Mindmap: Diabetic Ketoacidosis (DKA)

Etiology (Lewis et al, 2014)
1. TYPE 1 DIABETES MELLITIS (DM)
  1. Hyperglycemia
  2. Ketonuria
  3. Acidosis
  4. Dehydration
2. Common causes (Lewis et al, 2014)
  1. 40% → Underlying or concomitant infection
  2. 20% → Missed insulin
  3. 15% Newly diagnosed, unknown
    1. Pregnancy
      1. Placental hormones cause insulin resistance --> increase insulin requirements
        Ketones harmful to fetus
    2. Stress, Infection/Illness, Surgery, Trauma
      1. Pancreas unable to meet insulin demand
  4. 20% → Various causes-
Assessment (Jarvis, 2016) / (Lewis et al, 2014)
1. Objective
  1. Blood studies
    1. Positive ketones
    2. Hyperclycemia (Blood glucose > 14 mmol/L
    3. CBC (increase in WBC)
  2. Arterial Blood Gases (ABGs)
    1. Arterial Blood pH < 7.3
    2. Serum bicarbonate <20 mmol/L
    3. CO2 level 10-20 mmHg
  3. Urinalysis
    1. Specific gravity
    2. pH
    3. Glucose (glucosuria)
    4. Ketones (ketonuria)
  4. Clinical manifestations
    1. Hyperosmalality
      1. Polyuria
      2. Polydypsia
      3. Altered LOA
    2. Dehydration
      1. Tachycardia
      2. Dry mucous membreanes
      3. Poor skin turgor
      4. Hypotension
    3. Metabolic Acidosis
      1. Nausea & vomiting
      2. Abdominal pain
      3. Kussmaul's respirations (laboured breathing)
    4. Ketosis
      1. Sweet, fruity breath
2. Subjective
  1. Past medical hx
  2. Family hx
  3. Physical examination
Treatment/Interventions (Lewis et al, 2014)
1. Ensure patent airway
2. Administer oxygen as per MD order
3. Restore fluid and electrolyte balance (IV NS) (Lewis et al, 2014)
  1. D5W infusion → prevention of hypoglycemia
  2. Administer K + IV → corrects hypokalemia
  3. Administration of IV fluids → corrects dehydration
  4. IV administration of rapid or short-acting insulin → corrects hyperglycemia & hyperketonemia
4. Insulin infusion- 0.1U/kg/hr (tx of ketoacidosis)
5. Nursing Management (Lewis et al, 2014)
  1. Monitor blood glucose & urine output for ketones
  2. Monitor level of consciousness
  3. Monitor signs of potassium imbalance (due to osmotic diuresis
  4. Monitor ECG → cardiac functioning is affected by movement of K+
  5. Assess cardiac and respiratory status
  6. Monitor VS for fever, hypovolemic shock, tachycardia, & Kussmaul's breathing
6. IV sodium bicarbonate to treat severe acidosis (pH < 7)
Pathophysiology (Copstead-Kirkhorn & Banasik, 2014)
1. Decrease supply of circulating insulin
  1. Glucose cannot be used for energy
    1. Body breaks down fat as secondary source
      1. Ketones arise as by-products, altering pH, in excess leading to metabolic acidosis
2. Ketonuria
3. Hyperosmolality
4. Hypokalemia
5. Hyperglycemia:
6. Metabolic Acidosis:
7. Clinical Manifestations (MacArthur & Phillips, 2015)
Complications (Lewis et al, 2014)
1. Rapid administration of IV fluids + insulin → cerebral edema
2. Treating hyperglycemia causes K+ to move rapidly into cells
  1. impacts cardiac functioning
3. Overcorrection of fluid losses
  1. Fluid overload & pulmonary edema
4. Untreated hyperglycemia
  1. Decreased levels of sodium, potassium, chloride, magnesium, & phosphate
5. Renal failure caused by hypovolemic shock
  1. Retention of ketones & glucose
    1. Progressive metabolic acidosis
      1. Comatose due to dehydration, electrolyte imbalance, & acidosis
Special Considerations
1. Children with Type 1 Diabetes
  1. Presenting factor for diabetic ketoacidosis (McFarlane, 2011)
    1. Cerebral edema occurs in <1% of all paediatric DKA cases (Long & Koyfman, 2017)
    2. Children < 3 years old & come from areas with low prevalence of diabetes are at risk for moderate to severe DKA (Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018)
2. Risk factors for children that increase likelihood of DKA: (Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018; Oettingen, Rhodes, & Wolfsdorf, 2018; MacArthur & Phillips 2015)
  1. Low socioeconomic status
  2. High family conflict
  3. Limited access to health care
  4. Poor metabolic control
  5. Previous episodes of DKA
  6. Adolescent females
  7. Children with psychiatric disorders
  8. Ethnic minorities
3. Management of DKA for children
  1. Fluid resuscitation is the primary goal
    1. Always weigh child before because rapid rehydration can lead to cerebral edema (McFarlane, 2011)
    2. Fluid bolus of 10-20 mL/kg is likely safe for children (Long & Koyfman, 2017)
  2. Potassium replacement therapy & insulin therapy (McFarlane, 2011)
  3. Mannitol or hypertonic saline used for treatment of cerebral edema

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Mindmap: Diabetic Ketoacidosis (DKA)

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