Problem:
Kevin Harney, age 14 years, did not appear for breakfast when his mother called him. "That is unusual," she thought, "He has been so hungry lately, and he is so skinny; he really needs the food!" She found Kevin lying on his bed, breathing rapidly and deeply. He responded slowly with one or two words at a time to her increasingly frantic questions. Some of his answers did not make sense. Kevin's parents took him to the nearest emergency department, where his laboratory tests showed arterial blood pH 7.20, Paco2 21 mm Hg (2.8 kPa), serum HCO3 - concentration 8 mEq/L (8 mmol/L), and glucose concentration 450 mg/dL (25 mmol/L). Kevin was diagnosed with DKA arising from previously undiagnosed type 1 diabetes. During Kevin's hospitalization, interventions focused initially on intensive collaborative management of his disrupted acid-base balance with insulin and IV fluid to treat the diabetes. As a safety intervention, Kevin was positioned on his side to prevent aspiration if he vomited. During this phase of management, attention also was given to supporting his parents, explaining that Kevin's unusual breathing pattern actually was beneficial to him and coaching his mother to assume the task of protecting Kevin's lips by keeping