Nursing Care Plan (NCP) for Diabetic Ketoacidosis (DKA)

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Outline

Pathophysiology

Diabetic ketoacidosis is a serious complication of diabetes mellitus that occurs when uncontrolled blood sugar rises and the body can’t produce enough insulin to use the glucose. When this happens, the body begins to break down fat as energy which produces a build-up of acid in the bloodstream called ketones.  This is a serious life-threatening condition that occurs most often in Type I diabetics

Etiology

Ketoacidosis can occur when diabetic patients experience emotional or physical stress such as with bacterial infections (UTI, etc), prolonged vomiting, surgery or when they miss doses of insulin. Alcohol and drug abuse in a diabetic patient can also cause the body to produce ketones that poison the blood.

Desired Outcome

Maintain blood glucose level within the target range, maintain normal fluid balance

Diabetic Ketoacidosis (DKA) Nursing Care Plan

Subjective Data:

  • Excessive thirst
  • Nausea
  • Abdominal pain
  • Weakness / fatigue
  • Shortness of breath
  • Reports of:
    • Blurry vision
    • Excessive urination

Objective Data:

  • Frequent urination
  • Vomiting
  • Fruity-scented breath
  • Confusion
  • Hyperglycemia, usually >400 mg/dL
  • High urine ketone levels
  • Kussmaul respirations
  • Metabolic Acidosis with elevated Anion Gap

Nursing Interventions and Rationales

  • Monitor blood glucose levels and administer insulin as appropriate

 

Consistently high blood glucose levels, over 400 mg/dL, are the primary indicator of  ketone production. Monitor glucose and intervene with prescribed insulin as appropriate to reduce glucose levels and prevent further ketone production.

 

  • Monitor fluid and electrolyte  balance to prevent dehydration and complications such as decreased sodium, potassium, calcium and magnesium

 

Excess blood glucose can cause nausea and vomiting resulting in electrolyte imbalances. These electrolyte deficiencies can lead to further complications and cardiac arrhythmias.

 

  • Monitor for and treat signs / symptoms of infection

 

DKA is often the result of an underlying infection such as a common cold, flu or bacterial infection like pneumonia or urinary tract infections. Assess for fever and other symptoms of infection and administer antibiotics as necessary.

 

  • Administer medications as appropriate
    • Insulin as necessary
    • Antibiotics
    • IV fluids
    • Electrolyte replacement
    • Antiemetics

 

Medications may be given to lower the blood glucose level in order to prevent further production of ketones or to manage symptoms of vomiting and underlying infection.

 

  • Monitor vitals for signs / symptoms of hypovolemia

 

Vomiting and frequent urination can cause a deficiency in fluid volume, thus leading to a decreased circulatory volume. This will be evident by low blood pressure and tachycardia

 

  • Prevent injury and falls; assist with ambulation

 

Fatigue and weakness are common due to the cells inability to use glucose to produce energy, also following vomiting, and in cases of dehydration.

 

  • Nutrition and lifestyle education
    • Avoid alcohol / illicit drug use
    • Choose foods that are high in fiber and low in fats, sugars and simple carbs
    • Eat regular meals and snacks, don’t miss meals
    • Check for urine ketones when you have symptoms
    • Do not exercise when urine shows positive for ketones
    • Maintain compliance with medication and insulin therapy

 

Maintaining a high blood glucose level, missing doses of insulin or being sick can cause ketones to form in the blood. Educate patients on healthy diet and lifestyle to prevent DKA. Teach patients and caregivers of the warning signs / symptoms of DKA.

Writing a Nursing Care Plan (NCP) for Diabetic Ketoacidosis (DKA)

A Nursing Care Plan (NCP) for Diabetic Ketoacidosis (DKA) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

Hey everyone in this care plan, we will be discussing diabetic ketoacidosis. Okay, so in this care plan, we’re going to be looking at a description of diabetic ketoacidosis, the subjective and objective data that’s relevant, and your nursing interventions and rationales. 

 

Alright, so let’s take a look at what DKA actually is. So, it’s very important to know that this is a very serious complication of diabetes mellitus that can occur when blood sugars are poorly controlled. So, what happens is you get really increased blood sugar levels and they rise to an extreme level. So, they’re very, very high, but the body doesn’t have the insulin that it needs to use the glucose. So, this glucose and blood sugar is not accessible to the body. When that happens, the body has to start using fat for energy. So we’re not using blood sugar, we’re using fat for energy. When the body uses fat as an energy source, a type of acid called ketones actually builds up in the bloodstream, so you can see where the name for diabetic ketoacidosis comes from, again, acidosis that’s caused by these ketones that are building up secondary to using fat for energy. 

 

Okay, so let’s think a little bit about why this might actually happen to a patient. So, we said it often happens in diabetic patients, but it’s usually in patients who are either newly diagnosed and so they don’t know that they’re diabetic, or it’s in patients who aren’t really compliant with their treatment plan. so maybe they’re not taking enough insulin to keep blood sugars low, or they might be stressed sick, or having surgery. All of those types of things can increase the patient’s insulin requirements. So when a patient’s insulin requirements change, it might be difficult for them to keep up with their blood sugars and to keep them in a normal range.

