What is the medical and nursing management for a patient with diabetic ketoacidosis?

How do I care for a patient with diabetic ketoacidosis?

Sally May Miller is director of the skills and simulation lab at Vanderbilt University School of Nursing in Nashville, Tenn. Clinical Queries is coordinated by Joan E. King, RN,C, ACNP, ANP, PhD, program director for the acute care nurse practitioner program at Vanderbilt University and a member of the Nursing2009 editorial advisory board.

Our medical unit is caring for more patients with diabetic ketoacidosis (DKA). What's the focus of treatment for these patients?—O.R., FLA.

NCLEX review on Diabetic Ketoacidosis for nursing lecture exams and the NCLEX exam. DKA is a life-threatening condition of diabetes mellitus.

It is important to know the differences between diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) because the two complications affect the diabetic patient. However, there are subtle difference between the two conditions.

Don’t forget to take the DKA Quiz.

In these notes you will learn about:

• Key Player of DKA
• Causes of DKA
• Signs and Symptoms of DKA
• Nursing Interventions of DKA

Lecture on Diabetic Ketoacidosis

Define: a complication of diabetes mellitus that is life-threatening, if not treated. It is due to the breakdown of fats which turn into ketones because there is no insulin present in the body to take glucose into the cell. Therefore, you will see hyperglycemia and ketosis and acidosis.

Key Players of DKA:

Glucose: fuels the cells so it can function.  However, with DKA there is no insulin present to take the glucose into the cell…so the glucose is not used and the patient will experience hyperglycemia >300 mg/dL.

Insulin: helps take glucose into the cell so the body can use it for fuel. In DKA, the body isn’t receiving enough insulin…so the GLUCOSE can NOT enter into the cell. The glucose floats around in the blood and the body starts to think it is starving because it cannot get to the glucose. Therefore, it looks elsewhere for energy.

Liver & Glucagon: the body tries an attempt to use the glucose stores in the liver (because it doesn’t know there is a bunch of glucose floating around in the blood and thinks the body is experiencing hypoglycemia).  In turn, the liver releases glucagon to turn glycogen stores into more GLUCOSE….so the patient becomes even more hyperglycemic.

Ketones: a byproduct of fat break down. In DKA, the body needs FUEL to function so it starts to break down FATS since it cannot use the glucose in the body. The patient will experience increased ketones in the body which are LIFE-THREATENING to a diabetic patient because it causes the blood to become acidic (metabolic acidosis)

Kidneys: plays a role in reabsorbing glucose in the renal tubules. However, there is too much glucose present in the blood and it cannot be reabsorbed.  So,  it leaks into the urine and this causes OSMOTIC DIURESISwhich causes polyuria and excretion of electrolytes (sodium,potassium, chloride)

Happens mainly in TYPE 1 Diabetics…rare in type 2 but possible if they are experiencing a severe illness.

Causes of DKA

• Undetected diabetes: patient doesn’t know they are diabetic and this is the first sign, usually.
• More Insulin needed by the body than normal: the body needs more units of insulin than it is actually receiving from injections.
  • Example: when a diabetic become sick (INFECTION) with illness or recovering from surgery or experiences some type of stress on the body like certain drugs such as, corticosteroids or thiazide diuretics.
• Not eating (skipping meals): body starts to go into “starvation” mode and begins to burn ketones (normally in nondiabetics when the body goes into starvation mode it can cope when ketones are released by regulating insulin and glucagon to maintain sugar levels…but in the diabetic they don’t have that ability and ketones production is dangerous).
• Not taking insulin as scheduled: therefore the blood glucose levels are not controlled…ketones are produced and the cycle of acidosis starts to take place in the body.

Signs & Symptoms of Diabetic Ketoacidosis:

Recap of what is going on:

• Hyperglycemia (intracellular to extracellular shifting takes place which will lead to electrolyte imbalances)
• Ketones in the blood (leads to metabolic acidosis, weight loss because of all the fat burning, electrolyte shifting as well)
• Metabolic Acidosis (blood pH <7.35 and HCO3 <15 mEq/L)

Happens suddenly (there may be warning signs present if the patient is monitoring their blood glucose which will be elevated consistently (>300 mg/dL)

• Polyuria: due to the extreme levels of glucose in the body that causes the water inside the cells to shift to the extracellular area. The kidneys try to compensate by increasing urinary production to eliminate this extra fluid but the kidneys cannot reabsorb all the glucose so it leaks into the urine. This causes OSMOTIC DIURESIS which causes SODIUM AND POTASSIUM (along with calcium, phos) TO BE EXCRETED.

*NOTE potassium levels typically stay normal or elevated in DKA because of the shifting of potassium from the inside of the cell to the outside BUT WHEN TREATMENT STARTS TO BE INITATED WITH INSULIN IT WILL CAUSES THE K+ TO MOVE BACK INTO THE CELL. Therefore, you have to watch POTASSIUM LEVELS closely during treatment.

• Polydipsia: frequent drinking due to extreme thirst….vicious cycle of frequent urination and the body is trying to keep itself hydrated.
• Dehydration: dry mucous membranes, decreased skin turgor (the extreme drinking doesn’t work)
• Nausea & vomiting, Abdominal pain-> (especially children…causes not 100% known but could be due to the ketones present in the blood)
• Kussmaul Breathing: due to metabolic acidosis….the respiratory system tries to compensate by getting rid of extra acid in the body by blowing off carbon dioxide which is an acid…this is rapid deep breathing
• Acetone Smell of the Breath “fruity”: due to the breakdown of ketones
• Ketones present in the urine
• Tachycardia, hypotension, confusion, fatigue

Nursing Interventions of DKA

*Get treatment early because DKA is fatal*

Teach patient early signs and when to seek treatment:

• Monitor glucose and ketones during illness every 4 hours, especially if dealing with illness/infection
• If vomiting and cannot eat food or drink liquids notify doctor (if can tolerate drink liquids every hour)
• Notify medical doctor if blood sugars are higher than normal or greater than 300 mg/dL consistently
• Ketones present in the urine
• Excessive thirst, frequent urination, abdominal pain, nausea and vomiting, acetone breath

Treatment of DKA

Goal: Hydrate, decrease blood glucose, monitor Potassium level and cerebral edema (esp. in children), correct acid-base imbalance

• Administering IV fluids: (depending on MD order) such as 0.9% normal saline (start out with a bolus of this) and progress with 0.45% NS to hydrate the cells (depends on how dehydrated the patient is)
  • 5% dextrose may be added to the 0.45% NS when glucose is around 250 to 300 mg/dL. This will help gradually bring the blood sugar down and help the insulin do its job by removing the ketones.
• Administered insulin: REGULAR (only type given IV) and make sure K+ is normal >3.3
  • Typically started out by giving unit IV bolus…then start an infusion (checking blood glucoses around the clock…hospital protocols)…you will be titrating the insulin base on blood glucose checks.
    • NOTE: if you rapidly bring a patient’s blood glucose down (or up) the brain can’t cope and water will be moved from the blood to the CSF and you will get cerebral edema and increased intracranial pressure

Tip for insulin administration: when priming tubing for insulin infusion waste 50cc to 100cc (per institution protocol) because insulin absorbs into the plastic lining of the tubing.

• Watch potassium levels very closely because insulin causes K+ to move back into the cell
• Administer Potassium solution IV to combat this….note renal function before administering.