Report on Ndt Dye Penetrant free essay sample

This document will give the procedures to be carried out for detection of surface crack on aircraft aerofoil suspected to be cracked using the color contrast Dye Penetrant technique. Inspection should be carried with the field kit consist of 1) Penetrant 2) Cleaner or remover 3) Developer-to eccentricity any indications. All three items are readily available in aerosol forms. 1. Pre-cleaning: 1. Make sure that proper hand gloves and face mask is readily available. . Clean the surface of a part and remove the surface paint using paint strip removers thoroughly followed with degreasing the part in accordance with the given instructions. 3. Do not use any abrasive methods . If the surface is slightly spoiled, clean it by aerosol application of penetrant remover. 2. Application of Penetrant: 1. Make sure that surrounding temperature is between 10-30 degree. If the temperature is lower, then extra care should be taken for precleaning and extra time should be given for drying of the penetr ant. We will write a custom essay sample on Report on Ndt Dye Penetrant or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page 2. Before applying the penetrant, make sure that the penetrant is correct for the purpose required and use aerosol can to spray the penetrant on to the surface of the item. 3. Maintain a distance of 8-12 inches between the aerosol can and the testing surface to prevent over spraying. 4. The penetrant gets pulled into the surface defects by capillary action. 5. Allow the penetrate to soak into any flaws for 30-40 minutes. Make sure that the dye has penetrated to the narrowest crack. Generally a smaller flaw takes a longer penetrate time. 3. Excess Penetrant Removal: 1. Use the solvent remover and lint free cloth for removing the excess penetrant form the surface. 2. Make sure that solvent is not sprayed directly on to the test surface as this may remove the penetrant from the flaws. 3. This process must be done very carefully to ensure that penetrant trapped in the surface remains in the defects only. 4. Allow the penetrant to soak into any flaws for 30-40 minutes. Make sure that the dye has penetrated to the narrowest crack. Generally a smaller flaw takes a longer penetrate time. . Application of Developer: 1. After the excess penetrant is removed, apply the white powder called developer available in aerosol spray can from a distance of 12-18 inches from the surface forming an evenly thin coating on the surface. 2. After 10 minutes of developing time, the developer tries to draws the penetrant from the surface defects on to the top portion and gives the visible indication. 5. Inspection

The most influential musician from 1870 to 1950

The most influential musician from 1870 to 1950 This paper tries to look at some of the greatest musician of all times to ever walk on the face of the world. The methodology that we are going to adapt for the essence of this debate will be based on the musician influence in relation to fun base and popularity during their time. Advertising We will write a custom essay sample on The most influential musician from 1870 to 1950 specifically for you for only $16.05 $11/page Learn More It will also use their success in the music industry which will be gauged by the number of times their records have held the first position in the billboards and also the number of record sells not only in America, but in the rest of the world. The source material for this discussion will include journals and articles that give reference to the musician’s success and influence during their time. It is critical to mention that between 1870-1950 music and performance was on an upsurge, it was not until after the 1950 that m ost of the musicians and bands rose to make the most world changing hits that have gone down in history as the top fifty greatest songs with only one being of pre-1950 to make on the list. The song by Hank Williams â€Å"I’m so lonesome I could cry† is the only song from the top fifty greatest songs to be featured before 1950. The two musicians this debate will focus on will include Harry Launder and Hank Williamsas the casing point (Brackett7). Harry Launder is one of the greatest musicians and a performer in the Scottish and British realm.The entertainer was born in 1870 in Portobello Edinburgh to a John Launder a designer in China artefacts and Isabella a descendant from the black isle. Harry Launder started his early careerby working at the coal mines at the tender age of thirteen years and also realised his potential in singing at the time. He started performing his music shortly after getting married to Anna Vallance in 1891 (Gordon20). Launders first profession al performance took place at a local Lark hall where he used to make about five shillings each night. He later moved to perform at the â€Å"go-as-you please† which was amore prestigious event in the town and made him prominent among the local community. Fame and fortune for Harry Launder came around 1905 when he successfully led a troop of pantomimes known as the Howard and Wyndham. This catapulted Launder to become one of the greatest performers in England and these lead to various contracts and music