Evidence Based Practice Ketoacidosis Diabetes

Posted: February 09, 2017

Introduction

Provision of quality care requires that health workers to judiciously and explicitly use current evidence to make their decisions. Ciliska (2016) notes the necessity of integrating personal clinical skills with the best available evidence from external sources. The healthcare professional aims to incorporate the best research evidence with patient values while relying on the clinical expertise to make the daily decisions concerning the delivery of care service. Rosival (2014) asserts that the occurrence of the conditions is on the rise with serious economic implications. It is thus critical to propose an effective management strategy to control the disorder. This paper seeks to evaluate an EBP (Evidence Based Practice) guideline for managing and preventing diabetic ketoacidosis.

Importance of Evidence-Based Practice Guideline for Diabetic Ketoacidosis

Delivery of high-quality healthcare and optimum patient outcomes are some of the essential goals of health system. Evidence-based care practice is an important element in the provision of the required health services. The items that are considered “evidence” include research findings, expert opinion, knowledge from basic science and clinical science. It is, however, seen that practices that are based on the results of the research are likely to lead to more desired patient outcomes across the various regions and locations. EBP demands changes on the education, relevant investigations and working closely with clinicians and scholars. EBP guidelines are currently gaining momentum for use in the nursing practice. The guidelines offer some of the best methods for managing some of the most life-threatening health complications. The management goal of the DKA (Diabetic Ketoacidosis) therapy is to reduce acidosis with immediate aims of expanding the intravascular volume, correcting the deficiency of fluids, electrolytes, and the acid-base status; initiating insulin therapy and monitoring and evaluating the treatment that is in use (Nyenwe & Kitabchi, 2016). Some of the important considerations that employed in the treatment of DKA may also include treatment of present concurrent infections.

My facility currently utilizes the outlined guidelines to manage and treat DKA. The facility has put in place interdisciplinary team that is tasked with continuous review of the guidelines as well as providing the framework on which the guidelines can be implemented. My role as APN in helping others to recognize the values of the guidelines includes being a role model by strictly adhering to the practices proposed in the guidelines.

The Purpose of the Guideline

The purpose of the guidance is to review the pathophysiology of DKA and to discuss the various recommendations. The guideline is also meant to reduce the risk factors associated with the contraction of DKA. The DKA risk factors include poor management of the previous cases of the illness; psychiatric disorders (eating disorders as well); insulin omission; limited access to medical services and insulin pump therapy. EBP guidelines are also crucial for accurate diagnosis of DKA (Anzola, Gomez, & Umpierrez, 2016). The guideline may also help to eliminate diagnostic dilemmas that may arise due to euglycemic ketoacidosis in which, for instance, children with carbohydrate deficiency may present a rare increase in the glucose levels. Another case that may present diagnostic dilemma is when there is a mild acidosis, ketonuria or ketonemia.

The guideline relates to my current area of specialization by availing a framework upon which proper management and treatment of DKA can be achieved.

Overview of Agree Tool Findings

The objective of the guideline is specifically stated as to review the pathophysiology of DKA and to discuss the various recommendations. The different stakeholders have been somewhat involved with the various professional groups having been assigned respective roles. The target users of the guidelines have been clearly identified as the care providers for children, adolescents and adults suffering from type 1 or 2 diabetes with the manifestation of DKA.

The guidelines can be seen to be clearly presented with information and recommendations that can easily be extracted from the presentation. The guidelines have been rigorously developed using proper and systematic methods which have been used to carry out the studies used in the development of the guidelines. Based on the above observation, the overall rank for the guideline can be said to be 6 having properly addressed the six domains. Improvements that should be made to the guidelines include the inclusion of the views and preferences of the intended populations. The recommendations in the guidelines are needed to reduce the risks associated with the DKA. The Agree tool was used to assess the guideline as presented in the appendix.

Implementation of the Guidelines Based on the IOM Aims

The primary importance of the guideline is the need to provide DKA care and treatment service that is safe, effective, and efficient. Patient-centeredness, timeliness, and equity are other aims that can also be achieved through the implementation of the guideline (Peeters et al., 2015). Efficiency and effectiveness are two IOM goals that are discussed regarding the benefits upon implementation of the directive.

The recommendations are efficient and effective ways of treating DKA since they provide mechanisms for controlling fluids and electrolytes are important for determining the magnitude of the specific deficits since hyperglycemia and hyperketonemia lead to osmotic diuresis, loss of electrolyte and dehydration that stimulates the production of stress hormone. Stress hormone induces insulin resistance. A vicious cycle develops resulting in the worsening of the hyperketonemia and hyperglycemia. Lack of management can lead to fatal dehydration and metabolic acidosis. Further complications are manifested through poor tissue perfusion leading to lactic acidosis a complication that can aggravate ketoacidosis (Wolfsdorf, 2014). Such evaluations are critical for the establishment of the severity of the illness leading to the efficient and effective formulation of treatment programs.

Guideline for Maintaining and Treating Diabetic Ketoacidosis

Correcting of fluid levels creates a clearer picture of the clinical process. Discharge of the patients is recommended to be done only after the patients have completely switched back to the daily insulin without recurrence of ketosis. In stable conditions and healthy bicarbonate levels, the patients should be allowed to eat a meal that is heralded with a subcutaneous (SC) prescribed amount of regular insulin. Infusing of insulin should be stopped thirty minutes after the meal if the patient is still unable to eat or if there is still evidence of nausea (Crasto et al., 2015). In such cases, dextrose blend should be applied continuously and the routine or ultra-short-acting subcutaneous insulin administered after every 4 hours depending on the levels of blood glucose while trying to sustain the levels of glucose between 100 and 180 mg/dL. Further guidelines recommend that insulin should be infused intravenously based on weight fixed rate until ketosis has subsided. In cases that the insulin levels are observed below 14 mmol/L (250 mg/dL), it is required that 10% glucose to be added to allow the continuation of the infusion of insulin on a fixed-rate basis. Patients with established diabetes should have an SC long-acting insulin dose before the observation of the DKA symptoms. Examples of long-acting insulin include insulin Glargine and Detemir. In cases in which neutral protamine Hagedorn (NPH) insulin had been applied previously, the usual dose should be started on instances when the patient starts to eat normally and to be able to maintain food without vomiting. The dosage should otherwise be reduced to prevent cases of hypoglycemia during the efficacy peak of the insulin-containing drug (Abdelghaffar, 2013). Caution should be taken in estimating the dose for the long lasting insulin to be administered in such cases for patients who have been newly diagnosed with type 1 diabetes. It is recommended that small doses should be applied to avoid cases of hypoglycemia.

Steps that are Considered Priority

The steps that are seen as a priority for the implementation of the guideline include stakeholder involvement, financial resource utilization, and staff support. The various stakeholders that will be involved include health policy makers, general practitioners, and scholars. Engagement of the stakeholders will be done to assure approval and support in the implementation of the guidelines. Financial implication is a critical factor in the implementation process thus the facility will take the various finance impacts in an attempt to implement the directive while assessing the availability of funds to address such needs. The link to the guideline is http://www.intechopen.com/books/type-1-diabetes/diabetic-ketoacidosis-clinical-practice-guidelines#article-front.

Conclusion

Diabetic ketoacidosis is an example of hyperglycemic emergency that has the potential of resulting in fatal complications if not well controlled (Rosival, 2014). The guideline presented above is an example of how DKA can be clinically managed and treated. From the guideline, it is proposed on how the illness can be properly managed. The overall rank for the guideline can be said to be 6 having properly addressed the six domains.a

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