02.04 Nursing Care and Pathophysiology of Diabetic Ketoacidosis (DKA)

Overview

1. Severe Hyperglycemia with Ketoacidosis

Pathophysiology:

Diabetic Ketoacidosis (DKA) occurs with severe hyperglycemia and ketoacidosis. This occurs because the blood sugar is so elevated and there is not enough insulin to take the sugar to the cell. The cell needs energy. Since the cell can not get the energy from the sugar (because no insulin) it uses fatty acids for energy. As the body burns up fatty acids to produce energy, it produces a by-product. The by-product of this process is ketones which is acidic. As acids build up this will cause metabolic acidosis. As the ketones build up in the body the patient will spill ketones into the urine showing positive ketones in the urine. The body will do Kussmaul respirations to try and breathe out the CO2 and get rid of the acid.

Nursing Points

General

1. Type I Diabetes Mellitus – Acute Exacerbation
   1. Body has NO insulin→ can’t get glucose into cell → breaks down fatty acids for energy → Ketones (Acids)
2. Sudden onset → stress, infection

Assessment

1. Ketoacidosis
   1. Acidosis (pH <7.35, HCO3- <22)
   2. Ketones in Urine
   3. Fruity Breath (due to ketones)
   4. Kussmaul Respirations
      1. Trying to breathe off Co2 to compensate for acidosis
      2. Patients can tire easily
   5. Hyperkalemia
      1. K+ leaves the cell to compensate for acidemia
2. Hyperglycemia
   1. Blood Glucose 400-600 mg/dL
   2. Severe Dehydration
      1. Osmotic Diuresis
      2. Polyuria
   3. ↑ BUN, Creatinine
   4. Altered LOC (cellular dehydration)

Therapeutic Management

1. First nursing action = begin fluid replacement and check electrolytes
2. Treatment Priority = correct acidosis
   1. Insulin therapy → so the body can STOP breakdown of fatty acids
   2. Without insulin, DKA will continue to progress, despite fluid replacement
   3. Insulin therapy continues until anion gap acidosis has fully resolved
3. Continue replacing fluids as needed
   1. Helps manage the dehydration caused by the hyperosmolarity
4. Monitor neurological status
5. Monitor and treat electrolyte imbalances

Nursing Concepts

1. Acid-Base Balance
   1. Monitor Arterial Blood Gases and Anion Gap
   2. Monitor Respiratory status
2. Glucose Metabolism
   1. Blood sugar checks q1h
   2. Intensive insulin therapy (IV – Regular Insulin)
      1. May continue even after blood sugar down (goal = correct acidosis)
   3. Evaluate urine for glucose/ketones
3. Fluid & Electrolytes
   1. Give IV Fluids (IVF)
   2. Monitor electrolytes & replace as needed
   3. Potassium may ↓ with insulin therapy
      1. May add KCl to IVF

Patient Education

1. Continue to monitor blood sugars and take insulin even on a sick day
2. Do not skip doses of insulin
3. Signs and symptoms of hyperglycemia (before DKA) to alert to a problem earlier