deals. Launder was estimated to earn  £1000 a night for his performances in the United States by the year 1911. In the following year Launder topped the charts in Britain becoming the first British in the history of entertainment(Graeme25).Advertising Looking for essay on art and design? Let's see if we can help you! Get your first paper with 15% OFF Learn More Some of the greatest hits by Harry Launder include â€Å"Roamin in the Gloamin†, â €Å"I love a Lassie†, â€Å"Keep right unto the end of the road† and â€Å"A wee Deoch-an-Doris†. These songs made Launder the highest paid performer of his time with an estimated amount of  £12,700 for each performance (Williams 138; Lauder 14). During his forty year music career, Launder had made twenty two visits to the United States and a couple of other trips to Australia with his own train. Other accolades to his title include being knighted after the world war one for raising  £1million for the troops to be rehabilitated and inculcated to the society. According to the Prime Minister Winston Churchill, Harry Launder had rendered to the Scottish race and entire British Empire an immeasurable service through his music and philanthropy. Harry Launder died in 1950 at the age of 79 years leaving behind a legacy of songs, books and films that he had written or stirred in (William70). The other musician to make history in the music industry was Hank William s. He was born in 1923 with his birth name being Hiram King William (Brackett 32). Hiram would later change his name to Hank which sounded well according to him in country songs. In 1937, Hank would start his career in a radio station WSFA with the producer offering him a program of 15 minutes as the host with a salary of $15. This was after Hank had won a talent show at the Empire theatre pocketing the grand price of $15. With the rising popularity Hank would go on to form a band with the money he got from the radio show which he called â€Å"the drifting cowboys†, and this eventually led him to quit school.Hank would record songs like â€Å"Never again† and â€Å"Honky Tonkin† which did not do better. It was only after releasing the song â€Å"Move it on over†, that fame and fortune started to stream in.In1948,he signed a recording contract with MGM records. The following year, Hank went on to release â€Å"Love sick blues† which propelled his music to the mainstream media thus increasing his popularity as a singer. According to Helander (9), Hank was estimated to make $1000 at this point in his career for every performance he went. It is important to mention that, Hank had eleven number one songs in the American chart since 1948-1953 making him the most successful American musician of his time and also the most popular America singer only for his record to be broken by the likes of Elvis Presley and Michael Jackson in years after (Flippo16)Advertising We will write a custom essay sample on The most influential musician from 1870 to 1950 specifically for you for only $16.05 $11/page Learn More Other hits by Hank that have gone down in history of music include â€Å"You’re cheatin heart†, â€Å"Hey, Good looking† and â€Å"I’m so lonesome I could cry†. Even though by this time Hank had become a star, he nevertheless had issues that cut off his career and life. Excessive consumption of alcohol and morphine and other painkillers saw him being divorced by his wife and being kicked out of the band. Hank died in 1953 at the tender age of 29 years (Graeme 38). Hanks songs and composition have been used by other musicians in different fields such as pop, blues, gospel and even rock which have become instant hits (Wallace 84) In conclusion, it is critical to mention that the above artists even though they have a divergent appeal in relation to their music genre, their success is varied in regards to one opinion.It is crucial to mention that they made music that changed the world and entertained their audience even years after they themselves had gone. They achieved musical success at their time that made them become icons of their time. This aspect has been proved by both fame and fortune that this musicians were able to produce through their songs and lastly and the most important legacy to leave behind is their music which up to date resonate to the audience delight. Brackett, David. Interpreting popular music. New York: University of California Press. 2000. Print. Flippo, Chet. Your cheatin heart: a biography of Hank Williams. London: Plexus. 1997. Print. Gordon,Irving. Great Scot! The life story of Sir Harry Lauder, legendary laird of the music hall. London:Plexus 1968. Print.Advertising Looking for essay on art and design? Let's see if we can help you! Get your first paper with 15% OFF Learn More Graeme, Smith.The Theatre Royal: Entertaining a Nation. Saddle River: Cengage, 2008. Print. Helander, Brock. The rockin 50s: the people who made the music. New York: Schirmer Books. 2010. Print. Lauder, Harry.The Ancestry of Sir Harry Lauder, in the Scottish Genealogist, Edinburgh:Sage.2006. Print. Wallace, Lewes. Harry Lauder in the Limelight.London: OUP. 1988. Print. Williams, Lycrecia, Vinicur, Dale. Still in Love with You: Hank and Audrey Williams. London: Thomas Nelson Incorporated: 1991. Print.

