Diabetic ketoacidosis DKA

Diabetic ketoacidosis DKA Nursing Care Plans Diagnosis and Interventions

Diabetic ketoacidosis DKA NCLEX Review Care Plans

Nursing Study Guide for Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is an acute and life-threatening complication of diabetes, often characterized by excessive glucose in the blood (hyperglycemia) and presence of ketones in the blood and urine.

Diabetes mellitus (DM) is chronic disease affecting the insulin production of the pancreas.

However, if the glucose in the body is not metabolized effectively, the patient will develop diabetic ketoacidosis.

Signs and Symptoms of Diabetic Ketoacidosis

  • Polydipsia – extreme thirstiness
  • Polyuria – frequent urination
  • Nausea and vomiting
  • Abdominal pain – diffused in origin
  • Body malaise, weakness or fatigue
  • Decreased perspiration
  • Shortness of breath
  • Fruit-scented breath – or “ketone breath”
  • Altered consciousness – disorientation, confusion

Causes and Risk Factors of Diabetic Ketoacidosis

Two main factors trigger for the development of DKA:

  1. An illness. Any infection or other condition may cause the body to produce hormones that may otherwise counter the effect of insulin. One of such hormones is cortisol during bouts of infections.
  2. Problems with insulin regimen. Inconsistencies in complying with insulin therapy (e.g. Missed doses) will leave the body with little insulin, thus triggering DKA.

Other triggers of DKA include trauma (physical or emotional), heart attack, stroke, pancreatitis, pregnancy, alcohol or drug abuse and certain medications (e.g. corticosteroids).

The risk factors that predispose a patient to DKA are:

  • Having Type 1 diabetes
  • Frequently missed doses in insulin treatment.

Some cases of diabetic ketoacidosis can occur with patients having type 2 diabetes or may initially start first as a sign of a beginning diabetes diagnosis.

Complications of Diabetic Ketoacidosis

Managing Diabetic ketoacidosis involves correction fluid loss with intravenous fluids, correction of hyperglycemia with insulin regimen, addressing electrolyte and acid-base imbalances, and management of infection if present.

In relation to this, the most common complications of DKA often stem from the treatment options given to the patient.

Treatment complications include:

  • Hypoglycemia – over correction with insulin causing sudden drops in serum levels of glucose in the blood
  • Hypokalemia – over and sudden correction of potassium that will impair the heart, nerves, and muscles.
  • Cerebral edema – brain swelling due to sudden adjustments in serum glucose will cause and produce swelling in the brain.

Leaving DKA untreated will lead to serious complications like loss of consciousness, even death.

Diagnosis of Diabetic Ketoacidosis

  1. Laboratory studies
  • Serum glucose levels – levels 250mg/dL and above indicates hyperglycemia
  • Serum electrolytes – serum potassium levels are usually high, and sodium levels low
  • Bicarbonate levels – usually levels less than 18 mEq/L with pH of less than 7.3
  • Amylase and lipase levels – unusually elevated for patients with DKA (hyperamylasemia)
  • Urine dipstick – to test for presence of excessive ketones and glucose in urine
  • Ketone levels – as by products of fat metabolism in the liver, serum ketone levels will be elevated
  • Serum or capillary beta-hydroxybutyrate levels – monitored to assess treatment response. Levels greater than 0.5 mmol/L are abnormal values.
  • Arterial blood gasses – will typically show manifestations of metabolic acidosis (low bicarbonate levels, low pH less than 7.3)
  • CBC – baseline data to assess for infections. Elevated WBC count will signify infections
  • BUN and creatinine levels – oftentimes elevated for patients with DKA. Good indicator for renal health
  • Urine and blood cultures – to assess organisms causing infections to allow for appropriate antibiotic treatment
  • ECG – due to changes in serum potassium, monitoring for ECG changes will be advantageous to check for arrhythmias that may be present with these changes.

2. Imaging studies

  • Chest xray – utilized to rule out pneumonia
  • Cranial CT scan – used to assess for presence of cerebral swelling due to manifestations of altered mental state
  • Cranial MRI – utilized once the patient has altered consciousness and to assess cerebral edema.

Treatment for Diabetic Ketoacidosis DKA

The goals of treatment for Diabetic ketoacidosis revolve around the following approaches:

  1. Addressing fluid loss with intravenous fluids
  • A critical part of treating patients with DKA
  • Initial correction utilizes isotonic sodium chloride solution or Lactated Ringer’s solution.
  • Involves incremental increases of 1 liter of IV fluid for the first 3 hours then every 4 hours, depending on the degree of dehydration and hemodynamic stability.
  • Correction of hyperglycemia with insulin regimen

2. Correction of hyperglycemia with insulin regimen

  • Starting with a low dose regimen to reduce episodes of severe of hypoglycemia or hypokalemia observed in high dose insulin treatment.
  • Used of short-acting insulin for correction of hyperglycemia via the intravenous route; insulin treatment through the subcutaneous route is reduced in DKA.
  • The optimal rate for decreasing serum glucose levels in DKA patients is 100mg/dL/h. This is done to prevent sudden onset of hypoglycemic episodes due to the resolution of ketoacidosis and increased response and utilization of insulin by the body.

