Uncontrolled Diabetes Mellitus

Nirmala^1*, Subathra Devi. M², Maha Lakshmi³

¹Assistant Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

²Nurse Educator, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

³Nursing Superintendent, Kauvery hospital, Cantonment, Trichy, Tamil Nadu

*Correspondence

Abstract

Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes mellitus characterized by hyperglycemia, ketosis, and metabolic acidosis. Prompt recognition and management are essential to prevent morbidity and mortality. This case study describes a 45-year-old female with a known history of type 2 diabetes mellitus who presented with painful oral ulceration, decreased food intake, excessive thirst, fruity-smelling breath, rapid breathing, and altered sensorium.

Key words: Diabetic ketoacidosis (DKA); Hyperglycemia; Metabolic acidosis

Introduction

Diabetic ketoacidosis is a serious metabolic emergency resulting from insulin deficiency and increased production of ketone bodies. It is characterized by hyperglycemia, ketosis, and metabolic acidosis. Early identification and prompt treatment are essential to reduce complications and mortality. Nurses play a crucial role in the assessment, monitoring, and management of patients with DKA. This case study aims to highlight the importance of comprehensive nursing care in the management of DKA.

Case Presentation

A case of 45-year-old female who is a known diabetic for 7 years, now presented to our ER with history of reduced food intake, abdomen discomfort giddiness and oral ulcers for 2 weeks, on arrival to our ER her sensorium was E4V4M6, hypotensive, hypovolemic with high sugars. ABG showed HAGMA with elevated lactates and sugar levels, bedside USG screening showed Good LV contractility and collapsed IVC.

Relevant Clinical Findings

Social History	Nil
Allergies	Nil
Past Medical History	Nil
Past Surgical History	Nil

Physical Examinations

PR	108/min
BP	80/60mmHg
Temp	97.1'F
SpO2	98% on room air
RR	20/min
GCS	E4 V3/4 M6
GRBS	500 mg /dl

