Diabetic ketoacidosis and Normal saline Situation

Mr. Robert Formosa, a 40-year-old male, has been admitted to Mater Dei Hospital with a diagnosis of diabetic ketoacidosis (DKA). He lives alone and has a history of frequent non- adherence to both his dietary and medication regimens. This is not his first hospital admission with DKA. On arrival, Robert is drowsy but responsive 

• Identify and explain the priority nursing actions you would take when caring for Robert during the acute phase of diabetic ketoacidosis.
• State the initial intravenous fluid therapy typically prescribed in the management of Will Robert remain on this solution throughout his care? Justify your response.
• List and briefly explain the key laboratory findings commonly associated with diabetic ketoacidosis.
• As Robert’s blood glucose levels begin to stabilise, which electrolyte imbalance is most likely to occur? Explain why this happens and how it should be monitored.

Part 1: Mr. Robert Formosa‘s Case of Diabetes Ketoacidosis

1.1 Nursing Actions Take on Priority

First, I would assess and secure the airways of the patient, along with circulation and breathing, to ensure adequate oxygenation and perfusion. Next, I’d establish two large-bore intravenous lines to facilitate prompt fluid resuscitation and medication administration. Simultaneously, I will start constant cardiac and vital signs monitoring to identify hemodynamic instability and arrhythmias. I would measure his level of consciousness using the Glasgow Coma Scale and perform frequent neurological checks. Early point-of-care capillary glucose and bedside ketone testing would guide ongoing treatment decisions. Lastly, I’d collaborate with the multidisciplinary team to commence insulin therapy after initial fluid replacement (Gosmanov et al., 2014).

1.2 Fluid Therapy based Initial IV 

Management begins with 0.9% sodium chloride (normal saline) at 15–20 mL/kg during the first hour to correct dehydration and restore perfusion. Robert will not stay on normal saline during his care. After the serum sodium levels return to normal and the volume status is corrected, we will switch to 0.45% saline or add dextrose to prevent hyponatremia and continue with his fluid and glucose needs, as insulin helps lower his blood sugar levels. (Barski et al., 2023).

1.3 Key Laboratory Findings 

Laboratory hallmarks of DKA include (Xu et al., 2015):

1. Hyperglycemia: Blood glucose Level greater than 250 mg/dL.
2. Metabolic acidosis: Arterial pH level less than 7.30 & bicarbonate less than 18 mEq/L.
3. Ketosis: Elevated serum and urine ketones (β-hydroxybutyrate, acetoacetate).
4. Elevated anion gap: Usually > 12 mEq/L, indicating unmeasured acids.
5. Electrolyte disturbances: Sodium often appears low (osmotic shift), potassium initially high despite the total-body deficit and phosphate depleted due to diuresis.

1.4 Glucose Stabilizes due to Electrolyte Imbalance 

When insulin pushes potassium into cells, there is a high chance of hypokalemia. Serial potassium levels can be normal or high at admission, but total body potassium is depleted. As insulin therapy and correction of acidosis shift potassium intracellularly, serum levels fall. We perform hourly serum potassium measurements and replace potassium to maintain levels between 4.0 and 5.0 mEq/L, preventing dangerous cardiac arrhythmias.

Part 2: Cholecystectomy – Preoperative Situation

Ms. Joann Caruana, a 33-year-old mother of four with obesity, is diagnosed as having acute gallbladder inflammation. Her symptoms continue to recur and therefore she is scheduled for gallbladder surgery

• What key information should the nurse verify on the consent form before surgery, and how should the nurse support the patient if she expresses uncertainty about the procedure? (1 mark; 60 words).

• Which nursing interventions can help alleviate Joann’s preoperative anxiety, considering her role as a mother of four and her upcoming surgery? 
• Identify the preoperative assessments and investigations that should be completed for Ms. Caruana, especially considering her obesity and history of gallbladder issues. 
• Explain the importance of patient education regarding preoperative fasting (nil by mouth) and medication adjustments prior to surgery. How would you ensure Joann understands and adheres to these instructions?
• Joann is scheduled for a laparoscopic cholecystectomy under general anaesthesia. Before surgery, the surgeon suspects that a gallstone is blocking the common bile duct. What is the name of the procedure used to remove the obstruction, and in your own words, briefly explain what it involves. 

Part 2: Preoperative Situation for Cholecystectomy.

2.1 Key Consent Verification & Supporting Uncertainty 

Before surgery, I will verify the patient’s details, including Name, Date of birth, and the planned procedure (“laparoscopic cholecystectomy”). The surgeon’s Name, signature, and Date and time are all correctly documented. If she seems unsure, I would sit with her privately, listen empathetically, encourage her to voice concerns, answer her questions in plain language, and offer to arrange for the surgeon or anesthetist to clarify any remaining doubts  (Brown et al., 2025).

2.2 Nursing Interventions to Alleviate Preoperative Anxiety

I would offer emotional support to Joann by knowing that she has concerns about abandoning her children. I’d arrange a preoperative tour of the surgical unit and anesthesia area, teach her simple deep breathing and progressive muscle relaxation exercises, and facilitate a brief phone call or video chat with her family. Offering distractions—such as soothing music or a guided imagery script—can also help her feel calmer and more in control (Guo et al., 2025).

2.3 Preoperative Assessments & Investigations 

Key assessments include measuring weight and height (to calculate BMI), airway evaluation (using the Mallampati score), and skin inspection for pressure-risk areas. Vital signs and baseline ECG screen for obesity-related cardiac risk. Laboratory tests: Complete Blood Count (CBC), electrolytes, liver function tests, coagulation profile, and blood glucose levels. A preoperative abdominal ultrasound or MRCP confirms gallbladder inflammation and stones. An OSA (obstructive sleep apnoea) questionnaire helps predict anesthesia risk (Kermansaravi et al., 2024).

2.4 Education on Fasting & Medication Adjustments 

Preoperative fasting prevents aspiration during anesthesia; typically, six hours before surgery, no solids are allowed, and two hours before surgery, clear fluids are permitted. Certain medications, like anticoagulants or diabetic agents, must be held or adjusted to reduce bleeding or hypoglycemia risk. I would explain these instructions clearly, use a teach-back method to confirm her understanding, provide written guidelines, and remind her again the evening before surgery (Denkyi, 2020).

2.5 Process for Alleged Collective Bile Duct Obstruction 

The surgeon would perform an endoscopic retrograde cholangiopancreatography (ERCP) to remove the stone blocking the common bile duct. ERCP is a technique in which an endoscope is inserted through the mouth into the duodenum, and contrast dye is injected into the bile ducts under X-ray guidance. Then, the sphincter is cut (sphincterotomy), and tiny baskets or balloons are used to retrieve the obstruction