- It is primarily associated with type 1 diabetes mellitus.
- Diabetic ketoacidosis (DKA) is a state of uncontrolled hyperglycemia due to insulin insufficiency.
- Insulin is a hormone that drives glucose into the cells for energy use.
- In DKA, this process is compromised, leaving glucose in the blood while the cells are starved.
- In response to this cell starvation of glucose, the body exhibits compensatory mechanisms that lead to the clinical picture of DKA.
- Overproduction of glucose in an attempt to feed cells more glucose → hyperglycemia
- Kidneys are no longer able to reabsorb glucose molecules back into the body; as a result, glucose stays in the kidney tract pulling molecules such as sodium, potassium, and water molecules into the kidney tract via osmosis; kidneys excrete more water, glucose molecules, sodium and potassium in urine → osmotic diuresis → polyuria (excessive urination), glycosuria (glucose in the urine) dehydration, polydipsia (excessive thirst)
- Alternative energy production via fat metabolism (lipolysis) instead of glucose metabolism (glycogenolysis) → ketone bodies; Excessive ketones lead to
- Characteristic sweet breath
- Ketone bodies are acidic and, in large amounts, cause metabolic acidosis; the body now tries to compensate for metabolic acidosis by breathing off CO2 → Kussmaul breathing (deep, labored breathing).
- The movement of hydrogen ions into cells and potassium out of the cells is another compensatory mechanism for ketoacidosis and causes hyperkalemia.
- Environmental stressors
- Mismanagement of insulin treatment
- Infectious process
- Emotional stressors
- New onset of diabetes
- Cardiovascular disease
Signs & Symptoms
- Deep, fast respirations (Kussmaul respirations)
- Increased thirst (polydipsia)
- Polyphagia (extreme hunger)
- “Fruity” breath
- Frequent urination
- Nausea and vomiting
- Abdominal pain
- Weakness, fatigue, lethargy
- Dry skin
- Blood testing
- Serum glucose to determine hyperglycemia (>300 mg/dL)
- Positive for serum ketones
- BUN >30 mg/L
- Creatinine > 1.5 mg/L
- Serum sodium varies
- Serum potassium high during acidosis; low during rehydration and insulin treatment
- Arterial blood gas to determine acidosis
- Serum pH <7.35
- Serum bicarbonate <15 mEq/L
- Urinalysis positive for ketones
- Blood glucose control
- Fluid and electrolyte management
- Correction of acidosis and ketosis
Nursing Diagnosis for DKA
|Ineffective Breathing Pattern r/t deep, fast breathing as a compensatory mechanism of metabolic acidosis |
Deficient Fluid Volume r/t increased urination and vomiting
Imbalanced Nutrition: Less Than Body requirements r/t body’s inability to use glucose; nausea; vomiting
Deficient Knowledge r/t new onset of diabetes mellitus
Nursing Care Plans for Diabetic Ketoacidosis (DKA)
Ineffective Breathing Pattern r/t deep, fast respirations secondary to compensation of metabolic acidosis
Expected Outcome: The patient will have respirations within the normal range with a corrected metabolic profile.
|Perform a rapid assessment within the ABC (airway, breathing, circulation) framework, and assess level of consciousness. |
Patients in DKA are considered emergent cases. They may be conscious or unconscious, and therefore, not be able to protect their airway. This initial assessment allows nurses to identify immediate life-threatening issues.
|Count respirations and note characteristics.|
Patients in DKA exhibit fast and labored respirations. This heavy breathing is a compensatory mechanism to breathe out excess carbon dioxide to decrease acidosis.
|Obtain necessary laboratory work to treat DKA. Such lab work includes|
Fingerstick blood glucose
Arterial blood gas
BUN and creatinine
Serum ketones or urinalysis with a dipstick to measure ketones in the urine
Lab work helps identify the severity of DKA and guides treatment. Patients in DKA typically present with serum glucose above 300 mg/ dL, positive serum ketones, a serum pH of less than 7.35, a bicarbonate level of less than 15 mEq/L, increased BUN and creatinine (dehydration), high potassium, a positive ketone urine test, and an increased anion gap. Sodium levels may vary.
|Initiate a continuous intravenous insulin infusion as per order to lower serum glucose levels. |
Regular IV insulin has a rapid onset and takes effect much faster than intramuscular or subcutaneous insulin. Therefore, patient’s blood glucose levels should be checked every hour if they are on an insulin drip. Treatment is essential because it helps tissues use insulin to drive glucose into the tissue cells. This process decreases compensatory mechanisms such as increased glucose production and ketogenesis (which cause metabolic acidosis and dehydration).
|Monitor potassium levels frequently during treatment and replace as ordered. |
As glucose levels, acidosis, ketosis, and fluid status improve, potassium moves back into the cells causing low serum potassium (hypokalemia). Low potassium levels are associated with cardiac arrhythmias. Prompt electrolyte replacement is therefore essential.
Deficient Fluid Volume r/t increased urination and vomiting
Expected Outcome: The patient will be euvolemic and not experience any nausea or vomiting.
|Assess the patient’s fluid status. Note |
Acute weight loss
Decreased skin turgor
Dry mucous membranes
Oliguria with high specific gravity
Increased heart rate
Cold, clammy skin
All these manifestations may indicate a deficit in fluid volume and put the patient at risk for dehydration and shock. In addition, frequent urination due to osmotic diuresis and vomiting causes vascular volume depletion, leading to dehydration.
|Monitor vital signs. Note |
Decreased vascular volume due to osmotic diuresis can cause low blood pressure and even orthostatic hypotension.
