02.04 Diabetic Ketoacidosis (DKA)

Overview

  1. Severe Hyperglycemia with Ketoacidosis

Nursing Points

General

  1. Type I Diabetes Mellitus – Acute Exacerbation
    1. Body has NO insulin→ can’t get glucose into cell → breaks down fatty acids for energy → Ketones (Acids)
  2. Sudden onset → stress, infection

Assessment

  1. Ketoacidosis
    1. Acidosis (pH <7.35, HCO3- <22)
    2. Ketones in Urine
    3. Fruity Breath (due to ketones)
    4. Kussmaul Respirations
      1. Trying to breathe off Co2 to compensate for acidosis
      2. Patients can tire easily
    5. Hyperkalemia
      1. K+ leaves the cell to compensate for acidemia
  2. Hyperglycemia
    1. Blood Glucose 400-600 mg/dL
    2. Severe Dehydration
      1. Osmotic Diuresis
      2. Polyuria
    3. ↑ BUN, Creatinine
    4. Altered LOC (cellular dehydration)

Therapeutic Management

  1. First nursing action = begin fluid replacement and check electrolytes
  2. Treatment Priority = correct acidosis
    1. Insulin therapy → so the body can STOP breakdown of fatty acids
    2. Without insulin, DKA will continue to progress, despite fluid replacement
    3. Insulin therapy continues until anion gap acidosis has fully resolved
  3. Continue replacing fluids as needed
    1. Helps manage the dehydration caused by the hyperosmolarity
  4. Monitor neurological status
  5. Monitor and treat electrolyte imbalances

Nursing Concepts

  1. Acid-Base Balance
    1. Monitor Arterial Blood Gases and Anion Gap
    2. Monitor Respiratory status
  2. Glucose Metabolism
    1. Blood sugar checks q1h
    2. Intensive insulin therapy (IV – Regular Insulin)
      1. May continue even after blood sugar down (goal = correct acidosis)
    3. Evaluate urine for glucose/ketones
  3. Fluid & Electrolytes
    1. Give IV Fluids (IVF)
    2. Monitor electrolytes & replace as needed
    3. Potassium may ↓ with insulin therapy
      1. May add KCl to IVF

Patient Education

  1. Continue to monitor blood sugars and take insulin even on a sick day
  2. Do not skip doses of insulin
  3. Signs and symptoms of hyperglycemia (before DKA) to alert to a problem earlier

Reference Links

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Video Transcript

This lesson is going to talk about Diabetic Ketoacidosis or DKA.

Diabetic Ketoacidosis is a state of severe hyperglycemia WITH ketoacidosis. This is essentially an acute exacerbation of Type I Diabetes Mellitus. Remember in Type 1 Diabetes, the body has NO insulin. Normally, insulin allows glucose to enter the cell and that creates energy or ATP. The insulin is the key that unlocks the cells for glucose to come in. Without the key, the cells have to find another way to get energy. It’s like a burglar – the door is locked, there’s no key – so what does he do? He breaks a window. So that process is called gluconeogenesis and it involves breaking down fatty acids for energy. A byproduct of that process is Ketones, which are acids. So we end up with this buildup of acids in the system – leading to a metabolic acidosis. Specifically, it’s what’s known as an anion gap acidosis. It is usually a sudden onset and can be caused by stress or infection. Or it could be a medication issue – if they aren’t taking their insulin, or if their insulin pump malfunctions, that can lead to DKA.

So what will we see? Well we’re going to see two MAIN sets of problems. First, we see hyperglycemia – elevated blood glucose levels around 400-600, maybe a little higher. That causes hyperosmolarity, where the fluids are shifting out of the cells into the bloodstream to try to balance this concentration. That leads to severe cellular dehydration. When blood glucose is that high, the kidneys can’t hold onto all of it, so they’ll begin dumping the sugar into the urine. Not only is there more water in the vessels, but the water now follows glucose out into the urine, so we see polyuria. The dehydration causes their BUN and Creatinine to elevate, and we could also see altered LOC because of that cellular dehydration in the brain.

The second set of problems is due to the Ketoacidosis. Their pH will drop below 7.35 and their Bicarb could be less than 22. We’ll see ketones in their urine – either on a UA or a dipstick. They’ll also have fruity breath because of those ketones – that’s one of your classic signs of DKA in addition to the lab values. We also see Kussmaul Respirations. This is when patients are breathing very fast and very deep. Why? Well their body is acidotic and they’re trying desperately to compensate. So they’re trying to blow off as much CO2 as they can. Remember CO2 is acidic, so if they can get rid of some, it might correct the pH. Problem is, patients can only breathe this way for so long before they get fatigued and worn out. And finally we see hyperkalemia. This is a result of the acidosis and it’s another one of the body’s attempts to balance out electrical charges. Hydrogen ions (those are your acids) and potassium ions both have the same charge, so the body tries removing the hydrogen from the bloodstream and replacing it with potassium – except we know how dangerous hyperkalemia can be for our patients, right?