How to handle work when youre depressed

How to handle work when youre depressed Work can be challenging in even the best of circumstances- but when you’re depressed and not feeling your absolute best, getting through each workday can be a real struggle. Many folks grapple with depression in both their personal and professional lives, and it can make getting through each day and handling daily responsibilities difficult. According to a recent study by The National Institute of Mental Health (NIMH), â€Å"an estimated 16.1 million adults aged 18 or older in the United States had at least one major depressive episode in the past year. This number represented 6.7% of all U.S. adults.† The NIMH defines a major depressive episode as â€Å"a period of two weeks or longer during which there is either depressed mood or loss of interest or pleasure, and at least four other symptoms that reflect a change in functioning, such as problems with sleep, eating, energy, concentration, and self-image.†Depression in the workplace is a significant issue- both f or employees and employers. Mental Health America recently reported that â€Å"Clinical depression has become one of America’s most costly illnesses. Left untreated, depression is as costly as heart disease or AIDS to the U.S. economy, costing over $51 billion in absenteeism from work and lost productivity and $26 billion in direct treatment costs. Depression tends to affect people in their prime working years and may last a lifetime if untreated.†Furthermore, a significantly higher percentage of adults suffer from minor or moderate depressive episodes. Although they typically include less pervasive symptoms, it can nonetheless make it hard to handle work and a spiraling effect can result- you feel depressed, which effects your ability to work, which makes you more depressed, and so on.Are you among the millions of Americans who suffer from depression? If so, then you’re not alone and there is a way forward- use the following strategies to help you learn to hand le work when you’re depressed.Don’t ignore the signs.If you’re struggling at work, try your best to recognize the signs that it might be due to depression.Are you feeling tired and lethargic throughout the day for no reason?Are everyday tasks- things that you used to do before with ease- becoming increasingly more difficult for you to handle and complete, or have become completely overwhelming for you?Is interacting with others at your workplace, or working collaboratively on team-based projects, becoming so uncomfortable or unappealing to you that you avoid contact or social interactions with colleagues at all costs?Do you find that your self-care routine is falling by the wayside?Are you noticing negative changes in your overall mood and attitude throughout the day?Has your productivity at work dipped?Do you find yourself missing work, coming in late, or leaving early more often?The truth is, any one or combination of these signs could be an indication that yo u’re suffering from depression. If you answered yes to any of these questions, the first step is to acknowledge that depression might currently be an issue for you.Assess your needs.As previously mentioned, there are varying degrees of depression that an individual can experience, and every person has their own unique symptoms, coping mechanisms, and needs. If you’ve made the determination that you’re suffering from depression- whether its mild or more profound- a good idea is to try and take an honest self-assessment and mental inventory regarding how it’s affecting your life. The last thing you want to have happen is to have your depression take complete control of your life and adversely affect your job situation- which can make your condition worse.Once you’ve determined how your depression is affecting you at work, try to assess your needs. Do you need to simply recalibrate, get organized, and wrap your head around your work responsibilities i n a new and fresh way? Do you need to make some behavioral and lifestyle changes in an effort to enact positive change? Or do you need additional outside help? Once you’re able to make a determination about what you need in order to effect change in your life and make the struggle a bit easier, you’ll be in a better position to choose the right steps for you.Seek help if needed.Do you think that you may need some guidance from others- perhaps friends or family, trusted colleagues, or professional help? The first thing to realize is that this isn’t a personal failure on your part. Many competent and functional adults suffer from depression, and there’s no shame or stigma in reaching out for help. Depression is a heavy weight to carry around on your own- seeking help from others can help ease the burden and allow you to focus on working towards an effective life solution.Explore workplace options.Many progressive workplaces offer benefits packages that incl ude mental health services- from finding the right professional help to meet your needs to financial coverage for associated costs. You may also be eligible to take paid time off from work to focus on getting help and getting better. Contact your HR representative to learn all of your options, which will help you formulate the best strategy for dealing with your depression.You are under no obligation to disclose a private health concern like depression to your colleagues and coworkers. That said, many people chose to be honest and up front about their depression and are met with sensitivity, guidance, and understanding, which can be an incredibly supportive and encouraging thing to have at a time when you need it most. The choice on how to handle disclosure is completely yours.Don’t just ignore your depression.How many problems in your life get better by simply ignoring them? If you feel that you’re experiencing depression at work and it’s affecting your ability to do your job, your best bet is to not ignore it and to use the steps outlined above to try and make some positive changes. Don’t forget- you’re not alone and your situation is not insurmountable. With a little proactive effort and the courage to effect positive changes in your life, you can go beyond learning how to handle depression at work. Instead, you can truly thrive.

