulation (Todd, Manz, Hawkins, Parsons, & Hercinger, 2008).
Builds student confidence (Lundberg, 2008).Takes a large amount of faculty time to develop and implement simulation scenarios (Jarzemsky & McGrath, 2008).
Useful for research purposes that may otherwise put patients in danger (Overstreet, 2008).Simulation products (especially human patient simulators) can be costly to purchase, maintain, and repair (Rauen, 2001).
Allows students to make mistakes without endangering live patients (Hovancsek, 2007).Computer literacy and technical support issues may arise (Rauen, 2001).
May provoke students to be more active in their own learning (Overstreet, 2008).Learner responses may vary within groups (Jeffries, 2005).
May be repeated when remediation is needed (Hovancsek, 2007).Simulations must be offered repeatedly because only small groups can participate in any given scenario (Rauen, 2001).

Simulation Design: Diabetic Ketoacidosis (Mild, Moderate, and Severe)

Discipline: NURSING (undergraduate)Reviewed by:

Course: PediatricsDebriefing/Guided Reflection: 30 minutes

Expected simulation run time: 20 minutes per scenario (mild, moderate, and severe) for 60 minutes totalLocation for debriefing: Nursing conference room

Location: Simulated Emergency Department Examination Room

Admission date:Today’s date:Brief summary: Students will be presented with a 14-year-old female patient with new onset type I diabetes mellitus presenting to the emergency department with diabetic ketoacidosis (DKA). The students must be able to recognize the signs and symptoms of DKA including hyperglycemia, ketosis, and acidosis. The students will be given basic medication orders and will be expected to intervene appropriately using the previously learned knowledge and skills required for participation in the simulation exercise. In particular, students must demonstrate knowledge of the importance of supplementing potassium for a patient being treated for DKA and must demonstrate an awareness of the high risk for cerebral edema present during the period when glucose is being normalized. In addition, students must demonstrate effective communication with the patient, her guardians, and parents. If students successfully perform an assessment and intervene with appropriate treatment, the teenager will appropriately progress to discharge status, where teaching should occur to help prevent recurrence of DKA.Prerequisite knowledge: Learners should have an understanding of pediatric client care involving the following skills:Psychomotor skills required prior to simulation:

Ability to measure vital signs and perform physical assessment techniques for neurological, respiratory, and circulatory systems

Ability to obtain blood sample for bedside blood glucose monitoring

Ability to perform ketone testing of urine sample

Ability to administer medications and administer intravenous fluids as ordered

Cognitive skills required prior to simulation:

History taking and knowledge of assessment activities (including vital signs and focused assessments of neurological, respiratory, and circulatory systems)

Basic knowledge of diabetes mellitus, including signs and symptoms of hyperglycemia and DKA (ketosis, acidosis, and associated electrolyte imbalances

Therapeutic communication skills (involving patient and family)


Patient information:
Name: Michelle ChasePast medical history: None
Gender: FAge: 14Past surgical history: None
Race: CaucasianWeight: 100 lbs.Social history: Denies use of alcohol and drugs
Height: 5’5”Significant: ParentsImmunizations: Up to date
Religion: Not statedPhone: 555-1212Medications: None
Allergies: PenicillinBackground information: Complains of nausea, vomiting, and hot dry skin. There is a faint alcohol-like smell on her breath, and she is confused. Her caregivers are concerned because she was “breathing funny.”
Attending Physician/Team: Dr. John Doe
Presenting complaint(s): Changes in mental status, nausea and vomiting, irregular breathing pattern

Setting: Presents to the emergency department with the parents of a classmate. She is spending the night at her friend’s house while her parents are out to dinner. A call has been placed to the child’s parents and they are on their way. There is a letter from the child’s parents granting consent to treat in an emergency.

Simulation Learning Objectives

At the conclusion of the simulation experience, the learner(s) will be able to:

Perform a focused physical assessment of a pediatric patient presenting with signs and symptoms of DKA. (cognitive – application; psychomotor – practicing/adapting)

Interpret assessment data in order to identify a plausible medical diagnosis. (cognitive – analysis)

Develop a brief nursing plan of care appropriate for the patient. (cognitive – synthesis)

Implement medical interventions as ordered by the physician. (cognitive – application; psychomotor – practicing/adapting)

Evaluate the effectiveness of nursing interventions included in the plan of care. (cognitive – evaluation)

Distinguish differences between mild, moderate, and severe states of DKA. (cognitive – evaluation)

Demonstrate evidence of therapeutic communication techniques when speaking with the patient and family. (affective – valuing)

Formulate a teaching plan for the patient and family related to new onset of diabetes mellitus. (cognitive – synthesis)

Fidelitya
Setting/Environment:

Emergency department

Medical-Surgical

Pediatrics

Intensive care unit

operating department/post-anesthesia care unit

Women’s Center

Behavioral Health

Home Health

Pre-Hospital

Medications and Fluids:

Intravenous fluids

Oral medications:

Intravenous piggyback:

Intravenous push:

Intramuscular or subcutaneous:

Simulator Manikin/s needed:SimPerson (Female)Diagnostics Available:

Laboratory tests

Glucometer for capillary blood glucose

Point of care testing – ketones in urine

Radiographs (Images)

Cardiac monitor

Oxygen saturation point

Equipment available in room:

Bedpan/urinal

Foley or straight catheter kit

Incentive spirometer

Fluids

Intravenous start kit

Intravenous tubing

Intravenous piggyback tubing

Intravenous pump

Feeding pump

Pressure bag

Oxygen delivery device type

Crash cart with airway devices and emergency medications

Defibrillator/pacer

Suction

Stethoscope, penlight, blood pressure cuff

Documentation Forms:

