Diabetic Ketoacidosis
Presented by RLE 5
Diabetic Ketoacidosis
life-threatening complication of diabetes that occurs when the body breaks down
fats too quickly.
Not enough sugar - liver turns fat into ketones - ketone builds up in blood
stream and spill over into urine - Blood becomes acidic due to excess ketones
Signs and symptoms
Symptoms of DKA can appear quickly and may include:
● frequent urination ● confusion
● extreme thirst ● fruity-smelling breath
● high blood sugar levels ● a flushed face
● high levels of ketones in the urine ● fatigue
● nausea or vomiting ● rapid breathing
● abdominal pain ● dry mouth and skin
Risks
RISK
● Anyone with type 1 or type 2 can develop DKA
● DKA is more likely to occur in type 1 diabetes (insulin dependent)
● Type 2 diabetes
○ Older people
○ People who are overweight
Clinical Manifestation
● Hypotension
● Profound dehydration (dry mucous membrane, poor
skin turgor)
● Tachycardia
● Variable neurologic signs (alteration of sensorium,
seizures, hemiparesis)
Diagnostic findings
● Increased blood glucose level (600 to 1200 mg/dlL)
● Osmolality exceeds 350 mOsm/kg
● Electrolyte and BUN level are increased (dehydrated)
● Mental status changes, focal neurologic deficits, and
hallucinations are common due to cerebral
dehydration
● Postural hypotension
Medical management
MEdical Management
1. IV fluid Replacements
○ .9% normal saline
○ Replaces intravascular and extravascular fluids
○ Helps dilute glucose level
2. IV Insulin therapy
○ Keeps blood sugar in normal range
○ Helps cells absorb sugar in the body
○ Reduces build up of ketones
3. IV electrolyte replacements
Nursing Management
Treatment is similar with DKA
● Fluid replacement (0.9% or 0.45% NS)
● Correction of electrolyte imbalances (Potassium is
added when urinary output is adequate)
● Insulin administration (administered through
continuous low rate)
● Close monitoring of fluid overload, heart failure,
cardiac dysrhythmias
● After recovery: maintenance of oral antidiabetic
medication
Hyperglycemic
Hyperosmolar Nonketotic
Syndrome
Presented by RLE 5
Hyperglycemic Hyperosmolar Nonketotic Syndrome
● Aka Hyperosmolar Hyperglycaemic State (HHS)
● A life-threatening emergency. It is caused by very high blood sugar (hyperglycemia).
Without prompt treatment HHNS can be fatal.
● A condition characterized by the presence of hyperglycemia, hyperosmolarity, and
dehydration.
Risk Factors
● History of diabetes mellitus type 2
● A stressful event such as infection, heart attack, stroke, or recent surgery
Other risk factors:
● Lack of sufficient insulin (but enough to prevent ketosis)
● Poor kidney function
● Poor fluid intake (dehydration)
● Older age (50–70 years)
● Certain medical conditions (cerebral vascular injury, myocardial infarction, sepsis)
● Certain medications (glucocorticoids, beta-blockers, thiazide diuretics, calcium channel
blockers, and phenytoin)
Signs and symptoms
Signs and symptoms
● Hypotension
● Dehydration (Dry mucous membranes, poor skin turgor)
● Tachycardia
● Variable neurologic signs (e.g. alteration of consciousness, seizures,
hemiparesis)
Characteristics DKA HHNS
Patients most commonly more common in type 1 diabetes More common in type 2 diabetes,
affected especially in older patients
Precipitating event Omission of insulin; physiologic stress Physiologic stress (infection,
(infection, surgery, stroke, MI) surgery, stroke, MI)
Onset Rapid (<24 hours) Slower (over several days)
Blood glucose levels Usually >250mg/dL Usually >600mg/dL
Arterial pH level <7.3 Normall
Serum and urine ketones Present Absent
Serum osmolality 300-350 mOsm/L >350 mOsm/L
Plasma bicarbonate level <15 mEq/L Normal
BUN and creatinine levels Elevated Elevated
Mortality rate 1%-5% 10%-20%
Medical management
● Intravenous fluids
○ Treatment of HHS begins with re-establishing tissue perfusion using
intravenous fluids.
● Electrolyte replacement
○ Potassium replacement is often required as the metabolic problems are
corrected.
● Insulin
○ Insulin is given to reduce blood glucose concentration.
● Maintain safety and prevent injury related to changes in the patient’s
sensorium secondary to HHNS.
○ Closely monitor fluid status and urine output
Nursing Management
Nursing Diagnoses
● Risk for deficient fluid volume related to polyuria and dehydration
● Risk for electrolyte imbalance related to fluid loss or shifts
Nursing Interventions
● Maintaining fluid and electrolyte balance
○ Intake and output are measured
○ IV fluids and electrolytes are given as prescribed
○ Oral fluid intake is encouraged when it is permitted
○ Laboratory values of serum electrolytes (especially Na and K) are monitored
○ Vital signs are monitored hourly for signs of dehydration (tachycardia, orthostatic
hypotension)
○ Assessment of breath sounds, level of consciousness, presence of edema, and cardiac
status (ECG)
● Monitoring and managing potential complications
○ Fluid overload
○ Hypokalemia
○ Cerebral Edema
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