Personal and Professional Development in Nursing Essay - 1

Personal and Professional Development in Nursing - Essay Example Nurses can use a variety of ways to demonstrate individual accountability; two methods are continued competency and professional development. Professional competency is an empowerment tool in that it enables the nurses to fulfil their responsibilities of care effectively. It is also, therefore, important to understand the factors that influence clinical competency (Memarian et al., 2007, 203-214). Accountability and Ethics: The codes of nursing ethics have focused on accountability as a central moral concept and value. Some national nursing organisations have identified accountability as the key standard of competent practice. The code of professional conduct calls for a high standard of professional behaviour from the nurses, regulating the nursing and midwifery practice in order to ensure standards and providing protection for the clients (Vanlaere and Gastmans, 2007, 758-766). Nursing, in essence, is a care system that springs from safe, caring, and competent and educated decision making, and nurse is a professional who is willing to accept personal and professional accountability for evidence-based practice guided by ethical principles (Wiseman, 2007). Accountability: The code of professional conduct enumerates that the nurse is personally accountable for her practice. Literally, this means the nurse is responsible for actions and omissions, "regardless of advice or directions from another professional." This directly relates to the law of the land and is guided by the duty to deliver safe and competent care. Therefore, this also involves the responsibility of reporting. However, it must be mentioned that accountability for standards of practice is judged by the peers or fellow professionals, and only they are in a position to make decisions about the appropriateness or quality of service. Nursing diagnoses, the first taxonomy created in nursing, have fostered the development of autonomy and accountability in nursing and have helped to delineate the scope of practice. In that sense, professionalism and accountability are inherent in nursing practice (Jos and Tompkins, 2004, 255-281). The nursing profession has traditionally used t hree methods of assuring accountability to the public-licensure examination, continuing education, and certifications, all of which are avenues of professional development that ensures quality and standards of care. The idea of a standard of care evolves from this principle. Standards of care provide a ruler for measuring nursing actions, and therefore, maintenance of accountability promotes both personal and professional development. This behaviour would uphold the profession, and accountability also ensures that the nurse acts quickly to protect the patient and his rights within the limits of contemporary professional competency. Nurses are accountable to their clients and to their colleagues. When providing care to clients, nurses are responsible for their own actions, good and not so good (Griffith and Tengnah, 2005, 339-343). The principle of autonomy has considerable merit and is supported by the Code of Ethics for Nurses. Following this ethical principle

Current macroeconomic situation Essay Example | Topics and Well Written Essays - 500 words

Current macroeconomic situation - Essay Example economic productivity in the US depicted in the numerous productions and purchases in terms of goods and services, the rates of national unemployment have remained steadily high. This implies that increment in the overall productivity of both goods and services is not playing any noteworthy role in the generation of fresh jobs for the general populace. It further implies that employers are not offering job opportunities to fresh workers in order to develop the required growth rates. In the most recent probe into the macroeconomic situation, Consumer Price Index with regard to urban consumers stood constant during the month of December similar to the month of November. The index for all goods except for food and energy rose significantly by 0.1% in December after it augmented to 0.2 in November (BLS, 2012). This has been presented as the inflation levels for US for the fiscal months of December and November. According to reports on employment and unemployment, a rise in the nonfarm payroll job offering augmented by 200, 000 in December 2011, while the unemployment rate continued to drop at 8.5% (Haskell, 2011). Job opportunities emerged in the conveyance, warehousing, retail vending, industrialized, medical and mining