Last updated on May 16th, 2022 at 08:17 am
Diabetic Ketoacidosis DKA Nursing Care Plans Diagnosis and Interventions
Diabetic Ketoacidosis DKA NCLEX Review and Nursing Care Plans
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 DKA
- 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 DKA
Two main factors trigger for the development of DKA:
- 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.
- 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 DKA
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 DKA
- 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:
- 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 of Diabetic Ketoacidosis DKA
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.
| DKA Nursing Interventions | Rationales |
| 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. |
Diabetic Ketoacidosis DKA 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
| DKA Nursing Interventions | Rationales |
| 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. |
Diabetic Ketoacidosis DKA Nursing Care Plan 3
Nursing Diagnosis: Risk for Infection
Desired Outcome: The patient will be able to avoid the development of an infection.
| DKA Nursing Interventions | Rationales |
| 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. |
Diabetic Ketoacidosis DKA 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.
| DKA Nursing Interventions | Rationale |
| 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. |
Diabetic Ketoacidosis DKA Nursing Care Plan 5
Nursing Diagnosis: Nausea related to depletion of sodium and potassium levels in the body secondary to diabetic ketoacidosis (DKA), as evidenced by gagging sensation, uremia, vomiting, presence of ketones in the blood or urine, and frequent urination.
Desired Outcomes:
- The patient will be able to report decreased severity or elimination of nausea.
- The patient will be able to maintain an adequate fluid and electrolyte balance.
- The patient will be able to identify different methods on how to minimize the severity of nausea.
| Diabetic Ketoacidosis Nursing Interventions | Rationale |
| Assess the cause of the patient’s nausea. | The choice of treatment will be guided by the patient’s assessment of the reasons for nausea. If the stimulus is removed, treatment may not be required. |
| Assess the characteristics of the patient‘s nausea, including the history, duration, frequency, severity, precipitating factors, measures done to alleviate nausea, and medications. | An in-depth assessment and evaluation of the characteristics of the patient’s nausea can aid in the development of solutions to lessen or resolve the problem. |
| Monitor and record the patient’s hydration, weight, blood pressure, intake and output, and skin turgor. | Nausea is frequently associated with vomiting and frequent urination can result in a change in a patient’s hydration status due to fluid loss that may cause dehydration. |
| Advice the patient to take an adequate number of fluids and closely monitor that patient’s fluid and electrolyte balance. To avoid dehydration and complications such as low sodium, potassium, calcium, and magnesium. | Electrolyte imbalances can develop from high blood glucose levels, which can produce nausea and vomiting. Further problems and heart arrhythmias can also result from electrolyte imbalance. |
| Place an emesis basin within the patient’s reach. | Vomiting and nausea are related closely. If the nausea is psychogenic, keep the emesis basin out of sight but within reach of the patient. |
| Educate and help the patient in maintaining good dental hygiene. | Anorexia and excessive salivation are linked to this condition. Oral hygiene aids in the treatment of nausea and makes it more comfortable. |
| Assist the patient in preparing for diagnostic tests and explain to the patient the importance of diagnostic tests. | To determine the contributing factor, a set of tests may be performed including upper gastrointestinal tract study, abdominal computed tomography scan, ultrasonography. |
| Keep the patient’s room clean and well- ventilated and remove any strong odors from the area surrounding the patient such as perfumes, dressings, emesis. | A well-ventilated room will help the patient to breath easily. Strong and unpleasant odors can contribute to the patient’s nausea. |
| Allow the patient to use non-pharmaceutical nausea management methods including relaxation, guided visualization, music therapy, distraction, or deep breathing exercises. | Non-pharmaceutical techniques have helped patients alleviate the nausea, but the methods should be used before the nausea occurs. |
| Include cold water, ice chips, ginger items, and room temperature broth or bouillon to the patient’s diet if tolerated and acceptable. | These help with hydration. Ginger, whether in the form of ginger ale, ginger tea, or candied ginger, helps to reduce nausea. Fluids that are excessively cold or too hot might be uncomfortable to drink. |
| Allow the patient to have a small amount of feedings with their own food preference, suggest including dry crackers, toast, broth, banana, rice or jelly to the diet. | Small feedings with the patient’s own food preference will aid in the maintenance of nutritional status. An empty stomach can aggravate nausea in certain patients. |
| Educate the patient or caregiver about nausea-relieving fluid and food options. | By noting dietary factors to consider while nauseated, patients and caregivers can support proper hydration and nutritional status. |
| Inform the patient to stay away from foods and scents which can aggravate nausea. | Strong and unpleasant odors can trigger the nausea of the patient. |
| 14. Keep the patient upright while eating and for 1 to 2 hours afterward. | Keeping the patient upright can assist to reduce the risk |
| 15. Educate the patient on the importance of taking prescribed medications as directed. | Taking drugs according to the healthcare provider instructions will help to prevent nausea. |
Diabetic Ketoacidosis DKA Nursing Care Plan 6
Risk for Unstable Blood Glucose Level
Nursing Diagnosis: Risk for Unstable Blood Glucose Level related to non-adherence to therapeutic regimen and inadequate blood glucose monitoring, secondary to diabetic ketoacidosis (DKA).
