DKA/HHNK Flashcards
1
Q
What is diabetes?
A
- Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from deficits of insulin
2
Q
What does insulin do?
A
Insulin helps lower the blood sugar by moving glucose from the blood into the muscle, liver, and fat
3
Q
DKA Pathophysiology
A
- Without insulin, the amount of glucose entering the cells decreases
- The liver produces and releases more glucose which causes elevated blood glucose
4
Q
How do the kidneys react during DKA?
A
They attempt to rid the body of the excess glucose along with water and electrolytes, so they excrete more fluid
- Results in:
- Loss of electrolytes
- Dehydration
- Results in:
5
Q
DKA - Acidosis
A
- It is metabolic acidosis
- The lungs try to compensate resulting in Kussmaul’s respirations (usually the first outward sign of DKA)
- Acidosis occurs when there is an increase in H+ production
6
Q
Causes of DKA
A
- Missed insulin doses
- Markedly inadequate amount of insulin
- Illness or infection
- Undiagnosed or untreated diabetes
7
Q
Who are increased risk for DKA?
A
- Chronic alcohol
- Drug abuse
- Mental illness
- African American
8
Q
Sick Day Rules
A
- Never omit insulin (cut long acting in half)
- Prevent dehydration and hypoglycemia (fluids every hour)
- Monitor blood sugar and ketones every 4 hours
- Provide supplemental fast acting insulin
- Treat underlying triggers
- Maintain contact with medical team
9
Q
Clinical Manifestations of DKA
A
- Polyuria
- Polydipsia
- Polyphagia
- Fatigue
- N/V
- Kussmauls
- Acetone fruity breath
- HA
- Extreme drowsiness
10
Q
Diagnostic Findings for DKA
A
- BG level 300-800 (but could be 250)
- Venous pH < 7.30 and bicarb of < 18 (tells how bad DKA is)
- Ketoacidosis is reflected in low serum bicarb and low pH
- Positive urine ketones
- Hyponatremia
- Hypokalemia
11
Q
pH ABG for Moderate DKA
A
7.15 - 7.25
12
Q
pH ABG for Severe DKA
A
Less than 7.15
** They need to be in the ICU!!!
13
Q
Nursing Assessment of DKA Patient
A
- Assess mucous membranes for dehydration
- Assess cardiac changes (ECG)
- Assess respiratory status (rapid, shallow breaths)
- Assess GI symptoms (N/V)
- Assess mental status (lethargy)
14
Q
DKA Treatment
A
- Correct dehydration
- Treat the hyperglycemia
- Correct the electrolyte loss
- Correct acidosis
15
Q
DKA Rehydration
A
- Draw labs first!!!!
- May need up to 6-10 L of fluid
- Normal saline is infused rapidly
- Frequent VS to be careful with BP
- Can lose 6-9 L of fluid
* Replace 50% of that in the first 24-36 hours
16
Q
DKA Electrolyte Concerns
A
- K is biggest concern
- Major loss of K from body stores
- K must be monitored frequently
- Cautious K replacement is vital to avoid dysrrhythmias
- CANNOT have insulin is K < 3.3 because insulin can cause a further drop in K (if it starts to drop, stop insulin!)
17
Q
DKA IV Insulin
A
- Initial bolus of 0.1 units/kg (ONE TIME)
- 0.1 units/kg/hr
- Once BG reaches 200-250, can decrease insulin by 50%
- SQ is effective but inferior to IV
- Insulin is given after fluids
- BG monitoring every hour to ensure it doesn’t drop too quickly
- Waste 20-50 mL so the insulin can have the initial adherence done
18
Q
When do we give bicarb to DKA patients?
A
- For a pH less than 6.9
- 100 mEq of sodium bicarb every 2 hours
- Giving bicarb is controversial but ADA continues to recommend it
19
Q
DKA Complications
A
- Infection
- Shock
- Vascular thrombosis
- Pulmonary edema
- Cerebral edema
- Hypoglycemia
20
Q
DKA Complications: Infection
A
- Precipitates DKA
- Fever
- Leukocytosis can be secondary to acidosis
21
Q
DKA Complications: Shock
A
If fluids does not improve it, then perform other tests to rule out an MI
22
Q
DKA Complications: Vascular Thrombosis
A
- Severe dehydration
- Cerebral vessels
- Occurs hours to days after DKA
23
Q
DKA Complications: Pulmonary Edema
A
Result of aggressive fluid resuscitation
24
Q
DKA Complications: Cerebral Edema
A
- First 24 hours
- Mental status changes
- Treat with Mannitol
- May require intubation with hyperventilation
25
How do you know when DKA is resolved?
1. Glucose is between 200-250
2. pH is > 7.3
3. Bicarb is > 15
* * Give intermediate insulin about 2 hours before terminating IV
26
HHNK
Hyperglycemic Hyperosmolar Nonketotic Coma
- Seen in Type 2 DM
- No ketones
- Usually evolves of several days to weeks
- Common in elderly
27
Why is HHNK common in the elderly?
1. Decreased fluids
2. Decreased kidney function
3. Increased sugar
28
Clinical Manifestations of HHNK
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Fatigue
5. Blood sugar > 600
6. Warm, dry skin
7. Hallucinations
8. Weakness on one side of body
9. NO KUSSMAULS
10. N/V less common
29
Diagnostic Findings for HHNK
1. Blood sugar > 600
2. pH > 7.3
3. Bicarb 20
4. CNS changes (degree related to serum osmolarity)
5. Dehydrated with high BUN and creatinine
30
HHNK Treatment
1. Fluids
2. Insulin
3. Monitor airway
4. Large bore IV to run fluids quickly
5. Brain can swell with rapid reduction
6. 24-48 hours to get back to normal levels (don't bring BG down too fast)
31
HHNK Fluid Resuscitation if patient has a normal BP
Use 0.45% NS
32
HHNK Fluid Resuscitation if patient is in shock or has severe hypotension
Use normal saline
33
HHNK Fluid Resuscitation Rate of IV
1. Initially 1 L/hr until BP and UOP are adequate
2. Then decrease to 100-200 mL/hr
3. Replace 1/2 fluid deficit in 12 hours
4. If LOC is not improving then you aren't giving them enough fluid!!
34
HHNK Fluid Resuscitation for CHF patients
Watch for fluid overload
35
HHNK Fluid Resuscitation for patients with kidney disease
Watch their respiratory status
36
If your HHNK patient's mental status declines what do you do?
Think cerebral edema!
| Give Mannitol
37
HHNK Complications
1. Stroke (from dehydration)
2. Cerebral edema (from BG being brought down too quickly)
3. Sepsis
38
HHNK Insulin Therapy
1. Initial bolus of 0.15 units per kg IV
2. Then, 0.1 units/kg/hr until BG is 250
* * Fluids first though!!!!