sector of the economy. According to the presented report, real GDP, which is the production of goods and services that US generated in labor and property augmented to a yearly rate of 1.8% as per the third quarter of last year (Haskell, 2011). Previously, the second quarter of last year saw an augment of the real GDP by 1.3%. Currently, the expansionary fiscal tools such as the purchases made by the government on taxes are not working within the current situation. The working group has been amassing less experience concerning jobs than expected, which consequently leads to augment in inflation and unemployment (Bullard, 2011). Although inflation is triggered by supply side dilemmas, inflation and unemployment augment in a similar manner making the

King Leopold and the Belgian Congo Essay -- African History Essays

King Leopold and the Belgian Congo It is widely debated why exactly King Leopold decided to conquer the Congo, but the general consensus seems to be that it was out of the belief that â€Å"the highlands of the Congo may be as rich in gold as the mountains of the western slope of the American Continent† (Stead). In the mid-1870s, the King hired Henry Stanley, who was familiar with many parts of Africa, to help him go about conquering. During the following years Stanley stayed in Africa, talking various tribes into signing over their lands and rights. After this was completed the King officially took over the Congo, renaming it the Congo Free State. This was especially ironic because all natives of the country were either forced to give up their way of life in exchange for virtual slavery in the ivory trade, agriculture, or the rubber traffic, or die trying to escape fate. Leopold was undeterred by the amount of suffering and death in the Congo, brought on by his rule. Belgian soldiers and officials were known f or their cruelty in their methods to make, and then keep, Congo natives wo...

Diabetic Ketoacidosis

DIABETIC KETOACIDOSIS INTRODUCTION Diabetic ketoacidosis (DKA) is a very serious complication of diabetes mellitus, a metabolic disorder that is characterized by hyperglycemia, metabolic acidosis, and increased body ketone concentrations. The most common causes of DKA are infection and poor compliance with medication regimens. Other causes include undiagnosed diabetes, alcohol abuse, and a multitude of medical conditions such as cerebrovascular accident (CVA), complicated pregnancy, myocardial infarction, pancreatitis, and stress. Diabetic ketoacidosis is a complicated pathology.Early recognition of DKA, a good understanding of the pathological processes of DKA, and aggressive treatment are the keys to successful treatment. With good care, DKA can be managed and the patient will survive. OBJECTIVES When the student has finished studying this module, he/she will be able to: 1. Identify the correct definition of DKA. 2. Identify a basic function of insulin. 3. Identify the insulin dera ngements of types I and II diabetes. 4. Identify the basic cause of DKA. 5. Identify two specific causes of DKA. 6. Identify the two pathogenic mechanisms that produce the signs/symptoms of DKA. . Identify metabolic consequences of increased hormone concentrations in DKA. 8. Identify the criteria used to diagnose DKA. 9. Identify common signs and symptoms of DKA. 10. Identify laboratory abnormalities seen in DKA. 11. Identify complications of DKA. 12. Identify the three most important therapies for treating DKA. 13. Identify the correct roles of sodium bicarbonate and phosphate in treating DKA. 14. Identify an important rule for using potassium replacement in DKA. 15. Identify an important rule for switching from IV to subcutaneous insulin.EPIDEMIOLOGY Most cases of DKA are seen in patients with type I diabetes, but approximately 10%-30% of all cases of DKA occur in patients with type II diabetes. 1 The incidence of DKA appears to be rising, and this may not be related to the well p ublicized increase in the incidence of diabetes that has become a serious public health problem. 2 Diabetic ketoacidosis accounts for 50% of all diabetes-related admissions in young people with the disease, and DKA is the most common cause of diabetes-related death in children and adolescents with type I diabetes. Diabetic ketoacidosis is much more common in children than in adults, it is more common in women than in men, and it is more common in Caucasians. 4 The exact incidence of death from DKA is not known, but it has been estimated to be between 1%-10%. 