DIABETIC KETOACIDOSIS

DIABETIC KETOACIDOSIS

1. Diabetic Ketoacidosis is a condition that results in life-threatening metabolic acidosis

   • A consequence of insufficient insulin production – seen with Type 1 diabetic patients
     • Rarely present in individuals with type II diabetes as a result of pancreas’ inability to meet insulin demands

2. CLINICAL MANIFESTATIONS

   • Polydipsia
   • Polyuria
   • Dehydration
     • Tachycardia
     • Poor skin turgor
     • Orthostatic hypotension
     • Dry mucous membranes
     • Comatose
   • Nausea
   • Vomiting
     • Fluid/electrolyte loss
       • Hypovolemic shock
   • Abdominal pain
   • Kussmauls respirations
     • Acetone breath (fruity)
     • Respiratory compensation
   • Hyperventilation
   • Fever- if associated with infection
     • Increased WBC count

3. Nursing Interventions

   • O2 administration
   • Establish IV access
     • fluid resuscitation with saline
       • 0.45% OR 0.9% NaCl
     • continuous insulin drip ad lib (rapid/fast-acting)
       • Rapid acting: onset (10-15 min), peak (60-90 mins), duration (3-5 hours) → lispro, aspart
       • Fast acting: onset (30 min -60 mins), peak (2-4 hours), duration (5-8 hours) → regular
     • K+/Bicarb (severe acidosis)
     • Fluid/electrolyte replacement
       • IV rate to restore urine output to 30-60 mL/hr and increase BP
       • 5% glucose is added to prevent hypoglycemia when glucose approaches 14 mmol/L
       • Correct deficits of sodium, chloride, bicarbonate, potassium, phosphate, magnesium, and nitrogen
       • Early potassium replacement is important
   • Assessment
     • Vital signs
     • Level of consciousness
       • Mental status
     • Cardiac rhythm monitoring
     • O2 saturation
     • Urine output
     • Serum glucose
       • greater than 14 mmol/L
     • Breath sounds
     • pH
       • less than 7.35
     • Fluid intake
     • Ketones in blood or urine
     • Cardiac and respiratory status

4. Diagnostic tests

   • History
   • Physical examination
   • Blood glucose levels
     • > 14 mmol/L
   • Complete blood count
   • pH
     • < 7.35
   • Ketones in blood and urine
     • From protein degradation
   • Electrolytes
     • Hydrogen ions move from intracellular fluid to extracellular space
       • Potassium ions follow hydrogen ions into extracellular space
         • Severe potassium depletion
   • Blood urea nitrogen
     • Protein degradation leads to nitrogen losses from tissues
   • Arterial blood gases
   • Serum bicarbonate < 15 mmol/L

5. Characteristics

   • Dehydration
     • Electrolytes and ketones are eliminated/depleted to maintain electrical neutrality
   • Acidosis
     • Ketones- acidic byproducts of fat metabolism
       • Blood pH is altered
         • Metabolic acidosis
   • Ketonuria
     • Byproduct of fat metabolism
       • Ketone bodies excreted in urine
   • Hyperglycemia
     • Insulin deficiency
       • Conversion of glucose from amino acids in liver

6. Causes

   • Insulin deficiency
     • Decreased glucose utilization by tissues
       • Excess glucose in blood

7. COMPLICATIONS

   • Hypovolemic shock
     • Caused by vomiting
     • Renal failure
   • Comatose
     • Result of dehydration, electrolyte imbalance, and acidosis
   • Death if left untreated

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