Relevant Investigation

Investigation Name	Result	Test Date Time
Alkaline Phosphatase	58 U/L	01-04-26 07:17:01
A/G Ratio	1.0.	01-04-26 07:17:01
Total Bilirubin	0.3 mg/dL	01-04-26 07:17:01
Aspartate Aminotransferase (AST/SGOT)	21 U/L	01-04-26 07:17:01
Gamma - Glutamyl Transferase (GGT)	31 U/L	01-04-26 07:17:01
Total Protein	5.5 g/dl	01-04-26 07:17:01
Albumin, Serum	2.8 g/dl	01-04-26 07:17:01
Globulin	2.8 g/dl	01-04-26 07:17:01
Indirect Bilirubin	0.2 mg/dL	01-04-26 07:17:01
Alanine Aminotransferase (ALT/SGPT)	15 U/L	01-04-26 07:17:01
Glucose In Glucometer POCT	238 mg/dL	01-04-26 07:18:39
Direct Bilirubin	0.1 mg/dL	01-04-26 07:28:28
Amylase	331 U/L	02-04-26 04:35:01
Lipase	6441 U/L	02-04-26 04:35:01
Chloride Blood	93 mEq/L	25-03-26 00:08:01
Glucose	750 mg/dL	25-03-26 00:08:01
HCO3(c)	3.8 mmol/L	25-03-26 00:08:01
02Sat	97.0 %	25-03-26 00:08:01
BE(B)	-22.4 mm Hg	25-03-26 00:08:01
PCO2	11 mm Hg	25-03-26 00:08:01
pH Blood	7.15 NA	25-03-26 00:08:01
K +	4.5 mmol/L	25-03-26 00:08:01
Blood Ketone (POCT)	<0.01	25-03-26 01:36:44
Magnesium	3.4 mg/dL	25-03-26 01:36:44
Calcium Serum	10.2 mg/dL	25-03-26 01:36:44
Potassium	5.3 mmol/L	25-03-26 01:36:44
Chloride	108 mmol/L	25-03-26 02:58:26
Sodium	140 mmol/L	25-03-26 02:58:26
Potassium	5.0 mmol/L	25-03-26 02:58:26
Urea Serum	64.2 mg/dL	25-03-26 02:58:26
AnGap	31 mEq/L	25-03-26 02:58:26
Blood Glucose Random (RBS)	>700 mg/dL	25-03-26 02:58:26
Calcium Free Ionized	1.32 mg/dL	25-03-26 02:58:26
Creatinine	1.8 mg/dL	25-03-26 02:58:26
Phosphorous	8.4 mg/dL	25-03-26 06:30:12
Albumin, Serum	4.6 g/dl	25-03-26 06:30:12
Total Protein	7.5 g/dl	25-03-26 06:30:12
Total Bilirubin	0.7 mg/dL	25-03-26 06:30:12
Aspartate Aminotransferase (AST/SGOT)	16 U/L	25-03-26 06:30:12
Gamma - Glutamyl Transferase (GGT)	61 U/L	25-03-26 06:30:12
Alkaline Phosphatase	187 U/L	25-03-26 06:30:12
Urine Nitrite	Negative	25-03-26 06:30:12
Globulin	2.9 g/dl	25-03-26 06:30:12
Alanine Aminotransferase (ALT/SGPT)	16 U/L	25-03-26 06:30:12
Indirect Bilirubin	0.3 mg/dL	25-03-26 06:30:12
Glucose In Glucometer POCT	492 mg/dL	25-03-26 07:32:26
Urea Serum	10 mg/dL	29-03-26 05:46:02
Creatinine	0.5 mg/dL	29-03-26 05:46:02
Amylase	758 U/L	29-03-26 05:46:02
Lipase	16012 U/L	29-03-26 05:46:02
RBC	Nil	25-03-26 06:30:12
Urine Blood	Negative	25-03-26 06:30:12
Casts	Nil	25-03-26 06:30:12
Urine Protein	Nil	25-03-26 06:30:12
Pus cells	1-2	25-03-26 06:30:12
PH Urine	5	25-03-26 06:30:12
Crystals	Nil	25-03-26 06:30:12
Epithelial cells	1-2	25-03-26 06:30:12
Urine Glucose	Present(+++)	25-03-26 06:30:12
Urobilinogen	Normal	25-03-26 06:30:12
Ketone	Positive(++)	25-03-26 06:30:12
Leuykocyte	Negative	25-03-26 06:30:12
Urine Specific Gravity	1.015	25-03-26 06:30:12
Bilirubin	Negative	25-03-26 06:30:12
Appearance	Clear	25-03-26 06:31:11
Colour	Pale Yellow	25-03-26 06:31:11
Haematocrit	48 %	25-03-26 00:08:01
Mean Corpuscular Volume (MCV)	86.6	25-03-26 01:28:01
Absolute Eosinophil Count (AEC)	10 cells/µl	25-03-26 01:28:01
Packed Cell Volume (PCV)	23.9 %	25-03-26 01:28:01
Lymphocyte	11.8 %	25-03-26 01:28:01
(MCHC) Mean Corpuscular Haemoglobin Concentration	32.2 g/dl	25-03-26 01:28:01
Haemoglobin	7.7 g/dl	25-03-26 01:28:01
(MCH) Mean Corpuscular Haemoglobin	27.9 pg/cell	25-03-26 01:28:01
Absolute Lymphocyte Count (ALC)	1210 cells/µl	25-03-26 01:28:01
Total WBC Count	10260 Cells/Cumm	25-03-26 01:28:01
Platelet Count	314000 cells/µl	25-03-26 01:28:01
Mean Platelet Volume (MPV)	8.2 NA	25-03-26 01:28:01
Monocyte	11.4 %	25-03-26 01:28:01
Neutrophil	76.5 %	25-03-26 01:28:01
Total RBC Count	2.76 ML/10^9	25-03-26 01:28:01
Basophil	0.2 %	25-03-26 01:28:01
Absolute Monocyte Count (AMC)	1170 cells/µl	25-03-26 01:28:01
Absolute Neutrophil Count (ANC)	7850 cells/µl	25-03-26 01:28:01
Test (PT)	13.3 Seconds	25-03-26 01:36:44
Control (PT)	10.7 Seconds	25-03-26 02:16:08
Packed Cell Volume (PCV)	47 %	25-03-26 02:58:26
Haemoglobin	16.0 g/dl	25-03-26 02:58:26
Haematocrit	34 %	25-03-26 05:34:01
Platelet Count	239000 cells/µl	26-03-26 05:27:15
Total WBC Count	19530 Cells/Cumm	26-03-26 05:27:15
Haematocrit	31 %	26-03-26 06:59:01
Platelets	Adequate in number.	27-03-26 17:46:03
White Blood Cells	Neutrophilic leukocytosis with toxic granulation. No left shift or atypical cells identified.	27-03-26 17:46:03
Haemoglobin	9.8 g/dl	29-03-26 05:46:02
C Reactive Protein (CRP)	145.0 mg/L	25-03-26 01:36:44
Impression	Mild normocytic normochromic anemia with neutrophilic leukocytosis and toxic granules.	27-03-26 17:46:03
Hepatitis B Surface Antigen (HBsAg)	Negative (0.05)	25-03-26 01:36:44
Hepatitis C Antibody (Anti HCV)	Non-reactive (0.01)	25-03-26 01:36:44