 

Other important factors that can influence this are lifestyle factors. So, things like drinking too much alcohol and drug abuse. The desired outcome for a patient that’s in DKA is number one, to maintain blood glucose level within the target range, and then two, to maintain normal fluid balance. 

 

So, let’s get started with our care plan by looking at the subjective data associated with DKA. Things that you’re going to see with this patient is excessive thirst, nausea, abdominal pain, weakness and fatigue, shortness of breath, sometimes blurry vision and excessive urination. Remember, anytime you’ve got a patient that’s really got a high level of blood sugar, maybe they’re a new onset diabetic as well, you want to think about the three P’s and that’s just a really easy way to remember some of these symptoms. So, the first P is polydipsia, which is excessive thirst. The second P is polyuria, which is excessive urination, and the third P is polyphagia, where you’ve got excessive hunger. 

 

For your objective patient with this, you’re going to see vomiting, they may have fruity-scented breath, confusion, hyperglycemia, so the blood sugar level is usually greater than 400, high urine ketone levels and  Kussmaul respirations, which is just deep-labored breathing that is often associated with metabolic acidosis. Then, when you look further into the blood, you’re going to see potentially even high ketone levels also, so you’ve got that high blood sugar level and a high ketone level as well, and with the metabolic acidosis that we mentioned, you’re going to see an elevated anion gap. 

 

For your nursing interventions, obviously, probably the first and most important thing to be aware of is that you want to monitor blood glucose levels very closely and you may need to administer insulin as appropriate for that patient. Again, the major problem the body is having is that it doesn’t have that insulin that’s going to allow the body to use the sugar for energy. So, you’re getting those really high blood sugar levels and that is what’s triggering the body to produce those ketones because it’s not able to use them. So when we give the body insulin, it can start to use the glucose for energy, and eventually the body will stop producing those ketones because it doesn’t have to use the fat.  

 

Okay, your next intervention here and it’s equally as important as the intervention we just talked about, is to monitor fluid and electrolytes very, very closely to prevent dehydration and complications such as hyponatremia. So, a drop in sodium and hyperkalemia, those are really important to try and monitor, so that we can prevent those issues. You can also see changes in calcium and magnesium, but the most common ones are going to be related to sodium and potassium. Major, major issues can arise from electrolyte abnormalities. The two most common ones that are really problematic are cerebral edema and cardiac arrhythmias, and really managing DKA is all about a balancing act. So, it’s keeping that patient hydrated, keeping electrolytes in balance, bringing ketones and blood sugar levels down to a normal level, and actually this can be really tricky for a lot of different reasons, but the key for us is that we’re going to be monitoring it closely, so that we can balance it all and make sure that insulin doses, fluids, and additives can all be adjusted to maintain that balance. 

 

Your next intervention here, is focused on finding out why we need to know again, why have this patient in DKA, remember a common cause is infection. So, you want to be looking for signs of infection so that we can treat it. Remember, if the patient is sick, this is going to make their insulin needs go up, so we need to treat that infection so we can get their insulin level requirements back down to normal. Infections that may commonly cause this type of problem for a diabetic patient are things like pneumonia and a urinary tract infection. 

 

Okay, the next one on our list for intervention, is you’re going to be expecting to administer some medications and some fluids as appropriate and as prescribed. Some things that you should be expecting to administer to these patients we’ve already said, are insulin, potassium, and antibiotics. You also may be giving medications to help treat nausea and vomiting, so be on the lookout for that as well. Okay, so earlier on we mentioned complications up here like cerebral edema and hypokalemia, but these patients are also at risk for having sepsis and shock, so it’s really important to look out for signs that the patient is becoming hypovolemic. Remember, we’re talking about maintaining that balance for this patient, so we want to keep a close eye on their vital signs  in addition to those electrolytes we talked about, looking for those signs of hypovolemia and sepsis. So, we want to think about things that are going to show us the signs of decreased blood pressure, delayed capillary refill and increased heart rate. All those things are going to give us an indication that maybe the patient is hypovolemic and maybe becoming septic. 

 

Okay, moving on to our last two interventions here, we’re going to think about patient safety and patient education. So, for our patient safety, we really need to prevent injuries and falls by assisting with ambulation and making sure that the patient’s environment is safe. Remember, these patients are fatigued and they’re weak. They’ve got a lack of energy, so it’s really important that we assist them and make sure that that doesn’t cause any problems for them. Once that DKA is in check and the patient’s blood sugar levels and ketones have all normalized, it’s really important to provide education, especially nutritional and lifestyle education for these patients. Sometimes this means re-educating on their insulin requirements and compliance with diet, but then it’s also teaching them how they can manage when they’re sick and stressed out. So, it’s really, really important that they know when they need to seek medical support and that they are aware of any symptoms that are associated with DKA, so that they can seek help very, very quickly.

 

Alright, that is all on our nurse care plan lesson for diabetic ketoacidosis. We love you guys. Now, go out and be your best selves today and as always, happy nursing!

 

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