3. Addressing electrolyte imbalances

  • Administer potassium supplement for levels below 6 mEq/L
  • Serum potassium levels are monitored hourly. Potassium infusion should be stopped once levels are greater than 5 mEq/L. Close monitoring should continue even after stopping potassium infusion to monitor for recurrence of hypokalemia.

4. Addressing acid-base imbalance

  • Acidosis will improve by utilizing the previous treatments alone.
  • Sodium bicarbonate is only started once acidosis becomes life-threatening for the patient, especially if associated with lactic or septic acidosis.

5. Treatment for infection, if present. Antibiotic treatment guided by culture sensitivity results is advisable.

Nursing Care Plans for Diabetic Ketoacidosis DKA

Nursing Care Plan 1

Nursing Diagnosis: Fatigue related to decreased metabolic energy production as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, blood sugar level of 11 mg/dL, and shortness of breath upon exertion

Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

InterventionsRationales
Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.To gradually increase the patient’s tolerance to physical activity.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.To allow the patient to relax while at rest. To allow enough oxygenation in the room.
Refer the patient to physiotherapy / occupational therapy team as required.To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.

Nursing Care Plan 2

Nursing Diagnosis: Risk for Fluid Volume Deficit due to osmotic diuresis secondary to DKA

Desired Outcome: The patient will demonstrate adequate hydration and balanced fluid volume

InterventionsRationales
Assess vital signs and signs of dehydration.Hyperglycemia may cause Kussmaul’s respirations and/or acetone breath. Hypotension and tachycardia may result from hypovolemia, or low levels of intravascular volume.
Commence a fluid balance chart, monitoring the input and output of the patient.To monitor patient’s fluid volume accurately and effectiveness of actions to monitor signs of dehydration.
Start intravenous therapy as prescribed. Encourage oral fluid intake of at least 2500 mL per day if not contraindicated.To replenish the fluids lost from polyuria and to promote better blood circulation around the body.
Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside.To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. 
Monitor patient’s serum electrolytes and recommend electrolyte replacement therapy (oral or IV) to the physician as needed.Sodium is one of the important electrolytes that are lost when a person is passing urine. Hyponatremia or low serum sodium level may cause brain swelling.

Nursing Care Plan 3

Nursing Diagnosis: Risk for Infection

Desired Outcome: The patient will be able to avoid the development of an infection.

InterventionsRationales
Assess vital signs and observe for any signs of infection.Ketoacidotic state in diabetic patients may increase their risk for infection.
Perform an initial head-to-toe assessment, particularly checking for the presence of any wounds and cuts.Diabetic and DKA patients suffer from slow wound healing. Any wound or cut needs to be managed early and appropriately to prevent infection which may spread and may lead to amputation of the affected toe, finger, or limb.
Educate the patient for the need to monitor and report any signs of infection or new wounds and cuts.To facilitate early detection and management of infection and to provide proper wound management as needed.
Teach the patient how to perform proper hand hygiene.To maintain patient safety and reduce the risk for cross contamination.
Provide careful skin care. Massage the limbs and keep the skin dry. Provide wrinkle-free linens.To reduce the risk of skin breakdown that may lead to infection. To facilitate a better peripheral blood circulation.
Administer prescribed antibiotics if an infection is found.To immediately treat an infection as healing can be slow for DKA patients.

Nursing Care Plan 4

Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to insulin deficiency, as evidenced by unexplained weight loss, increased urinary output, dilute urine, high blood glucose levels, fatigue, and weakness

Desired Outcome: The patient will be able to achieve a weight within his/her normal BMI range, demonstrating healthy eating patterns and choices.

InterventionRationale
Explain to the patient the relationship between diabetes and unexplained weight loss.To help the patient understand why unexplained weight loss is one of the signs of diabetes.
Create a daily weight chart and a food and fluid chart. Discuss with the patient the short term and long-term goals of weight loss.To effectively monitory the patient’s daily nutritional intake and progress in weight loss goals.
Help the patient to select appropriate dietary choices to follow 60% carbohydrates, 20% fats, 20% proteins.These proportions are ideal for diabetic ketoacidosis patients.  
Refer the patient to the dietitian.To provide a more specialized care for the patient in terms of nutrition and diet in relation to diabetic ketoacidosis.  

Other possible nursing diagnoses:

  • Acute Confusion
  • Impaired Urinary Elimination
  • Deficient Knowledge

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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