A decreased blood pressure may cause the heart rate to increase. This serves as a compensatory mechanism to maintain an adequate cardiac output to perfuse vital organs.
As mentioned earlier, reparations may be increased and labored. These Kussmaul respirations serve as an effort to rid carbon dioxide from the body to correct metabolic acidosis.
An elevated temperature may be present because of dehydration.
|Monitor urine output every hour. |
As fluid replacement therapy is ongoing, urine output should decrease and normalize. Urine output should be between 30 to 50 ml/hour.
|Use central venous monitoring (CVP) to watch fluid balance closely. |
CVP gives data about the patient’s fluid status. Trending this measurement provides information about the effectiveness of treatment.
|Monitor for fluid volume overload during fluid resuscitation. Note |
Acute weight gain
Distended neck veins
Full, bounding pulses
Fluid boluses and rapid IV infusions can often cause fluid volume overload, especially in patients with previous conditions such as cardiovascular disease or kidney disease.
|Administer isotonic intravenous fluids such as 0.9% sodium chloride (normal saline) to restore circulatory volume as ordered. |
Patients in DKA can have up to a 12-liter deficit of fluid volume. This substantial fluid deficit puts vital organs such as the kidneys, the heart, and the brain at significant risk for failure. Rehydration is therefore essential to maintain adequate organ perfusion.
|Once the fluid status is corrected and blood glucose levels reach 250 mg/dL, change fluids to hypotonic fluids with added dextrose as ordered. |
Hypotonic solutions with dextrose prevent hypoglycemia and sudden interstitial changes, which could cause cerebral edema.
Imbalanced Nutrition: Less Than Body Requirements r/t inability of tissue cells to use glucose; nausea, vomiting
Expected Outcome: The patient will exhibit balanced nutrition, meeting cell energy requirements by providing appropriate insulin dosages.
|Obtain a thorough medical, surgical, social, and family history.|
The reason for uncontrolled blood glucose may have different causes. A complete history may provide more information about unstable blood glucose. Some patients may not be knowledgeable enough to manage their blood sugar, and others might not have the financial means to afford proper equipment. Knowing the exact reason may determine an appropriate treatment plan.
|Assess for nausea and other possible reasons for decreased oral intake. |
Patients may have a decreased oral intake of food or fluid during an episode of DKA. It can be accompanied by nausea or vomiting. If the patient displays a decreased LOC, he or she may have to be NPO.
|In acute situations (DKA), monitor blood glucose hourly if the patient receives insulin via insulin IV infusion. |
Hourly insulin adjustments require close observation but keep blood glucose levels tightly controlled. Patients with type 1 diabetes mellitus lack hormones that are involved in insulin production. Receiving insulin allows glucose to enter and nourish tissue cells.
|After acute hypoglycemia treatment, anticipate a long-term insulin treatment plan. |
Non-acute situations require consistent insulin therapy to prevent conditions such as DKA from developing. Patients may receive an insulin pump that delivers bolus infusions and infusions adjusted to eating patterns to ensure consistent blood glucose levels.
|Collaborate with the physician and dietitian about transitioning from intravenous insulin to subcutaneous insulin and oral intake.|
With the patient eating and blood glucose normalizing, insulin has to be adjusted to meals.
Deficient Knowledge r/t new onset of diabetes mellitus
Expected Outcome: The patient will identify learning needs and exhibit the motivation to learn about health conditions.
|Assess the patient’s knowledge about diabetes and insulin management. |
The patient’s knowledge base creates a baseline in developing an education and treatment plan.
|Identify barriers to receiving care or necessary equipment. |
Patients may have various reasons for being noncompliant with their insulin treatment regimen. For example, there may be financial, social, cultural, or even psychological reasons for not complying with medication regimens.
|Explore the factors leading to DKA. |
Knowing the chain of events helps identify strategies to avoid subsequent episodes of DKA.
|Teach the patient and family to check blood glucose levels at designated times.|
Before meals and after meals
Before and after exercising
Blood glucose levels may increase because of these factors and may need insulin adjustments.
|Emphasize the importance of not skipping insulin doses. |
Often skipping insulin leads to uncontrolled hyperglycemia and DKA. Managing insulin as prescribed by the physician prevents these instances.
|Educate about the signs and symptoms of DKA and when to call the physician. |
Blood glucose higher than 250 mg/L
Inability to take in food or fluids
Illness or infection
Being familiar with these signs prevents delaying care and promotes better outcomes.
|Teach patients and families about healthy nutrition. |
Nutrition therapy aims to minimize uncontrolled episodes of hyperglycemia and hypoglycemia by eating a healthy variety of foods. In addition, a consistent blood glucose level can be achieved by timing insulin medication with meals and activities.
|Teach the patient and family about sick-day rules. |
The patient needs to know guidelines about self-management when ill. When sick, managing blood sugar can be more complex than usual. The patient should check his or her blood sugar more often than usual, drink extra fluids if not contraindicated, check the temperature every day, and take diabetic medications as usual.
More Care Plans
2021. [ebook] Available at: <https://www.southampton.ac.uk/assets/centresresearch/documents/wphs/RBInitial%20Assessment%20and%20Treatment%20of%20Diabetic.pdf>
2021. [ebook] Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085289/>
Medicinenet.com. 2021. [online] Available at: <https://www.medicinenet.com/type_1_diabetes_diet/article.htm>
Cdc.gov. 2021. Managing Sick Days | Living with Diabetes | Diabetes | CDC. [online] Available at: <https://www.cdc.gov/diabetes/managing/flu-sick-days.html>
Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing (8th ed.). Elsevier.