Comprehensive Simulation Scenario for Nurse Training: Diabetic Ketoacidosis (DKA) Case History and Initial Assessment
Scenario Title: Structured Interview, Vital Signs Monitoring, and Diagnostic Preparation for Diabetic Ketoacidosis
Setting: Emergency Department / Endocrinology Unit
Characters:
- Nurse (RN) – Responsible for the comprehensive assessment and education of the patient
- Mr. Seungmin Lee (Patient) – 44-year-old male with suspected diabetic ketoacidosis
Phase 1: Patient Identification and Introduction
Nurse: Good morning, Mr. Lee. I’m the nurse assisting you today. Could you confirm your full name and date of birth for me?
Patient: Good morning. My name is Seungmin Lee, and my date of birth is February 15, 1980.
Nurse: Thank you, Mr. Lee. I’ll ask you some questions to better understand your condition. Everything you share will remain confidential. Please let me know if you feel uncomfortable at any point.
Phase 2: Chief Complaint and History of Present Illness (HPI)
Nurse: When did your symptoms first begin?
Patient: About two days ago.
Nurse: On a scale of 0 to 10, how severe are your symptoms?
Patient: I'd say they're about an 8.
Nurse: Have you noticed symptoms like excessive thirst, frequent urination, or dry mouth?
Patient: Yes, I've been extremely thirsty and urinating much more than usual.
Nurse: Have these symptoms been constant since they started?
Patient: Yes, it’s been consistent.
Nurse: Have you experienced nausea, vomiting, abdominal pain, or fruity-smelling breath?
Patient: I've vomited a few times, and my breath feels weird. I also feel like I'm breathing faster than normal.
Nurse: Have you been feeling fatigued or confused?
Patient: Yes, I've been extremely tired and had difficulty concentrating.
Nurse: Have any actions made your symptoms better or worse?
Patient: They seem to get worse when I try to eat or drink.
Phase 3: Past Medical History (PMH)
Nurse: Have you ever been diagnosed with diabetic ketoacidosis before?
Patient: No, this is my first time.
Nurse: What type of insulin or medication are you currently prescribed for your diabetes?
Patient: I take rapid-acting insulin before meals and long-acting insulin at night.
Nurse: Have you missed any insulin doses recently?
Patient: Yes, I missed a couple over the past few days due to a busy schedule.
Nurse: Do you monitor your blood sugar regularly?
Patient: I usually do, but I haven’t checked as often in the past few days.
Phase 4: Family History (FH)
Nurse: Do you have any family members with diabetes or similar health issues?
Patient: My mother has type 2 diabetes.
Nurse: Has anyone in your family experienced ketoacidosis or severe complications?
Patient: Not that I know of.
Phase 5: Social History (SH)
Nurse: Do you smoke or drink alcohol?
Patient: I don’t smoke, but I drink occasionally, about once a week.
Nurse: Are you under a lot of stress recently?
Patient: Yes, work has been very stressful.
Nurse: Do you follow a consistent diet and meal schedule?
Patient: Not really. With my schedule, I sometimes skip meals.
Phase 6: Medication History and Allergies
Nurse: Besides insulin, are you currently taking any other medications or supplements?
Patient: No, just insulin.
Nurse: Have you experienced any side effects from medications?
Patient: No side effects so far.
Nurse: Do you have any known allergies to medications, foods, or environmental factors?
Patient: No known allergies.
Phase 7: Vital Signs Assessment
Nurse: Mr. Lee, I’ll now measure your vital signs to assess your current condition. Please let me know if you feel uncomfortable.
7.1 Temperature
Nurse: I’ll begin with your temperature using a tympanic thermometer.
(Nurse performs hand hygiene, attaches a probe cover, gently positions the thermometer.)
Nurse: Your temperature is 37.8°C – slightly elevated, possibly indicating a mild fever or inflammatory response.
7.2 Blood Pressure
Nurse: Now, I’ll take your blood pressure. Please relax your arm on the cushion.
(Nurse applies cuff, listens with stethoscope, inflates, and slowly deflates.)
Nurse: Your blood pressure is 140/90 mmHg – mildly elevated and consistent with dehydration or stress.
7.3 Pulse
Nurse: I’ll now check your pulse at your wrist.
(Counts radial pulse for one full minute.)
Nurse: Your pulse is 110 beats per minute – tachycardic and expected in DKA cases.
7.4 Respiratory Rate
Nurse: Lastly, I’ll assess your breathing. Please breathe normally.
(Observes for one minute without alerting the patient.)
Nurse: Your respiratory rate is 26 breaths per minute – elevated and may indicate compensatory hyperventilation (Kussmaul breathing).
Phase 8: Clinical Summary and Immediate Action
Nurse: Based on the findings:
- Fever (37.8°C) may indicate underlying infection or stress.
- Blood Pressure (140/90 mmHg) is slightly elevated.
- Pulse (110 bpm) and Respiratory Rate (26/min) are significantly elevated, indicating systemic stress and possible acidosis.
We'll proceed with immediate diagnostic evaluation and stabilization:
- Blood Tests:
- Blood glucose level
- Serum ketones
- Electrolytes (Na+, K+, Cl−)
- Arterial blood gases (ABGs)
- Renal function (BUN, Creatinine)
- Urinalysis: To detect ketonuria and glycosuria
- Cardiac Monitoring: For electrolyte-induced arrhythmias
- Continuous Vital Sign Monitoring
Phase 9: Patient Education and Support
Nurse: Mr. Lee, the symptoms and vital signs indicate that you may be experiencing diabetic ketoacidosis. This condition is serious but treatable.
You’ll receive IV fluids to rehydrate your body, insulin to lower your blood sugar, and electrolyte replacement therapy as needed. If you feel dizzy, nauseous, or notice chest pain, notify us immediately.
Patient: Will I need to stay in the hospital?
Nurse: Yes, for monitoring and treatment. Once stabilized, the doctor will discuss long-term insulin adjustment and self-care strategies.
Until then:
- Avoid solid foods until nausea resolves
- Stay hydrated with IV fluids
- Rest and avoid physical exertion
Patient: Thank you for explaining everything.
Nurse: You're welcome. Let’s begin with your lab tests.
Learning Objectives for Nurse Trainees
- Conduct structured history taking focused on DKA symptoms
- Assess and interpret vital signs relevant to DKA
- Recognize risk factors such as insulin non-compliance, stress, and infection
- Prepare for and explain laboratory and diagnostic procedures
- Deliver clear patient education and emotional reassurance
End of Scenario
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