Diabetic Ketoacidosis Flashcards
What are signs and symptoms of hypoglycemia?
- Reduced cognition
- Tremors
- Diaphoresis
- Weakness
- Hunger
- Headache
- Irritability
- Seizure
What are signs and symptoms of hyperglycemia?
- Polyuria
- Polydipsia
- Dehydration
- Fatigue
- Fruity odor to breath
- Kussmaul breathing
- Weight loss
- Hunger
- Poor wound healing
What are the causes and characteristics of hyperglycemic crisis known as diabetic ketoacidosis?
- Results from absolute or relative deficiency in insulin
- Potentially severe, sometimes life-threatening
- Elevated total ketones (ketosis)
- Metabolic acidosis
- Uncontrolled hyperglycemia
What are clinical features of DKA?
- Hyperglycemia
- Dehydration and electrolyte loss
- Acidosis (Metabolic)
- Manifestations include polyuria, polydipsia, blurred vision, weakness, headache, anorexia, abdominal pain, nausea, vomiting, acetone breath, hyperventilation with Kussmaul respirations, and mental status changes
What are some patient and precipitating factors?
- Type 1 diabetes
- younger age (<45)
- non-white
- female
- infection
- severe stress (precipitates imbalance in glucose-insulin relationship)
- inadequate insulin dosing
- undiagnosed and untreated diabetes
- Alcohol abuse and certain drugs
What leads to metabolic acidosis in DKA?
- Lack of insulin leads to lipolysis, and the liver converts the free fatty acids into ketone bodies
- Ketone bodies are acids; their accumulation in circulation leads to metabolic acidosis
What are manifestations of hyperglycemia?
- Polyuria and polydipsia,
- blurred vision
- weakness
- headache,
- hypotension with a weak, rapid pulse (intravascular volume depletion)
What are manifestations of ketosis & acidosis?
- GI symptoms (anorexia, nausea, vomiting, and abdominal pain)
- Acetone breath (elevated ketones)
- Kussmaul Respirations (compensation for acidosis)
What are manifestations of osmotic diuresis?
- LOC changes
- Dehydration
- Elevated BUN & Creatinine
- Electrolyte Abnormalities
What does osmotic diuresis lead to?
Polyuria, then dehydration, and marked electrolyte loss
How do you assess for DKA?
- Blood glucose levels vary between 16.6 mmol/L and 44.4 mmol/”
- Severity of DKA is not related to blood glucose level
- Electrolytes vary according to water loss and level of hydration
- Ketosis
- Ketone bodies in blood and urine
- Anion gap, nausea and vomiting
- Low serum bicarbonate and low pH (6.8 - 7.3)
- May have low PCO2 (reflects respiratory compensation through Kussmaul breathing)
What are some strategies to prevent DKA when person with diabetes is ill?
- Don’t eliminate insulin with nausea and vomiting
- When ill, try to take fluids in q 1 h and test blood glucose and urine ketones q 3-4 h
Ketosis – Which imbalance is it?
metabolic acidosis
What is the nurse’s role in caring
for the patient with DKA?
- Monitoring fluid and electrolyte status and CBGs
- Administer fluids, insulin and other medications
- Prevent fluid overload
- Monitor urine ourput
- Monitor ECG for dysrhythmias
- Vital signs, arterial blood gases (documentation)
- Assess underlying cause
- Patient education
What treatment is involved with DKA?
Rehydrate with IV fluid (may need 6-10 L of fluid; usually give normal saline initially, then 1/2 saline; eventually give D5W with insulin)
Reverse acidosis and restoration of electrolyte balance
Continuous IV infusion of regular insulin
Note: Rehydration leads to increased plasma volume and decreased K+; insulin enhances the movement of K+ from extracellular fluid into the cells
What type of insulin is used in the IV insulin?
Regular insulin
What are some collaborative interventions for DKA and who might the nurse collaborate with?
- Restore intravascular fluid volume
- Correct electrolyte imbalances
- Clear ketones and correct acidosis
- Normalize serum glucose
- Closely monitor patient’s status
- Identify precipitating cause
- Prevent further complications
May collaborate with:
* physician
* nutritionist
* lab
* social worker
* pharmacist
* diabetes educator
What is the major electrolyte of concern with DKA?
Potassium
Why is potassium a major concern is DKA?
- Loss from body stores and intracellular to extracellular shift can cause rapid changes
- Serum level drops during treatment as potassium reenters the cells
- Cautious but timely potassium replacement is vital to avoid dysrrhythmias related to hypokalemia
What is involved in insulin therapy during a DKA crisis?
Continuous Low-dose Intravenous Insulin Infusion
Only regular insulin administered intravenously
Insulin binds to polyvinylchloride in I V bags and tubing, lowering insulin concentration in fluid
One form of insulin, Velosulin, buffered with phosphate, which prevents insulin from binding to plastic tubing
Blood glucose levels must be monitored frequently
Insulin reverses acidosis related to DKA; it inhibits fat breakdown, ending ketone production and acid build up
Insulin often infused separately from the rehydration solutions to allow frequent rate changes
It is a continuous infusion to prevent reaccumulation of ketone bodies and worsening acidosis
Which drugs are precipitating factors in DKA?
thiazide diuretics, corticosteroids, pentamidine, sympathomimetic agents
Does DKA cause a high or low anion gap?
High anion gap
Which of the following is not a sign or symptom of Diabetic Ketoacidosis?
A. Positive Ketones in the urine
B. Oliguria
C. Polydipsia
D. Abdominal Pain
B. Oliguria
Oliguria means low urinary output….in DKA you have high urinary ouput
A patient is admitted with Diabetic Ketoacidosis. The physician orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient’s labs are the following: pH 7.25, Glucose 455, potassium 2.5. Which of the following is the most appropriate nursing intervention to perform next?
A. Start the IV fluids and administer the insulin bolus and drip as ordered
B. Hold the insulin and notify the doctor of the potassium level of 2.5
C. Hold IV fluids and administer insulin as ordered
D. Recheck the glucose level
B. Hold the insulin and notify the doctor of the potassium level of 2.5
What advice would you provide to prevent DKA in an ill patient/patient with infection?
- Don’t eliminate insulin with nausea and vomiting
- Take in fluid q 1 h
- Test blood glucose and urine ketones q 3-4 hours
