DKA Flashcards
Pathophysiology of DKA
Environment, infection, emotional stressor ⬇️ Lack of insulin ⬇️ Breakdown of fat in cells, glycogen to glucose, protein. ⬇️ Hyperglycemia ⬇️ Osmotic diuresis ⬇️ Dehydration ⬇️ Hyperosmolarity hemoconcentration ⬇️ Acidosis ⬇️ Coma
S/S of DKA
- 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.
Difference between hypoglycemia & hyperglycemia?
Hot and dry, sugar high
Cold and clammy, give ‘em candy
Clinical criteria for Diagnosis of DKA
🔹Serum glucose: >300
🔹Ketones: + at 1:2 dilutions
🔹pH: 7.30 mg/dL (⬆️ because dehydration)
Creatinine: >1.5 mg/dL (⬆️ dehydration)
What electrolyte drops rapidly after initial treatment of DKA?
Serum potassium levels drops rapidly
Nuemonic for treatment of DKA
No- NS
Kidding- K+
Insulin
Always- Antibiotics
Helps- HCO3
When do you change fluids from NS to 5% dextrose & why?
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.
VS for DKA
Every 15 min until stable.
Urine output, temp, mental status q1h
Nursing priorities for DKA
-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
To prevent hypokalemia we…
Administer K+ replacement after serum levels are normal.
Hypokalemia can cause fatal cardiac dysrhythmias
What insulin can be given IV?
Regular insulin
ONLY insulin that can be given IV
Assess blood glucose q1h
When can we switch to sub Q insulin?
When pt is taking an oral fluids & keypads has stopped.
Criteria for resolution of DKA?
Blood glucose 18 mEq/L
pH: >7.3
Calculated ion gap:
S/S hypokalemia
- Fatigue
- malaise
- confusion
- muscle weakness
- shallow respirations
- abdominal distention or paralytic ileus
- hypotension
- weak pulse
When is bicarbonate used in DKA?
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
Patient/family teaching to prevent DKA
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!
Call provider when….
- 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
Hyperglycemic-hyperosmolar state
HHS
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:⬇️
Monitor for complications to DKA
Fluid volume overload Hypoglycemia Hypo/hyperkalemia Hyponatremia Cerebral edema Infection
Who is affected by HHS?
Deadly complication of type 2 DM
Who is at risk for DKA?
Most often type 1 DM.
Can occur in type 2.
Environment, infection, or emotional stressor
⬇️
Lack of insulin
Management of HHS
Same as DKA except:
Start D5W when glucose reaches 300
Fluid overload s/s
- Elevated CVP
- tachycardia
- bounding pulse
- tachypnea
- lung crackles
- JVD
Factors that differentiate DKA & HHS
- level of hyperglycemia
- amount of ketones
- serum bicarbonate levels
Human lispro injection
Rapid acting
Onset: 15 min
Peak: 30-90 min
Duration: 5 hrs
Regular insulin
Short acting
Onset: 30 min
Peak: 2-4 hr
Duration: 5-7 hr
When given IV half-life is 4 min
What is hyperglycemia?
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
How are insulin & K+ relevant to each other?
Insulin allows K+ to move inside cell.
Have to watch K+ closely can shift quickly
What do you always make sure a patient is doing before K+ administration?!
Pee before K+
What drug is given in cerebral edema occurs?
Mannitol
Osmotic diuretic
When do you test urine for ketones?
Pt education
When FSBS >240
BRAT diet
Bananas
Rice
Applesauce
Toast
Key & lock
Insulin is the “key” that’s opens “locked” membranes to glucose.
Allowing glucose in the blood to move into cells to generate energy
