DKA

Question 1

Pathophysiology of DKA

Answer 1

Environment, infection, emotional stressor
⬇️
Lack of insulin
⬇️
Breakdown of fat in cells, glycogen to glucose, protein.
⬇️
Hyperglycemia 
⬇️
Osmotic diuresis
⬇️
Dehydration 
⬇️
Hyperosmolarity hemoconcentration 
⬇️
Acidosis
⬇️
Coma

Question 2

S/S of DKA

Answer 2

• kussmaul respirations
• fruity breath
• N/V
• abdominal pain
• AMS
• shock
• malaise
• polyuria, polydipsia, polyphagia
• wt. loss
• stuporous
• COMA

-dehydration: flushed dry skin, sunken eyes, ⬇️ skin turgor, hypotension, tachycardia, dry mucous membranes.

Question 3

Difference between hypoglycemia & hyperglycemia?

Answer 3

Hot and dry, sugar high

Cold and clammy, give ‘em candy

Question 4

Clinical criteria for Diagnosis of DKA

Answer 4

🔹Serum glucose: >300

🔹Ketones: + at 1:2 dilutions

🔹pH: 7.30 mg/dL (⬆️ because dehydration)

Creatinine: >1.5 mg/dL (⬆️ dehydration)

Question 5

What electrolyte drops rapidly after initial treatment of DKA?

Answer 5

Serum potassium levels drops rapidly

Question 6

Nuemonic for treatment of DKA

Answer 6

No- NS

Kidding- K+

Insulin

Always- Antibiotics

Helps- HCO3

Question 7

When do you change fluids from NS to 5% dextrose & why?

Answer 7

Serum glucose reaches 250mg/

Prevents pt from becoming HYPOglycemic & cerebral edema, which can occur when serum osmolarity declines too rapidly

We want to keep sugar between 150-200
Until metabolic control is established.

Question 8

VS for DKA

Answer 8

Every 15 min until stable.

Urine output, temp, mental status q1h

Question 9

Nursing priorities for DKA

Answer 9

-blood glucose management

-fluid & electrolytes
D5W or D10W when glucose 150-250

-drug therapy
To lower glucose 50-75 mg/dL/hr
Initial IV bolus 0.1 unit/kg/hr

-acidosis management
Hyperkalemia common w/hyperglycemia
Insulin therapy, & correction of acidosis & volume expansion decrease K+ concentration

Question 10

To prevent hypokalemia we…

Answer 10

Administer K+ replacement after serum levels are normal.

Hypokalemia can cause fatal cardiac dysrhythmias

Question 11

What insulin can be given IV?

Answer 11

Regular insulin

ONLY insulin that can be given IV

Assess blood glucose q1h

Question 12

When can we switch to sub Q insulin?

Answer 12

When pt is taking an oral fluids & keypads has stopped.

Question 13

Criteria for resolution of DKA?

Answer 13

Blood glucose 18 mEq/L
pH: >7.3
Calculated ion gap:

Question 14

S/S hypokalemia

Answer 14

• Fatigue
• malaise
• confusion
• muscle weakness
• shallow respirations
• abdominal distention or paralytic ileus
• hypotension
• weak pulse

Question 15

When is bicarbonate used in DKA?

Answer 15

Only with severe acidosis.
Can reverse acidosis too rapidly & lead to sever hypokalemia, which can cause fatal cardiac dysrhythmias

Given slow IV over several hours when pH

Question 16

Patient/family teaching to prevent DKA

Answer 16

Check FSBS q4-6h when anorexia, N/V present. & as long as FSBS are >250

Reduce risk of dehydration by maintaining food & fluid intake. (3L/day) unless contraindicated

When nausea present drink fluid with glucose & electrolytes (soda, Gatorade, diluted fruit juice)

When FSBS normal or elevated drink 8-12 oz
of cal-free, caffeine-free liquids q1h while awake to prevent dehydration

DO NOT STOP TAKING INSULIN WHEN SICK!

Question 17

Call provider when….

Answer 17

• persistent N/V
• moderate or large ketones
• blood glucose elevation after two supplemental doses of insulin
• high (101.5 temp) or increasing, or fever lasting >24hrs

Question 18

Hyperglycemic-hyperosmolar state

HHS

Answer 18

Gradual onset (days-weeks)
Precipitated by: infection, stressors, poor fluid intake

Manifestations:
AMS, dehydration or electrolyte loss like DKA

Labs-
Glucose: >600
pH: >7.4
HCO3: >20

(pH & HCO3 opposite of DKA)

BUN: ⬆️
Creatinine: ⬆️
Hct: ⬆️
Ketones: negative
K+ & phosphorus:⬇️

Question 19

Monitor for complications to DKA

Answer 19

Fluid volume overload
Hypoglycemia
Hypo/hyperkalemia 
Hyponatremia
Cerebral edema
Infection

Question 20

Who is affected by HHS?

Answer 20

Deadly complication of type 2 DM

Question 21

Who is at risk for DKA?

Answer 21

Most often type 1 DM.
Can occur in type 2.

Environment, infection, or emotional stressor
⬇️
Lack of insulin

Question 22

Management of HHS

Answer 22

Same as DKA except:

Start D5W when glucose reaches 300

Question 23

Fluid overload s/s

Answer 23

• Elevated CVP
• tachycardia
• bounding pulse
• tachypnea
• lung crackles
• JVD

Question 24

Factors that differentiate DKA & HHS

Answer 24

• level of hyperglycemia
• amount of ketones
• serum bicarbonate levels

Question 25

Human lispro injection

Answer 25

Rapid acting

Onset: 15 min

Peak: 30-90 min

Duration: 5 hrs

Question 26

Regular insulin

Answer 26

Short acting

Onset: 30 min

Peak: 2-4 hr

Duration: 5-7 hr

When given IV half-life is 4 min

Question 27

What is hyperglycemia?

Answer 27

Too much sugar in blood.
Not enough insulin to “chaperone” glucose into cells.

Glucose is just free floating in blood

Body thinks it does not have enough glucose so it breaks down glucagon to create glucose

Question 28

How are insulin & K+ relevant to each other?

Answer 28

Insulin allows K+ to move inside cell.

Have to watch K+ closely can shift quickly

Question 29

What do you always make sure a patient is doing before K+ administration?!

Answer 29

Pee before K+

Question 30

What drug is given in cerebral edema occurs?

Answer 30

Mannitol

Osmotic diuretic

Question 31

When do you test urine for ketones?

Pt education

Answer 31

When FSBS >240

Question 32

BRAT diet

Answer 32

Bananas
Rice
Applesauce
Toast

Question 33

Key & lock

Answer 33

Insulin is the “key” that’s opens “locked” membranes to glucose.
Allowing glucose in the blood to move into cells to generate energy