Desired Outcomes:
- The patient will be able to show willingness to participate in the therapeutic management plan.
- The patient will be able to demonstrate blood glucose levels less than 180 mg/dL, fasting blood glucose levels that are less than 140 mg/dL, and hemoglobin A1C less than 7%.
| DKA Nursing Interventions | Rationale |
| Assess the patient for symptoms of hypoglycemia or hyperglycemia. | Hypoglycemia symptoms vary from person to person, although they are consistent in the same person. Increased adrenergic activity and reduced glucose transport to the brain cause the symptoms. Tachycardia, diaphoresis, tremors, dizziness, headache, weariness, hunger, and visual abnormalities may occur in the patient. When there is insufficient insulin to glucose, hyperglycemia occurs. An osmotic effect occurs when there is too much glucose in the blood, resulting in increased thirst (polydipsia), hunger (polyphagia), and urination (polyuria) (polyuria). Nonspecific symptoms such as anxiety and impaired vision may also be reported by the patient. |
| Monitor the patient’s fasting and postprandial blood glucose levels. | An adult’s fasting blood glucose level should be between 70 and 105 mg/dL. Hypoglycemia has a critical value of less than 40 to 50 mg/dL. Hyperglycemia has a critical value of more than 400 mg/dL. Because the solution includes up to 50% dextrose, patients receiving total parenteral nutrition (TPN) may have a higher-than-normal blood glucose level. After eating, patients with reactive hypoglycemia will have a lower blood glucose level than normal. |
| Determine the patient’s blood insulin levels regularly. | Early on in the progression of type 2 diabetes, hyperinsulinemia develops. Insulin production from the pancreas is stimulated by obesity and insulin receptor dysfunction in peripheral organs. Insulinomas and some extra pancreatic tumors raise insulin levels, which can lead to hypoglycemia. |
| Assess the patient’s feet and note the temperature, pulses, color, and feelings. | This is to assess for peripheral perfusion and neuropathy. |
| Assist the patient in recognizing and changing unhealthy eating habits. | This information serves as the foundation for personalized dietary advice related to the clinical condition that causes blood glucose levels to fluctuate. |
| Monitor the patient’s vital signs and report the blood pressure reading of more than 160 mm Hg (systolic). Administer hypertensive medication as directed. | Diabetes and hypertension are frequently linked. Controlling blood pressure helps to prevent heart disease, stroke, retinopathy, and nephropathy. |
| Educate the patient about the foods or other glucose sources that are allowed to be taken if hypoglycemia is present. | To treat hypoglycemia, a fast absorbed type of glucose is recommended. Oral ingestion of hard candies or fruit juice is one of these sources of glucose. If a patient is unable to take something orally, an intravenous glucose infusion may be necessary. |
| Instruct the patient on the need and importance of sticking to a meal plan. | A meal plan advised by the doctor will assist the patient in maintaining stable blood glucose levels. |
| Educate the patient on how to take the prescribed medications correctly. | To lower blood glucose, the diabetic patient must learn how to use oral or parenteral hypoglycemic medications. |
| Discuss with the patient the importance of a healthy diet and exercise routine. | Exercise helps to keep a balanced glucose levels by boosting glucose uptake into cells. The relationship of exercise, food intake, and blood glucose levels must all be understood by the patient. |
| Teach the patient on how to properly take capillary blood glucose readings. | Capillary blood glucose monitoring gives the patient real-time blood glucose readings. |
| Determine the patient’s physical activity pattern. | Physical activity helps in the reduction of blood glucose levels. Exercise is an important aspect of diabetes care since it lowers the risk of cardiovascular problems. |
| Refer the patient to a licensed dietitian for individualized diet advice. | The patient’s body, weight, blood glucose levels, exercise habits, and specific clinical condition all factor into a tailored food plan. Blood glucose levels will be stabilized as a result of changes in the patient’s diet. |
Diabetic Ketoacidosis DKA Nursing Care Plan 7
Nursing Diagnosis: Risk for Injury related to drowsiness secondary to diabetic ketoacidosis (DKA).