So what are our priorities for management of DKA? Well, of course we want to identify and treat the cause, especially if it’s an infectious source. But our #1 priority is going to be to correct the acidosis. The only way to really do this is to give IV Insulin therapy with Regular insulin. Not only will this bring the sugars down, but it will also let the body know it’s okay to stop using the fatty acids and stop making ketones. So, sometimes, we keep giving insulin even after their sugars come down to keep working on getting the acidosis reversed. We’ll just give them sugar to balance the process. Our secondary priority is going to be to replace the lost IV fluids. Remember they have polyuria and cellular dehydration, so we still need to address the fluid situation. We want to monitor their LOC and respiratory status during the treatment – remember they can get very tired with that heavy breathing or have some neuro changes, so we want to make sure we keep them safe. And we monitor electrolytes, specifically potassium, as well as our ABGs, glucose, and anion gap levels to know where we’re at and how they’re responding to treatment.

Our top nursing concepts for a patient with DKA are acid-base balance, glucose metabolism, and fluid & electrolytes. Check out the care plan attached to this lesson to see more detailed nursing interventions and rationales.

Let’s recap for DKA – It’s an acute exacerbation of Type 1 Diabetes where the body is breaking down fatty acids for energy instead of glucose – this causes ketones to buildup in the bloodstream, leading to a severe metabolic acidosis. Remember that’s a pH off less than 7.35 and a bicarb less than 22. This causes an altered LOC, deep, fast Kussmaul respirations, and hyperkalemia. The severe hyperglycemia causes a hyperosmolar state which pulls fluid out of the cells and into the bloodstream – causing severe cellular dehydration and osmotic diuresis. Our number one goal is to correct the acidosis through insulin therapy. That helps reverse the gluconeogenesis process so the body stops making ketoacids. Then, we’ll make sure we give IV fluids and monitor potassium levels. Insulin actually drives potassium INTO the cells, so with intensive insulin therapy, we can actually see their potassium levels drop significantly. So sometimes we’ll just add 20 mEq of KCl into their IV fluids to keep those levels up.

So those are the things you need to know for DKA – you’ll see in the HHNS lesson that they’re very similar, but the priorities are different, so check out that lesson as well. Don’t miss all the resources attached to this lesson, including a cheatsheet on the differences between DKA and HHNS. Now, go out and be your best selves today. And, as always, happy nursing!

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  • Question 1 of 10

A 25 year-old female with altered mental status and fruity breath has been brought into the ED. You believe this patient is likely in diabetic ketoacidosis (DKA). What is main concern for this patient?

  • Question 2 of 10

The nurse is caring for a client with diabetic ketoacidosis (DKA). The client suddenly becomes confused. Which of the following actions should the nurse perform first?

  • Question 3 of 10

A 45-year-old diabetic client has been brought in for care of diabetic ketoacidosis. The client’s blood glucose level is 367 mg/dL and blood pH is 7.28. Which of the following respiratory rates would the nurse most likely expect to see in this situation?

  • Question 4 of 10

A nurse is working with a client is brought in the emergency department with abdominal pain and dehydration. His glucose level is 388 mg/dL and he has positive serum ketones. Based on theses symptoms and lab values, which action would the nurse expect to perform first?

  • Question 5 of 10

A nurse is caring for a client who has developed diabetic ketoacidosis. The client has a breathing pattern in which he takes rapid and very deep breaths with large tidal volumes. Which of the following best describes this type of breathing?

  • Question 6 of 10

A patient has been diagnosed with diabetic ketoacidosis. You are reading through the patients lab work. What do you expect the patients pH level to be?

  • Question 7 of 10

The nurse working in the emergency department is receiving report. Out of the following group of clients, which would the nurse be concerned about developing hypovolemic shock?

  • Question 8 of 10

You are admitting a patient with diabetic ketoacidosis. She has a history of Type I diabetes. She has told you that she doesn’t know why this happened because she’s been taking really good care of herself and her blood sugars have been “really really good.” Which of the following assessment data leads you to question this statement?

  • Question 9 of 10

A nurse receives a client that came by ambulance. The nurse suspects that this client is in diabetic ketoacidosis (DKA). Which of the following signs would suggest DKA?

  • Question 10 of 10

A 25 year-old female with altered mental status and fruity breath has been brought into the ER. You know this patient is likely in Diabetic Ketoacidosis (DKA), which interventions will be included in the treatment of this patient? Select all that apply