DKA/HHS

Question 1

Acute Complications of Diabetes Mellitus

Answer 1

• Diabetic Ketoacidosis (DKA)
• Hyperosmolar hyperglycemic syndrome (HHS)
• Hypoglycemia

Question 2

Diabetic Ketoacidosis (DKA)

Answer 2

• Caused by profound deficiency of insulin
• Characterized by: Hyperglycemia, ketosis, acidosis, dehydration
• Most likely occurs in type 1
• When supply of insulin insufficient: glucose cannot be properly used for energy; Body breaks down fat stores - Ketones are by-products of fat metabolism, alter pH balance, causing metabolic acidosis, ketone bodies excreted in urine, electrolytes become depleted.
• Serious condition that must be treated promptly
• Depending on s/sx may or may not need hospitalization: in instances where fluid and electrolyte imbalances are not severe and blood glucose levels can be safely monitored at home, less severe forms of DKA may be managed on an outpatient basis.

Question 3

Precipitating Factors of Diabetic Ketoacidosis

Answer 3

• Illness
• Infection
• Inadequate insulin dosage
• Undiagnosed type 1
• Poor self-management
• Neglect

Question 4

Signs and Symptoms of Diabetic Ketoacidosis

Answer 4

• Lethargy/weakness: early symptoms
• Dehydration: poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension
• Abdominal pain: anorexia, vomiting
• Kussmaul respirations: rapid deep breathing, attempt to reverse metabolic acidosis, sweet fruity odor
• Laboratory findings include a blood glucose level >250 mg/dL (13.9 mmol/L), arterial blood pH <7.30, serum bicarbonate level <15 mEq/L (15 mmol/L), and moderate to large ketones in the urine or blood ketones.

Question 5

Nursing Interventions for DKA

Answer 5

• Airway Mgmt: oxygen administration
• Correct fluid/electrolyte imbalance: IV infusion 0.45% or 0.9% NaCl (Restore urine output, raise blood pressure); When blood glucose levels approach 250 mg/dL (5% dextrose added to regimen, prevent hypoglycemia); potassium replacement, sodium bicarbonate
• Insulin therapy: Withheld until fluid resuscitation has begun; bolus followed by insulin drip; Insulin allows water and potassium to enter the cell along with glucose and can lead to depletion of vascular volume and hypokalemia.

Question 6

Hyperosmolar Hyperglycemic Syndrome (HHS)

Answer 6

• Life-threatening syndrome
• Less common than DKA
• Often occurs in patients older than 60 years with type 2
• Patient has enough circulating insulin that ketoacidosis does not occur.
• Produces fewer symptoms in earlier stages
• Neurologic manifestations occur because of ↑ serum osmolality.
• Common causes of HHS in a patient with type 2 diabetes include infection of the urinary tract, pneumonia, sepsis, any acute illness, and newly diagnosed type 2 diabetes.
• Medical emergency
• High mortality rate
• Therapy similar to DKA: except HHS requires greater fluid replacement; once the patient is stabilized, attempts to detect and correct the underlying precipitating cause should be initiated.

Question 7

Risk Factors for HHS

Answer 7

• Usually history of: inadequate fluid intake, increasing mental depression, polyuria
• Laboratory values: Blood glucose >400 mg/dL, Increase in serum osmolality, absent/minimal ketone bodies

Question 8

Nursing Management of HHS

Answer 8

• Patient closely monitored
• Administration: IV fluids, insulin therapy, and electrolytes
• Assessment: Renal status, cardiopulmonary status, level of consciousness
• Signs of potassium imbalance
• Cardiac monitoring
• Vital signs

Question 9

Cardiac monitoring is initiated for a patient in diabetic ketoacidosis. The nurse recognizes that this measure is important to identify:

1. Dysrhythmias resulting from hypokalemia.
2. Fluid overload resulting from aggressive fluid replacement.
3. The presence of hypovolemic shock related to osmotic diuresis.
4. Cardiovascular collapse resulting from the effects of excess glucose on cardiac cells.

Answer 9

Answer: 1
Rationale: Electrolytes are depleted in diabetic ketoacidosis. Osmotic diuresis occurs with depletion of sodium, potassium, chloride, magnesium, and phosphate. Hypokalemia may lead to ventricular dysrhythmias such as premature ventricular complexes and bradycardia.