Diabetic Ketoacidosis

Nursing Implications
1. Evaluation/ Monitoring
  1. Continue to monitor vital signs to determine the presence of fever, hypovolemic shock, tachycardia, and Kussmaul's breathing (Lewis et al., 2014).
  2. Monitor the signs of potassium imbalance resulting from hypoinsulinemia and osmotic diuresis. Use Cardiac monitoring to detect hyperkalemia and hypokalemia (Lewis et al., 2014).
2. Assessments
  1. Assess potential Insulin On Board (IOB). When was the last time of insulin administration? How much insulin was administered at this time? Do adjustments need to be made due to illness or stress? (American Diabetes Association (Lilley et al., 2017)
  2. Assessment of mental status and level of consciousness (Lewis et al., 2014).
  3. Assess patient food intake.
  4. High blood glucose levels (above 14 mmol/L) (Diabetes Canada, 2018).
  5. Renal status (e.g Polyuria) (Lewis et al., 2014)
  6. Cardiovascular status related to hydration and electrolyte levels (Lewis et al., 2014).
  7. Respiratory status (eg. Kussmaul's breathing) (Lewis et al., 2014).
  8. Vital signs (Lewis et al., 2014)
  9. Signs and symptoms listed under "Disease Process"
3. Patient/Family Teaching
  1. Managing blood sugar levels when ill. Being sick may cause blood sugar levels to fluctuate and become unpredictable (CDA, 2019)
    1. Checking blood glucose levels more often than usual (e.g. every two to four hours) (CDA, 2019).
    2. Drink plenty of water or sugar-free fluids (avoid caffeinated drinks that can lead to dehydration) (CDA, 2019).
    3. Continue to take insulin or other diabetes medication (CDA, 2019).
      1. As an extra precaution, you should always check with your health-care team about guidelines for insulin adjustment or medication changes during an illness (CDA, 2019).
    4. Check for ketones every 4 to 6 hours. And check every 4 to 6 hours when your blood sugar is more than 14 mmol/L (Diabetes Canada, 2018)
    5. If you have a cold or flu and want to use a cold remedy or cough syrup, ask your pharmacist to help you make a good choice. Many cold remedies and cough syrups contain sugar, so try to pick sugar-free products (CDA, 2019).
    6. Monitoring for presence of ketones in urine, however, blood ketones are preferred for accuracy (Diabetes Canada, 2018)
  2. Insulin Information (CDA, n.d.).
    1. Discard insulin that has been frozen, exposed to temperatures greater than 30ºC, or expired.
    2. Unopened insulin should be stored in the fridge between 2ºC and 8ºC.
    3. Opened insulin can be stored at room temperature for up to 1 month.
  3. Patient educational support systems
    1. Patient awareness of when to contact the emergency room (CDA, 2019)
    2. Community support via telehealth programs (Vellanki & Umpierrez, 2018)
4. Diagnosis (Canadian Diabetes Association [CDA], 2019)
  1. ↑ glucose
  2. ↑ serum/urine ketones
  3. ↓ pH (venous and arterial and/or ↓ bicarbonate
5. Plan/Intervention (Lewis et al., 2014)
  1. Recording of intake and output
  2. Central venous pressure monitoring (if indicated)
  3. Check blood and urine for ketones
  4. Obtain blood glucose levels
  5. Administration of IV fluids to correct dehydration
  6. IV administration of rapid- or short-acting insulin reduce blood glucose and serum ketones
  7. Electrolyte replacement
Treatment (Lewis et al., 2014)
1. Drug Therapy
  1. Fluid resuscitation with NaCl solution until blood pressure stabilizes and urine output normalizes
  2. Continuous insulin drip @ 0.1 units/kg/hr
  3. Potassium IV to correct deficiency as a result of hyperglycemia
  4. Sodium bicarbonate if severely acidotic
2. Non-pharmacological Interventions
  1. Ensure patent airway
  2. Gather history of diabetes, when the person last ate, time/amount of latest insulin injection
Factors Associated With DKA Diagnoses (Malik et al., 2016)
1. Public Insurance
  1. Those with public insurance twice as likely to be hospitalized for DKA than those with private insurance
  2. More unmet prescription and medical needs than those with private
2. Non-hispanic Black race
3. Being older than 12 years old
  1. Parental monitoring, supervision, involvement in diabetic care declines as children age
4. Being a female
5. Mental health comorbidity
6. Celiac Disease
  1. Many people with diabetes may become celiac due to reasons beyond their control
Disease Process
1. Pathophysiology/Etiology (Lilley, Collins, Snyder, Swart, 2017))
  1. Severe insulin deficiency
  2. Presence of ketones in the serum and urine
  3. Acidosis
  4. Dehydration
  5. Electrolyte imbalance
    1. Low plasma levels
      1. Potassium
      2. Bicarbonate
2. Signs (Canadian Diabetes Association [CDA], 2019)
  1. Nausea
  2. Vomiting
  3. Abdominal pain
  4. Confusion
  5. Difficulty paying attention
  6. Feeling tired
  7. Difficulty breathing
  8. Extreme thirst and dry mouth
3. Symptoms (Derraik et al., 2018)
  1. Polyuria
  2. Hyperglycemia
  3. Polydipsia
  4. Weight loss
  5. Fruity odor on breath
  6. Dry or flushed skin
Complications
1. If left untreated, leading to reduced consciousness and coma (CDA, 2019)
  1. Can become fatal (CDA, 2019)
2. Brain changes, including decreasing IQ levels and short-term memory loss (Derraik et al., 2018))
3. Liposis and over-production of ketones (DKA) (Derraik et al., 2018)
Risk Factors
1. Newly diagnosed Type 1 Diabetics are at increased risk (Derraik et al., 2018; Lilley, Collins, Snyder, Swart, 2017))
2. Emotional or physical stress (ex. illness or infection) (Lilley, Collins, Snyder, Swart, 2017)
3. Uncontrolled diabetes Lilley, Collins, Snyder, Swart, 2017)

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Diabetic Ketoacidosis

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	Created by Sara Gervasi about 5 years ago