DIABETIC KETOACIDOSIS DKA is an acute complication of diabetes mellitus (usually type 1 diabetes) characterized by hyperglycemia, ketonuria, acidosis, and

dehydration. Pathophysiology and Etiology Insulin deficiency prevents glucose from being used for energy, forcing the body to metabolize fat for fuel. Free fatty acids, released from the metabolism of fat, are converted to ketone bodies in the liver. Ketone bodies are organic acids that cause metabolic acidosis. Increase in the secretion of glucagon, catecholamines, growth hormone, and cortisol, in response to the hyperglycemia caused by insulin deficiency, accelerates the development of DKA. Osmotic diuresis caused by hyperglycemia creates a shift in electrolytes, with losses in potassium, sodium, phosphate, and water. Caused by inadequate amounts of endogenous or exogenous insulin through: o Taking too little insulin o Skipping doses of insulin o Inability to meet an increased need for insulin created by injury. Trauma, pregnancy, stress, puberty or infection o Developing insulin resistance through the presence of insulin antibodies

Lack of Insulin

utilization of glucose by muscles, fats & liver production of glucose by liver Hyperglycemia

breakdown of fat

fatty acids

ketone bodies

Blurred vision

Polyuria

acetone breath poor apettite nausea n/v abdominal pain

Acidosis

Dehydration

increasingly rapid respirations

Weakness Headache

(thirst (polydipsia

Clinical Manifestations Early Polydipsia, polyuria Fatigue, malaise, drowsiness Anorexia, nausea, vomiting Abdominal pain, muscle cramps Later Kussmaul's respirations (deep respirations) Fruity, sweet breath Hypotension, weak pulse Stupor and coma Diagnostic Evaluation Serum glucose level is usually elevated over 300 mg/dL; may be as high as 1,000 mg/dL. Serum and urine ketone bodies are present. Serum bicarbonate and pH are decreased due to metabolic acidosis, and partial pressure of carbon dioxide is decreased as a respiratory compensation mechanism.

Serum sodium and potassium levels may be low, normal, or high due to fluid shifts and dehydration, despite total body depletion. BUN, creatinine, hemoglobin, and hematocrit are elevated due to dehydration. Urine glucose is present in high concentration and specific gravity is increased, reflecting osmotic diuresis and dehydration. Nursing Alert: Severity of DKA cannot be determined by serum glucose levels; acidosis may be prominent with glucose level of 200 mg/dL or less. Management I.V. fluids to replace losses from osmotic diuresis, vomiting. I.V. insulin dripregular insulin infused only to increase glucose utilization and decrease lipolysis. Electrolyte replacementsodium chloride and phosphate as required, potassium chloride and bicarbonate based on laboratory results. Complications Premature discontinuation of I.V. insulin can result in prolongation of DKA. Too-rapid infusion of I.V. fluids in cases of severe dehydration can cause cerebral edema and death. Failure to institute subcutaneous insulin injections before discontinuation of I.V. insulin can result in extended hyperglycemia. Nursing Assessment Assess skin for dehydrationpoor turgor, flushing, dry mucous membranes. Observe for cardiac changes reflecting dehydration, metabolic acidosis, and electrolyte imbalancehypotension; tachycardia; weak pulse; electrocardiographic changes, including elevated P wave, flattened T wave or inverted, prolonged QT interval. Assess respiratory statusKussmaul's respirations, acetone breath characteristic of metabolic acidosis. Perform GI assessmentnausea, vomiting, extreme thirst, abdominal bloating and cramping, diarrhea. Determine GU symptomsnocturia, polyuria. Observe for neurologic signscrying, restlessness, twitching, tremors, drowsiness, lethargy, headache, decreased reflexes. Interview family or significant other regarding precipitating events to episode of DKA. o Patient self-care management before hospitalization o Unusual events that may have precipitated episode (eg, chest pain, trauma, illness) Nursing Diagnoses Deficient Fluid Volume related to hyperglycemia Ineffective Therapeutic Regimen Management related to failure to increase insulin during illness Nursing Interventions Restoring Fluid and Electrolyte Balance Assess BP and heart rate frequently, depending on patient's condition; assess skin turgor and temperature. Monitor intake and output every hour. Replace fluids, as ordered, through peripheral I.V. line. Monitor urine specific gravity to assess fluid changes. Monitor blood glucose frequently. Assess for symptoms of hypokalemiafatigue, anorexia, nausea, vomiting, muscle weakness, decreased bowel sounds, paresthesia, arrhythmias, flat T waves, ST-segment depression. Administer replacement electrolytes and insulin as ordered. Flush the entire I.V. infusion set with solution containing insulin and discard the first 50 mL because plastic bags and tubing may absorb some insulin and the initial solution may contain decreased concentration of insulin. Monitor serum glucose, bicarbonate, and pH levels periodically. Provide reassurance about improvement of condition and that correction of fluid imbalance will help reduce discomfort. NURSING ALERT: Electrolyte levels may not reflect the total body deficit of potassium (primarily) and sodium (to a lesser extent) due to compartment shifts and fluid volume loss. Replacement is necessary despite normal to high values. DRUG ALERT: Interruption in insulin administration may result in reaccumulation of ketone bodies and worsening acidosis. Glucose will normalize before acidosis resolves, so I.V. insulin is continued until bicarbonate levels normalize and subcutaneous insulin takes effect and the patient starts eating. Preventing Further Episodes of DKA Review with patients precipitating events and causes of DKA.

Assist patient in identifying warning signs and symptoms of DKA. Instruct patient in sick-day guidelines. Patient Education and Health Maintenance Make sure that patient and caretakers can demonstrate drawing up and administering insulin in the proper dose, blood glucose monitoring, and urine ketone testing. Make sure that patient and caretakers know whom to notify in the event of hyperglycemia, stressful situation, or symptoms of DKA. Evaluation: Expected Outcomes BP and heart rate stable; glucose and bicarbonate levels improving Verbalizes sick-day guidelines correctly