5 Survival depends on the severity of the case, the age of the patient, the presence/absence of certain medical conditions, and how quickly DKA is recognized and how effectively it is treated. If the condition is promptly diagnosed and properly treated, the mortality rate can be 250 mg/dL) metabolic acidosis (blood pH ? . 30) and an elevated level of serum ketones (> 5 mEq/L) and/or ketones in the urine. 11 Patients will also ha ve an anion gap (Na+ – Cl- + HCO3-), an elevated blood urea nitrogen (BUN), hyponatremia, hyperkalemia, and the serum amylase may be elevated. The total body phosphate level may be low but the serum level may be normal or elevated. At this time, there is no universally agreed upon consensus for the diagnostic criteria of DKA, and some sources feel that an anion gap > 10-12 mEq/L and serum bicarbonate (HCO3) ? 8 mEq/L should be part of the criteria. Learning Break: Some authors feel that most important test for diagnosing DKA is total blood ketone concentration. 12,13 The acidosis and hyperglycemia of DKA and the electrolyte changes that are so commonly seen in DKA are closely related. The shift in metabolism and the high concentration of acidic ketones seen in cases of DKA produces a metabolic acidosis. Acidosis and insulin deficiency causes potassium to shift from the intracellular space to the extracellular space and serum hyperkalemia is common.However, the osmotic diuresi s that is characteristic of DKA causes potassium to be excreted in the urine; although the serum potassium level may be high, the patient may be profoundly depleted. Sodium and phosphate are also excreted by the osmotic diuresis, and hyponatremia is common. However, the serum phosphate level is often falsely normal or falsely elevated because phosphate, like potassium, is excreted in the urine but acidosis induces phosphate to move from the intracellular space to the extracellular space.The serum level might be normal, but the actual total body load is low. Learning Break: The serum glucose can be very elevated in severe cases of DKA. However, serum glucose can be close to normal, and approximately 10% of patients with DKA will be euglycemic with a serum glucose ? 250 mg/dL. 14 COMPLICATIONS OF DIABETIC KETOACIDOSIS Patients who have diabetic ketoacidosis that is promptly recognized and promptly and correctly treated should survive. The complications of DKA are complications of trea tment and cerebral edema.Treatment complications are hypoglycemia, hyperkalemia, and occasionally pulmonary edema. These can be avoided by using low-dose insulin therapy, monitoring blood glucose very closely, and by carefully managing fluid replacement. Cerebral edema is a very serious complication of DKA. It occurs in approximately 1% of all children with DKA, but the mortality rate and the rate of neurological sequelae for these children have both been reported to be 21%, and the mortality rate and rate of sequelae can be as high as 24% and 26% respectively15,16 Adults with DKA rarely develop cerebral edema. 7 Signs and symptoms include mental status changes, bradycardia, seizures, abnormal response to pain, and decorticate and decerebrate posturing. TREATMENT FOR DIABETIC KETOACIDOSIS The most important treatments for DKA are fluid replacement, insulin therapy, and correcting electrolyte balances. Obtain baseline serum electrolytes, BUN, creatinine, serum glucose, an arterial or venous blood gas (either one is appropriate), a complete blood count, an ECG, and a CXR. Consider other laboratory studies if DKA is thought to be caused by an underlying disease. Fluid replacement: Fluid replacement will replace the fluid deficit, help decrease the blood glucose level, and maintain renal function. If the patient is severely hypovolemic, give 1 liter of 0. 9% sodium chloride over 30 minutes. If the patient is mildly dehydrated, check the serum sodium. If it is normal or high, give 0. 45% sodium chloride IV at a rate of 250-500 mL/h. If the serum sodium is low, give 0. 9% sodium chloride IV at a rate of 15-20 mL/kg per hour. Once the blood glucose is approximately 200 mg/dL, a solution of % dextrose with 0. 45% sodium chloride can be used. 18Learning Break: In the first hour of treating a patient with DKA, fluid replacement is more important than insulin therapy and should take precedent. 19,20 †¢ Insulin therapy: Insulin is a critical part – perhaps the critical part – of the treatment of DKA. It can be given as an IV infusion or frequent subcutaneous injections: they are equally effective. Most clinicians prefer the IV route as the onset of action is quicker and the half-life is shorter with the IV route than the onset of action of and half-life of insulin given subcutaneously: because of that, therapy can be closely monitored.The American Diabetes Association recommends giving an initial IV bolus of regular insulin, 0. 