Desired Outcomes:
- Within eight hours of receiving nursing intervention and treatment, the patient will be able to identify the elements that increase their risk of injury and display injury-avoidance behaviors.
- The patient will be free of injuries after four hours of nursing interventions and training.
| DKA Nursing Interventions | Rationale |
| Determine the patient’s age, developmental stage, health status, lifestyle, impaired communication, sensory-perceptual impairment, mobility, cognitive awareness, and decision-making abilities of the client. | These elements influence the patient’s ability to protect oneself from harm. When establishing a treatment plan or teaching patients about safety precautions, nurses must properly analyze each of these elements. |
| Assess the patient’s health and cognitive awareness for any changes. | A patient’s risk for injury may increase as the health status changes. A postoperative patient, for example, may have confusion, disorientation, and memory loss, placing the patient at risk of falling or injuring themselves. Certain drugs might also affect the patient’s judgment. |
| Assess the patient’s lifestyle. | When determining injury risk, consider the patient’s lifestyle. For example, hazardous working conditions, settling in a high-crime area, having access to guns or weapons, being unable to obtain safety equipment owing to a lack of cash, and misusing prescription medicines are all examples. |
| Examine the patient for impairment in communication. | Language barriers, as well as speech and hearing difficulties, may impair the patient’s capacity to comprehend information, putting the patient at risk of an adverse incident. |
| Determine the patient’s ability to walk and identify the risks for fall by using the Morse Fall Scale. | Falls are more likely when there are changes in mobility due to muscle weakness, paralysis, poor balance, or lack of coordination. The Morse Fall Scale (MFS) is a regularly used fall risk assessment instrument in health care institutions. It evaluates six characteristics (history of falling in the previous three months, secondary diagnosis, use of assistive equipment, IV/heparin lock, gait/transferring, and mental status) using a point scale system. An MFS score of 0-24 (no risk) indicates that no interventions are required. Standard fall prevention treatments should be started if the score is 25-50 (low risk). A score of >51, which indicates a high risk of falling, necessitates the implementation of high-risk fall prevention treatments. |
| Note of the patient’s age and observe for evidence of physical injuries such as bruises, burns or scalds, history of fractures, lacerations, bite marks, social withdrawal, fearfulness. | Signs of suspected deliberate injury or abuse that must be properly evaluated to ensure that the patient receives medical attention, is referred for extra help, and is protected from further harm. All healthcare providers have a moral and legal obligation to report these types of injuries and abuse to social welfare or Child Protective Services as soon as possible (CPS). |
| Assess the patient’s safety at home or in the hospital if admitted. Nurses do an environmental risk assessment to look for things or equipment such as cords or hooks that could be used in suicidal hanging. As a result, it should be removed to safeguard the safety of the patient. | |
| Assist the patient in becoming familiar with the surroundings and place the patient’s important items within reach. | To prevent injury, the patient should be familiar with the layout of the area. Items kept too far away from the patient may pose a risk. |
| Assess the patient’s vital signs and blood glucose levels regularly. | An increase or decrease in blood glucose levels and blood pressure may cause dizziness, headache and blurring of vision that may increase the patient’s risk for injury. |
| Advice the patient to avoid thermal extremes like heating pads, hot water for baths/showers. | Patients with impaired intellect or sensory impairments are unable to distinguish between temperature extremes. Burn damage is more likely in people with age-related physiological changes (e.g., loss of dermal appendages, dermal atrophy, and loss of insulating subcutaneous fat) and cognitive diseases (e.g., dementia, peripheral artery disease, and diabetes) that compromise mobility and judgment. |
| Validate the patient’s feelings and concerns about environmental hazards. | Validation assures the patient that the nurse has heard and comprehended the concerns. It also aids in the development of the nurse-patient relationship. |
More DKA Nursing Diagnosis
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. (2022). 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
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