Medical Surgical DKA vs HHS #2

Question

An older adult client with Type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 623 mg/dL. The client’s daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing intervention has the highest priority?

Answers

  1. Fluid replacement
    • Rationale:

      This answer is correct because since HHS leads to serious dehydration, treatment (unless airway or breathing is involved) begins with fluid replacement to address the circulation concerns, then insulin therapy to address the elevated blood glucose, which should help lower elevated potassium levels. Hyperglycemic hyperosmolar syndrome (HHS) is a serious complication of type 2 diabetes mellitus. It occurs when a client has extremely high blood glucoses for an extended time. It is often caused or triggered by a recent infection or sickness, including gastrointestinal viruses, which can add to the extreme dehydration. Standard of care is to treat the underlying fluid deficit.

  2. Reversal of altered mental status
    • Rationale:

      This answer is not correct because reversal of altered mental status is not priority. Addressing the dehydration and extreme high blood glucose will fix the altered mental status. These treatments should be priority since altered mental status is a symptom of dehydration and elevated blood glucose.

  3. Insulin first then fluids
    • Rationale:

      This answer is not correct because since HHS leads to serious dehydration, treatment (unless airway or breathing is involved) begins with fluid replacement to address the circulation concerns, then insulin therapy to address the elevated blood glucose, which should help lower elevated potassium levels. It is often caused or triggered by a recent infection of sickness, including gastrointestinal viruses, which can add to the extreme dehydration and elevation of blood glucose. Furthermore, insulin administration prior to fluid restoration may actually increase the risk of shock.

  4. Give sodium bicarbonate
    • Rationale:

      This answer is not correct because in HHS, bicarbonate levels are normal to mildly low. If this condition was diabetic ketoacidosis (DKA), where there are ketones and acidosis present, bicarbonate would be needed to help treat the condition. Nevertheless, neither ketones or acidosis are present in HHS.

Overview

A recent infection (gastrointestinal virus) can cause hyperglycemic hyperosmolar syndrome (HHS). The highest priority treatment is fluid replacement to address the priority of circulation.

Explanation

Learning Outcomes

Hyperglycemic hyperosmolar syndrome (HHS) is a serious complication of type 2 diabetes mellitus. It occurs when a client has extremely high blood glucoses for an extended time. The interesting characteristics is there are no elevation of ketones in this situation. The condition leads to serious dehydration, excessive thirst, and confusion. It is often caused or triggered by a recent infection or sickness. Treatment (unless airway or breathing is involved) begins with fluid replacement to address the circulation concerns, then insulin therapy to address the elevated blood glucose. Since potassium levels may be elevated due to the insulin deficiency, the potassium levels may begin to lower with insulin treatment, otherwise, decreasing potassium should be addressed. Treating any underlying causes should also be addressed (nausea, vomiting, etc.)

Test Taking Tip

Remember that circulation in prioritization of ABCs may necessitate fluid replacement, not necessarily blood replacement.

Video Rationale