Mentoring DKA

cropped-image.jpegIt’s two A.M. and I’m the nurse manning the triage desk in your local emergency department. I’m reading an article from the American Journal of Nursing when I suddenly hear loud, raspy moaning coming from outside my door. I jump to my feet, round the corner and find its source. A human skeleton is stacked in a wheelchair. His concerned wife standing by his side says, “I found him like this when I got home from work. He’s a diabetic”. His Kussmaul respiratory pattern, the way his arid tongue sticks to his teeth when he attempts to talk and his deeply sunken eyes leave me no need to guess a diagnosis – this man is in severe diabetic ketoacidosis (DKA).

At the moment, this patient’s body is his worst enemy. Infection, dehydration or not taking his insulin led the patient to his current state. The free-floating glucose in his blood stream is useless as an energy source. Instead, fat (at 160 pounds and 6 feet he has little to spare) and muscle powers him via a catabolic process – his body is literally eating itself to survive. Compensatory mechanisms (diuresis, tachypnea, vomiting, etc) work to offset the byproducts of this process but it only worsens his situation. The end result is severe dehydration and an anion gap metabolic acidosis. Time is of the essence so I rush the patient to Resuscitation Bay #1. Here, our team launches into action.

I assist by placing one of two large-bore IVs then return to my post in triage. No one is waiting for me so I go back to reading the article, Effective Mentoring in the Clinical Setting – Strategies for clinical instructors and preceptors (AJN, April 2016). The article is part of my preceptor prep  for the new nurse starting next week; I’m one of two nurses assigned to mentor this new-to-ED practice hire. The authors cite outcomes evidence that shows effective mentors “improve self-confidence, maximize learning, enhance satisfaction and promote professional growth”. The article also confirms what I already believe – mentoring is an action; one must work at it to be successful. Five strategies are proffered as key components to effective mentoring:

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  • Communication
  • Questioning
  • Goal Setting
  • Role-Modeling/Socialization
  • Reflection

My thoughts turn to the pathophysiology and management of DKA as I draw similarities to the role of preceptor, as identified by this article.

DKA is communication breakdown at a cellular level. Insulin is unavailable and therefore cannot translate glucose into its storable form, glycogen. The compensatory mechanisms (as demonstrated by the patient in R1) take over but prove to be a poor “spokesmen” for the real deal.  In mentoring, failing to provide meaningful feedback to new staff (particularly new-to-practice ones) can lead to compensatory mechanisms in them. Fear of the perception of others, lack of confidence or straight out knowledge deficits may cause novice nurses to “fake it until they make it”. This strategy may yield consequences as lethal as untreated DKA. Mentors must use precise, truthful language given in a timely manner. This enables learners to recall the event in near real-time. Praising the positive behavior, identifying improvement opportunities and inspiring forward movement towards the next challenge “builds” the mentee. In the same way, administering IV fluid boluses of normal saline, obtaining lab samples and providing insulin at the time the data confirm the diagnosis is essential to restoring the patient from DKA.

DKA causes a disruption in electrolyte balance. Bi-directional intracellular/ extracellular electrolyte shifts exacerbate this disease process and can lead to death. Likewise, failing to incorporate effective questioning into a mentoring relationship can lead to similar harm. Close-ended questions require the respondent to remember facts but do not necessarily demonstrate an understanding. The sole or primary use of close-ended questions robs the learner. The use of open-ended questions offers a more balanced approach – a give and take. The learner gains critical thinking and reasoning skills as rationale is discussed.  The mentor also gains access to the mindset of the learner in the process. Ongoing learning needs are identified through this method. Similarly, in our DKA patient, closing the patient’s anion gap opens the door to hypokalemia. Understanding potassium moves back into the cell as insulin is given is important. The experienced nurse will not be surprised when previously normal or high serum potassium levels drop on subsequent lab studies. Instead, potassium repletion can be anticipated and electrolyte balance achieved as care progresses.

The patient in DKA requires critical care. Airway, breathing and circulation always remain the primary focus. Close monitoring of mental status, serial metabolic/electrolyte lab values and strict intake/output totals are key secondary areas for nursing consideration.  It is here where one gains insight into meeting patient care goals. Likewise, goals must be set for those we mentor. Goals give a mark for achievement. Achievement builds confidence, improves self-image and gives meaning/value to the work one does. Goals need to be measurable, challenging and stretch the learner to reach new ones.  The desired outcome in the DKA patient is closing the anion gap. Objectives like transitioning the patient to a dextrose containing IV solution at a given blood glucose level, converting IV insulin to subcutaneous insulin and preventing hypoglycemia are examples of nursing goals in this patient.

DKA, in its own name, is a condition of acidosis. pH levels, as in the patient presenting tonight, are often incompatible with life if left untreated. This is not unlike the acidic environments we often setup for new nurses. Preceptors sometime approach new learners, not as a mentor but, as a tormentor. Nurses are often described as “eating their young” when it comes to training new staff. “The hard way is the right way” is the attitude but this is just a form of professional bullying. There is no place for this nor should there be tolerance for it; it is a black eye on our profession. The opportunity to serve as a role model is a chance to build legacy. The effects of mentoring can last a lifetime in the career of those we are privileged to guide. By the same token, it is easy to “beat up” the “non-compliant diabetic”. Perform a literature search and the evidence shows low-income patients with diabetes are at an exponentially greater risk for admission due to DKA or hyperglycemic hyperosmolar non-ketotic (HHNK) coma. Nurses are advocates and judgement needs to be reserved when it comes to patient education. Digging deeper may reveal what obstacles prevent the patient from optimal care.  The caveat — you’ll never get there if you don’t model care and compassion!

Evaluation is integral in the care of any patient, including those in DKA. We assess, plan, implement then evaluate to answer “Did we get the job done?” Similarly, time for reflection must be taken with those we mentor. Reflection allows our learners to self-evaluate, recognize success, engage in their work and set benchmarks for demonstrating professional growth. Thomas Paine said, “The real man smiles in trouble, gathers strength from distress, and grows brave by reflection.” The patient in DKA can be an equally rewarding experience. Positive responses to treatment are often evident in short order. Participation on a team that takes patients from the edge of death to the road of recovery is most fulfilling.

I’m excited about another opportunity to precept and hope I’m worthy for the job. I’ll remember it’s okay not know everything, that novices always bring something to teach us old dogs new tricks and most of all, I’ll have a valued colleague on the other side of our journey.

 

Reference:

Effective Mentoring in the Clinical Setting. Shellenbarger, Teresa PhD, RN; Robb, Meigan PhD, RN AJN, American Journal of Nursing. 116(4):64-68, April 2016.

 

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