Mindmap: Diabetic Ketoacidosis (DKA) - Elaina Pham and Charity Kate de Leon

Pathophysiology (Copstead-Kirkhorn & Banasik, 2014)
1. Hypokalemia
2. Ketonuria
3. Metabolic Acidosis
4. Hyperglycemia
5. Hyperosmolality
6. Decrease supply of circulating insulin
  1. Glucose cannot be used for energy
    1. body breaks down fat as secondary source of energy
      1. ketones are created as a by-product, altering PH, in excess it leads to metabolic acidosis
7. Clinical Manifestations (MacArthur & Phillips, 2015)
  1. Dehydration
    1. Tachycardia
    2. Poor skin turgor
    3. Dry mucous membranes
    4. Hypotension
  2. Hyperosmolality
    1. Polyuria
    2. Polydypsia
    3. Altered LOA
  3. Metabolic Acidosis
    1. Kussmaul's respirations (laboured breathing)
    2. Abdominal pain
    3. Nausea & vomiting
  4. Ketosis
    1. Sweet, fruity breath
Assessment (Jarvis, 2016)/(Lewis et al, 2014)
1. Subjective
  1. Physical examination
  2. Past medical history
  3. Family history
2. Objective
  1. Blood studies
    1. Hyperglycemia (Blood glucose >14 mmol/L)
    2. Positive for ketones
    3. CBC (increase in WBC)
  2. Urinalysis
    1. Ketones (ketonuria)
    2. Glucose (glucosuria)
    3. pH
    4. Specific gravity
  3. Arterial Blood Gases
    1. CO2 level 10-20 mmHg
    2. Arterial blood pH <7.3
    3. Serum bicarbonate <20 mmol/L
Treatment/Interventions (Lewis et al, 2014)
1. NUrsing Management (Lewis et al, 2014)
  1. Monitor ECG --> cardiac functioning is affected by movement of K+
  2. Monitor vital signs for fever, hypovolemic shock, tachycardia, and Kussmaul's breathing
  3. Monitor blood glucose & urine output for ketones
  4. Monitor signs of potassium imbalance (because of osmotic diuresis)
  5. Monitor level of consciousness
  6. Assess cardiac and respiratory status
2. Insulin infusion - 0.1 U/kg/hr (treatment of ketoacidosis)
3. administer oxygen according to doctor's orders
4. ensure patent airway
5. IV sodium bicarbonate to treat severe acidosis (pH <7)
6. Resore fluid and electrolyte balance (IV NS) (Lewis et al, 2014)
  1. D5W infusion --> prevention of hypoglycemia
  2. administration of IV fluids --> corrects dehydration
  3. IV administration of rapid or short-acting insulin --> corrects hyperglycemia & hyperketonemia
  4. administer K + IV --> corrects hypokalemia
Etiology (Lewis et al, 2014)
1. DIABETES MELLITIS (DM)
  1. Acidosis
  2. Dehydration
  3. Hyperglycemia
  4. Ketonuria
2. Common causes (Lewis et al, 2014)
  1. 40% --> Underlying or concomitant infection
  2. 20% --> Various causes
  3. 20% --> Missed insulin
  4. 15% Newly diagnosed, unknown
    1. Pregnancy
      1. Placental hormones cause insulin resistance --> increase insulin requirements
        Ketones harmful to feus
    2. Stress, infection or illness, surgery, trauma
      1. Pancreas unable to meet insulin demands
Special Considerations
1. Children with Type 1 Diabetes
  1. Presenting factor for diabetic ketoacidosis (McFarlane, 2011)
    1. Cerebral edema occurs in <1% of all paediactric DKA cases (Long & Koyfman, 2017)
    2. Children <3 years old and come from areas with low prevalence of diabetes are at risk for moderate to severe DKA (Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018)
2. Management of DKA for children
  1. Mannitol or hyperonic saline used for treatment of cerebral edema
  2. Fluid resuscitation is the primary goal
    1. Fluid bolus of 10-20 mL/kg is likely safe for children (Long & Koyfman, 2017)
    2. It is critical to weigh the child before fluid resuscitation because rapid rehydration can occur and leads to cerebral edema (McFarlane, 2011)
  3. Potassium replacement therapy and insulin therapy (McFarlane, 2011)
3. Risk factors for children that increase the likelihood of DKA: (Diabetes Canada Clinical Practice Guidelines Expert Commitee, 2018; Oettingen, Rhodes, & Wolfsdorf, 2018; MacArthur & Phillips 2015)
  1. Low socioecominc status
  2. Adolescent females
  3. High family conflict
  4. Ethnic minorities
  5. Children with psychiatric disorders
  6. Previous episodes of DKA
  7. Poor metabolic control
  8. Limited access to health care
Complications (Lewis et al, 2014)
1. Rapid administration of IV fluids + insulin --> cerebral edema
2. Untreated hyperglycemia
  1. Decreased levels of sodium, potassium, chloride, magnesium, and phosphate
3. Overcorrection of fluid losses
  1. Fluid overload and pulmonary edema
4. Renal failure caused by hypovolemic shock
  1. Retention of ketones and glucose
    1. Progressive metabolic acidosis
      1. Comatose due to dehydration, electrolyte imbalance, and acidosis
5. Treating hyperglycemia causes K+ to move rapidly into cells
  1. affects cardiac functioning

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Mindmap: Diabetic Ketoacidosis (DKA) - Elaina Pham and Charity Kate de Leon

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