USG Abdomen and Pelvis

Grade I fatty liver
No free fluid in abdomen

CECT Abdomen and Pelvis

Hepatomegaly with fatty changes
Gall bladder wall edema with tiny calculi
Mild right pleural effusion
Upper GI Endoscopy
Gastric erosions present

Diagnosis

Uncontrolled diabetes mellitus – HBA1C – 10.9
Hypovolemic shock (resolved)
Metabolic encephalopathy (resolved)

Management

She started on IV fluids resuscitation and actrapid infusion. Necessary investigations were sent and patients were admitted to the ICU complex for further management. Initial lab investigations showed elevated total counts, anemia, dyselectrolytemia, AKI, elevated pancreatic enzymes and HbA1c value of 10.9. Patient was started on empirical antibiotics and antifungals along with renal protective drugs. Patient blood ketones were negative. Medical gastroenterologist and ENT opinion were obtained and orders were carried out. UGI scopy was done on 26/3/26, gastric erosions were noted and RT secured.

Outcome

The patient responded well to treatment with progressive improvement in metabolic parameters and clinical status. Acidosis resolved, blood glucose levels stabilized, hydration improved, and oral intake gradually increased. The patient was discharged in stable condition with follow-up advice.

Nursing Management

Nursing care played a significant role in the recovery of the patient.

Assessment

Continuous monitoring of vital signs
Neurological assessment
Respiratory assessment
Monitoring signs of dehydration

Monitoring

Hourly blood glucose monitoring
Intake-output chart maintenance
Electrolyte monitoring
Observation for signs of hypoglycemia and hypokalemia
Interventions
Administration of prescribed insulin infusion
Fluid replacement as ordered
Potassium replacement therapy
Maintenance of aseptic technique

Nutritional support and encouragement of oral intake after stabilization

Health Education
Importance of medication adherence
Blood glucose self-monitoring
Adequate hydration
Recognition of warning signs of DKA
Follow-up care and diabetic lifestyle modifications

Discharge medications

Drug Name	Strength	Frequency				Route of admin	Relationship with meal	Days
		M	A	E	N
Cap. Doxy	100MG	1	0	0	1	Oral	After Food	5 days
Tab. Pan	40MG	1	0	0	1	Oral	Before Food	5 days
Syp. Sucrafil - O	15ML	1	1	1	1	Oral	Before Food	5 days
Inj. Human Actrapid	-	12U	12U	0	8U	S/C	30 mins Before Food	5 days
Inj. Human Insulatard	-	12U	0	0	10U	S/C	30 mins Before Food	5 days

Importance of medication adherence
Blood glucose self-monitoring
Adequate hydration
Recognition of warning signs of DKA
Follow-up care and diabetic lifestyle modifications

Discussion

This case demonstrates how decreased food intake secondary to painful oral ulceration can precipitate diabetic ketoacidosis in patients with type 2 diabetes mellitus. Early recognition of dehydration, ketosis, and metabolic acidosis was crucial in preventing further deterioration. The case highlights the importance of comprehensive nursing assessment, meticulous monitoring, timely intervention, and patient education. Nursing care significantly contributed to successful recovery and prevention of complications.

Conclusion

Diabetic ketoacidosis remains a medical emergency requiring prompt multidisciplinary management. Effective nursing assessment, continuous monitoring, fluid management, insulin administration, electrolyte replacement, and patient education are essential components of care. This case emphasizes the critical role of nurses in improving patient outcomes and preventing recurrence of diabetic ketoacidosis.

Uncontrolled Diabetes Mellitus

Uncontrolled Diabetes Mellitus

Nirmala1*, Subathra Devi. M2, Maha Lakshmi3

Nightingale Journals

Nirmala^1*, Subathra Devi. M², Maha Lakshmi³