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Transcript of Diabetes Ketoacidosis
Clinical Manifestations :
Polyuria and polydipsia (increased thirst).
Blurred vision, weakness, and headache.
Orthostatic hypotension in patients with volume depletion.
Frank hypotension with weak, rapid pulse.
Gastrointestinal symptoms, such as anorexia, nausea/vomiting, and abdominal pain (may be severe).
Acetone breath (fruity odor).
Kussmaul respirations: hyperventilation with very deep, but not labored, respirations.
Mental status varies widely from patient to patient (alert to lethargic or comatose)
Diagnostic Findings :
Blood glucose levels may vary from 300 to 800 mg/dL (16.6 to 44.4 mmol/L).
Evidence of ketoacidosis is reflected in low serum bicarbonate (0 to 15 mEq/L) and low pH (6.8 to 7.3) values. A low PCO2 level (10 to 30 mm Hg) reflects respiratory compensation
for the metabolic acidosis.
Sodium and potassium levels may be low, normal, or high, depending on the amount of water loss (dehydration).
Elevated levels of creatinine, blood urea nitrogen (BUN), hemoglobin,and hematocrit may also be seen with dehydration.
Sick Day Rules
In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis.
DKA is caused by an absence or markedly inadequate amount of
insulin. This deficit in available insulin results in disorders in the
metabolism of carbohydrate, protein, and fat. The three main
clinical features of DKA are:
Nursing Diagnosis and Interventions:
The most important issue to teach patients is not to eliminate insulin doses when nausea and vomiting occur.
Drinking fluids every hour is important to prevent dehydration.
Blood glucose and urine ketones must be assessed every 3 to 4 hours.
Diabetes self-management skills (including insulin administration and blood glucose testing) should be assessed to ensure that an error in insulin administration or blood glucose testing did not occur.
Three main causes of DKA are
1. decreased or missed dose of insulin,
2. illness or infection, and undiagnosed
3. untreated diabetes
(DKA may be the initial manifestation of diabetes).
The major electrolyte of concern during treatment of DKA is
• Rehydration, which leads to increased plasma volume and subsequent decreases in the concentration of serum potassium.
Rehydration also leads to increased urinary excretion of potassium.
• Insulin administration, which enhances the movement of potassium from the extracellular fluid into the cells.
• Dehydration and electrolyte loss
In DKA there
is excessive production of ketone bodies because of the lack of insulin
that would normally prevent this from occurring. Ketone
bodies are acids; their accumulation in the circulation leads to
Patients may need up to 6 to 10 liters of IV fluid to replace fluid losses caused by polyuria, hyperventilation, diarrhea, and vomiting.
Monitoring fluid volume status involves frequent measurements
of vital signs (including monitoring for orthostatic changes in blood pressure and heart rate), lung assessment, and monitoring
intake and output.
Measurements of potassium are necessary during the first 8 hours of treatment. Potassium replacement is withheld
only if hyperkalemia is present or if the patient is not urinating.
Acidosis is reversed with insulin.
Step 1 :
Insulin (regular) is infused at a slow, continuous rate .
Step 2 :
IV fluid solutions with higher concentration of glucose, such NS solns. , are administered when blood glucose levels reach 250 to 300 mg/dl.
Step 3 :
IV insulin must be infused continuously until subcutaneous administration of insulin can be resumed.
Fluid and Electrolyte imbalance r/t fluid loss or shifts.
Maintaining Fluid and Electrolyte Balance
• Measure intake and output.
• Administer IV fluids and electrolytes as prescribed;
encourage oral fluid intake when permitted.
• Monitor laboratory values of serum electrolytes (especially sodium and potassium).
• Monitor vital signs hourly for signs of dehydration (tachycardia, orthostatic hypotension) along with assessment of
breath sounds, level of consciousness, presence of edema, and cardiac status (ECG rhythm strips).
Other Nursing Diagnosis :
Risk for fuid volume deficit related to polyuria and dehydration.
Deficient knowledge about diabetes self-care
Anxiety related to loss of control, fear of inability to manage diabetes, misinformation related to diabetes, fear of diabetes complications