Physician orders

Admit orders

Vital sign flow sheet

Medication administration record

Kardex

Graphic record

Shift assessment

Triage

Laboratory reports

Medications and intravenous fluids:

Insulin

Potassium

Dextrose 5½ normal sterile saline with 10 mEq potassium chloride

Role/guidelines for roles:

Primary nurse (student)

Secondary nurse–licensed practical nurse (student)

Clinical instructor

Family member 1: (student)

Family member 2:

Observer/s

Physician/advance practice nurse (faculty)

Respiratory therapy

Aesthesia

Pharmacy

Laboratory

Imaging

Social services

Clergy

Unlicensed assistive personal (student)

Code team:

Other (faculty to control simulator)

Student Information Needed Prior to Scenario:

Has been oriented to simulator

Understands guidelines/expectations for scenario

Has accomplished all presimulation requirements

All participants understand their assigned roles

Has been given time frame expectations

Important information related to roles:Each participant other than the primary and secondary nurses will be given a semi-scripted guide outlining the expectations of their roles in the simulation scenario.Critical laboratory values:See pathways below
Physician/Advanced Practice Nurse orders:To be determined by faculty
Scenario Progression Outline
Timing (Approximately)Manikin ActionsExpected InterventionsMay Use the Following Cues
First 5 minutesPresents in conditions as stated in pathwaysVital signs and physical assessment completed
5 to 10 minutesChanges dependent on student actionsEvaluate assessment data and implement interventions
Final 10 minutesResponds to treatment plan initiated by studentsEvaluate effects of interventions, reassess patient, alter plan of care as needed

Simulation Scenarios: Mild Diabetic Ketoacidosis Progressiona

Pathway #1: no treatment (with no recognition of diabetic ketoacidosis, no intravenous fluids, no insulin therapy, and no potassium supplementation)

Blood pressure begins to lower

Heart rate increases

Temperature decreases

Mental status decreases

Potassium level is unchanged

Pathway #2: partial treatment (recognition of hyperglycemia only)

Treated with insulin as ordered

Intravenous line initiated at KVO rate

Blood glucose slightly decreases, but not significantly (280 mg/dL)

No potassium supplementation

Potassium level decreases to 3.8

Heart rate remains slightly elevated, blood pressure stable

Remains confused, more difficult to arouse

Pathway #3: full treatment (recognition of hyperglycemia and potential development of ketoacidosis)

Treated with intravenous fluids for fluid resuscitation

Insulin therapy given as ordered

Blood glucose drops to 180

20 mEq KCl in 100 mL NSS given as ordered

Repeat potassium level = 4.3

Becomes more alert

Heart rate slows to normal, blood pressure remains stable

Blood pH increases to 7.4

Simulation Scenarios: Moderate Diabetic Ketoacidosis Progressiona

Pathway #1: no treatment (with no recognition of diabetic ketoacidosis, no intravenous fluids, and no insulin therapy)

Blood pressure begins to lower

Heart rate increases

Temperature decreases

Acidosis worsens

Increased ketones in urine

Mental status decreases

No potassium supplementation

Potassium level is unchanged

Pathway #2: partial treatment (recognition of hyperglycemia only)

Treated with insulin as ordered

Intravenous line initiated at KVO rate

Hydration improves

Blood glucose decreases slightly

No potassium supplementation

Potassium level decreases to 3.8

Blood pressure decreases

Heart rate increases

Temp decreases

Acidosis worsens

Pathway #3: full treatment (recognition of acidosis and hypoglycemia)

Oxygen given

Fluid resuscitation given

Insulin therapy given

Blood glucose lowers

Improvement of mental status

Blood pressure increases

20 mEq KCl in 100 mL NS given as ordered

Repeat potassium level = 4.3

Acidosis improves

Simulation Scenarios: Severe Diabetic Ketoacidosis Progressiona

Pathway #1: no treatment (with no recognition of diabetic ketoacidosis, no intravenous fluids, and no insulin therapy)

Hypotension worsens

Acidosis worsens

Mental status decreases

Acidosis leads to pulseless electrical activity

No potassium supplementation

Potassium level is unchanged

Pathway # 2: partial treatment (recognition of hyperglycemia only)

Treated with insulin as ordered

Intravenous line initiated at KVO rate

Blood pressure decreases

Heart rate increases

Temperature decreases

Acidosis worsens

Mental status continues to worsen

No potassium supplementation

Potassium level unchanged

Leading to eventual pulseless electrical activity

Pathway #3: full treatment (recognition of acidosis and hypoglycemia)

Fluid resuscitation given

Insulin therapy given

Improvement of mental status

Blood glucose lowers

Blood pressure increases

Acidosis improves

20 mEq KCl in 100 mL NS given as ordered

Repeat potassium level = 4.3

Authors

Ms. Schneider Sarver is Education Nurse Specialist, The Children’s Hospital of Philadelphia, Philadelphia, and Ms. Senczakowicz is Assistant Professor of Nursing, Misericordia University, Dallas, Pennsylvania. Ms. Murphy Slovensky is Clinical Care Manager, Peconic Bay Medical Center Emergency Department, Riverhead, and Adjunct Faculty, Suffolk County Community College School of Nursing, Ammerman Campus, Selden, New York.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Patricia A. Schneider Sarver, MSN, RN, CPN, Education Nurse Specialist, The Children’s Hospital of Philadelphia, Department of Nursing Education, Room 8516, 34th Street & Civic Center Boulevard, Philadelphia, PA 19104; e-mail: .sarver@email.chop.edu

10.3928/01484834-20100630-07

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