1 U/kg. (Note: If the serum potassium is < 3. 3 mEq/L insulin should not be given). Following the bolus dose, start a continuous IV infusion of regular insulin at a rate of 0. 1 U/kg/h. An alternative is to omit the bolus dose and start a continuous IV infusion of regular insulin at a rate of 0. 14 U/kg/h. If the serum glucose does not decrease by 10% within an hour of starting the insulin, give 0. 14 U/kg as a bolus dose, then continue the IV infusion.Once the serum glucose is < 200 mg/dL, reduce the insul in dose to 0. 02-0. 05 U/kg/h or give subcutaneous doses of rapid-acting insulin, 0. 1 U/kg every two hours. The goal at this point is to keep the serum glucose between 150-200 mg/dL. 21 0. 1 U/kg IV bolus v 0. 1 U/kg/hr * v When serum glucose < 200 mg/dL, decrease infusion to 0. 02-0. 05 U/kg/h v Keep serum glucose between 150-200 mg/dL until DKA resolves * If serum glucose doesn’t v by at least 10% in the 1st hour of insulin therapy, give an IV bolus of 0. 14 U/kg and adjust the infusion. Correcting electrolyte imbalances: If the serum potassium is < 3. 3 mEq/L, do not start insulin therapy and give 20-30 mEq of potassium per hour until the serum level is >3. 3 mEq/L. Fluid replacement and insulin therapy lower blood sugar and correct acidosis and they also move potassium into the cells. If the serum potassium is < 3. 3 mEq/L, serious arrhythmias could result. Once the hypokalemia has been corrected, insulin therapy can be started, and 20-30 mEq of potassium can be added to each liter of IV solution in order to maintain a serum potassium level between 4. -5. 0 mEq/L. Learning Break: Serum glucose and serum potassium should be checked every hour until the patient is stable. Two other considerations for treatment are administering sodium bicarbonate to help correct the acidosis and replacing phosphate losses. Using sodium bicarbonate is controversial. Severe acidosis can decrease myocardial contractility, can cause and prolong coma, shifts the oxyhemoglobin dissociation curve to the right, etc. , so correcting an acidosis would seem important. However, there are risks involved (e. g. making body hypokalemia worse, cerebral edema), there are many clinical studies that indicate sodium bicarbonate therapy is not effective for patients with DKA, and for many patients the acidosis will correct with fluids and insulin and because they have adequate stores of bicarbonate. 22 The use of sodium bicarbonate should not be standard care for DKA. However, the Americ an Diabetes Association does recommend that if a patient has a severe acidosis with a pH < 6. 9, the patent should receive 100 mEq of NaHCO3 in 400 mL IV fluid along with 20 mEq of potassium chloride; this should be infused at 200 mL/h.Repeat this every two hours until the pH is ? 7. 0. 23 Low phosphate levels will usually correct as the hyperglycemia and acidosis are corrected, and phosphate replacement is not standard care for DKA. However, if the phosphate is very low – < 1. 0 mg/dL – or the patient has anemia, cardiac disease, or hypoxia, 20-30 mEq of phosphate can be given. 24,25 SWITCHING TO SUBCUTANEOUS INSULIN Diabetic ketoacidosis is considered to be resolved when the blood glucose is < 200 mg/dL and at least two of these laboratory values are present: a venous pH > 7. 3, an anion gap < 12 mEq/L, and a serum bicarbonate level > 15. mEq/L. 26 If these laboratory values are present and the patient can eat, it is safe to start subcutaneous insulin. Intravenous in sulin should be continued for one to two hours after the first dose of subcutaneous insulin has been given. If this is not done, hyperglycemia and ketosis may recur. NURSING CARE, PREVENTION AND EDUCATION When providing care for a patient in the acute phase of DKA, the nurse should focus on hydration status/fluid replacement, monitoring of acid-base status, serum glucose, and serum electrolytes, close observation of the patient’s neurological status, and vital signs.Once a case of DKA has resolved it is important to know why it happened. Infections, medical conditions, and drugs are common causes of DKA. However, one of the most important causes of DKA is patient non-compliance with diabetic treatment regimens: patients do not take their medication or do not take them properly, they fail to follow their prescribed diet and lifestyle plans, and they do not or cannot understand the basics of self-care and prevention as they relate to diabetes.If non-compliance was the cause of a particular case of DKA, it is very important to determine why the non-compliance