NU298CL Unit 7 Insulin Rationing DKA Case Synthesis Example

One Vial Stretched Across Five Weeks: A Case Synthesis Joining the Physiology of Ketoacidosis, the Timing of a First Basal Dose and a 0215 Conversation About Cost for a Composite Warehouse Worker of 24 With Type 1 Diabetes

[Student Name]

Purdue University Global

NU298CL: Capstone Clinical

Unit 7 Case Synthesis

[Instructor Name]

[Date]

The patient is composite; values and times are bracketed where illustrative, and insulin orders, transitions and discharge plans belong to the provider and team.

The Claim

His ketoacidosis was caused by the cost of insulin as surely as by his pancreas, and the nursing care that protects him in hospital will fail at home unless the cost is treated as part of the clinical problem.

The Case

[Mr. J.], 24, type 1 diabetes since age [11], works part time at a warehouse. His insurance lapsed when he changed jobs [six] weeks ago. He began taking about half his usual doses to make one vial last. He arrived with vomiting, abdominal pain and deep, fast breathing. Glucose [486], pH [7.12], bicarbonate [9], anion gap [26], potassium [5.1]. He was treated with IV fluids, an insulin infusion and potassium replacement. By [hour 18], his gap had closed and he was eating. The infusion was stopped at [2300].

Ketones From Absent Insulin

Without enough insulin, cells cannot use glucose, so the body breaks down fat for energy. The liver turns fatty acids into ketones, which are acids, faster than the body can clear them, producing a metabolic acidosis with a widened anion gap. Glucose at that level overwhelms the kidneys, and the sugar lost in urine drags water out with it, so he became dehydrated (Kitabchi et al., 2009). His half doses kept him out of danger for weeks, then a stomach virus pushed him over.

Potassium That Looked Normal

His first potassium of [5.1] looked normal to high, but his total body potassium was low: acidosis and the lack of insulin shift potassium out of cells into the blood, while urine losses deplete the body's stores. Insulin drives potassium back into cells, so as treatment starts, blood potassium can fall quickly and dangerously. This is why insulin infusions in ketoacidosis are started only once potassium is above a safe threshold and why potassium is replaced throughout (Kitabchi et al., 2009).

His potassium looked fine on arrival because his body had moved its stores into the blood, not because it had enough.

Two Hours of Overlap

When the infusion ends, intravenous insulin leaves the blood within minutes. If long-acting insulin under the skin is not already working, ketones can rise again. Guidance recommends giving the basal dose and continuing the infusion for one to two hours before stopping it (Kitabchi et al., 2009). In his case, the record showed the basal dose was given at [2200] and the infusion stopped at [2300]: one hour of overlap. At [0200] his glucose was [248] and he felt nauseated again. The provider was called; a repeat check showed his gap had not reopened, and the team adjusted his basal dose. The overlap was at the short end of the range.

What He Said at 0215

While I rechecked his glucose at [0215], he asked how much a vial costs "if you don't have insurance." He said he had been "doing half" for weeks, that he knew it was risky, and that he would do it again rather than go into debt. He asked me not to tell his mother.

Cost as a Clinical Problem

In a survey at a diabetes center, roughly a quarter of patients said they had cut back on insulin because they could not afford it (Herkert et al., 2019). For Mr. J., the cause of the admission was not lack of knowledge about insulin; it was the price. Teaching him the signs of ketoacidosis again, without addressing cost, would send him home to repeat the same pattern. I reported his statement to my preceptor and, with his permission, the team requested a social work consult before discharge to look at insurance options and assistance programs. His request about his mother was respected.

What Teaching Should Look Like Now

His discharge teaching was rewritten around his situation. Instead of repeating sick-day rules he already knew, the nurse asked what he would do if his supply ran low again and helped him write a plan: who to call, where to get emergency insulin, and which signs mean he should come in rather than wait. He said nobody had asked him that before.

Joining the Pieces

The physiology explains why half doses work until they suddenly do not. The potassium explains why the hospital phase is dangerous. The overlap explains a vulnerable moment in the transition back to injections. The conversation explains why the same thing will happen again unless cost is treated. Each piece alone is a lesson; together they show that nursing care for this man includes the pharmacy counter (Harding et al., 2023).

Nursing Priorities, Ranked

1. Monitor glucose, potassium and anion gap through the transition to subcutaneous insulin, and report any rise in gap.

2. Confirm the basal dose timing relative to stopping any infusion.

3. Treat nausea and support oral intake.

4. Ensure a discharge plan that includes affordable insulin, not only education.

References

Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis's medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

Herkert, D., Vijayakumar, P., Luo, J., Schwartz, J. I., Rabin, T. L., DeFilippo, E., & Lipska, K. J. (2019). Cost-related insulin underuse among patients with diabetes. JAMA Internal Medicine, 179(1), 112-114. https://doi.org/10.1001/jamainternmed.2018.5008

Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N. (2009). Hyperglycemic crises in adult patients with diabetes. Diabetes Care, 32(7), 1335-1343. https://doi.org/10.2337/dc09-9032