occurred, and there many possible reasons. Some of the more common ones are: †¢ Poor access to medical care: The patient may not have access to health care information, may not have easy access to a physician, clinic, etc. , may not have or not know how to use community or public access health care resources. The patient may not have money for medications. Lack of information: The patient may have a poor understanding of diabetes, and the patient may not understand the treatment regimens that have been prescribed. Lack of information can be damaging in many ways. If the patient doesn’t understand the disease of diabetes, he/she might be less willing to comply with lifestyle and diet restrictions and less willing to take medications. The patient would not recognize possible warning signals of DKA. †¢ Emotional issues: For many people, diabetes requires lifestyle changes that they may n ot be willing to emotionally accept.Learning Break: Although it may be said that non-compliance happens when the patient fails to provide good self-care, the word fail typically has a negative connotation. Also, when many people hear the term non-compliance, they think of a person willfully failing to do what he/she knows is best. However, there are many cases of non-compliance that happen because the patient has not been properly educated, or doesn’t have or doesn’t know how to get the resources he/she needs.So when it has been determined that non-compliance was the cause of a particular case of DKA, interview the patient and find out a) the emotional impact of diabetes on the patient’s life, b) how much he/she knows about the disease and the treatments, and c) what financial, medical, personal, and social resources the patient has available for self-treatment. Some of these issues must be addressed by social workers, psychologists, or the patient’s phys ician. However, nurses have a primary role in supporting and educating patients who have had an incident of DKA related to on-compliance. The nurse will often be the first person to find out that the patient did not seek medical attention for an infection because of financial concerns, or due to inability to each a physician, or because of a lack of understanding of the implications of infection in diabetes. The nurse must then discuss making the appropriate referrals and then set up a teaching plan. Some of the nursing diagnoses that might apply in theses situations would be imbalanced nutrition, noncompliance, knowledge deficient, and risk for injury. SUMMARY Diabetic ketoacidosis is a metabolic disorder characterized by hyperglycemia, metabolic acidosis, and elevated body ketone concentrations. †¢ The basic cause of DKA is insulin deficiency, absolute or relative. The insulin deficiency most often occurs because of infection or non-compliance with diabetic treatment regimens . †¢ Excess hormone concentration and a metabolic shift are the pathogenic mechanisms that cause the signs and symptoms of DKA. †¢ The hormone concentrations cause hyperglycemia, and the metabolic shift causes acidosis and elevated body ketones. The basic diagnostic criteria for DKA are a blood glucose > 250 mg/dL, a serum pH < 7. 3, and elevated serum and/or urine ketone concentrations. †¢ Other important criteria are an anion gap > 10-12 mEq/L and serum bicarbonate (HCO3) ? 18 mEq/L. †¢ Hyperkalemia and hyponatremia are common in DKA. Hypophosphatemia can be seen. However, the total body load of potassium and phosphate is often low. †¢ Common signs and symptoms include dehydration, mental status changes, polydipsia, polyuria, vomiting, weakness, and weight loss. †¢ Complications of DKA include complications caused by treatment and cerebral edema. Treatment for DKA should focus on fluid replacement, insulin therapy, and correcting electrolyte abnormali ties. Sodium bicarbonate is not standard care. †¢ If DKA if promptly recognized and properly an aggressively treated, patients should survive. REFERENCES 1. Wilson JF. In the clinic: Diabetic ketoacidosis. Annals of Internal Medicine. 2010; 152:ITC-1-ITC-16. 2. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335-1343. 3. Wolfsdorf J, Glaser N, Sperling MA.Diabetic ketoacidosis in infants, children, and adolescents: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:1150-1159. 4. Hamdy O. Diabetic ketoacidosis. eMedicine. September 9, 2009. Available at: http://emedicine. medscape. com/article/118361. Accessed December 24, 2010. 5. Hamdy O. Diabetic ketoacidosis. eMedicine. September 9, 2009. Available at: http://emedicine. medscape. com/article/118361. 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