Diabetic Ketoacidosis (DKA)

Pathophysiology
1. 3. H+ ions released from lipolysis and proteolysis, ketone levels rise in the blood -> low pH level
  1. 2. Fat and protein become fuel source -> triglycerides broken down into glycerol and free fatty acids (lipolysis) -> liver converts free fatty acids to ketone bodies -> proteins broken down into amino acids (proteolysis) -> process continues
    1. 1. Insulin supply insufficient -> ↑ in counter regulatory hormones (glucagon, catecholamines, cortisol, growth hormone) -> insulin resistance -> ↑ hepatic glucose production -> inability of glucose to enter cells for energy use
      1. HYPERGLYCEMIA
        DKA PATIENT WILL HAVE A BLOOD GLUCOSE GREATER THAN 14 mmol/L
    2. HYPERKETONEMIA KETONURIA DEHYDRATION
  2. METABOLIC ACIDOSIS
    1. RESPIRATORY COMPENSATION
2. NORMAL PANCREATIC FUNCTION IMPAIRED IN DM
Nursing Interventions/Treatment
1. MAINTAIN A OPEN AIRWAY
2. ESTABLISH IV ACCESS
  1. ADMINISTER NORMAL SALINE VIA IV ACCESS (AS PER ORDERS)
    1. UNTIL BLOOD PRESSURE IS STABLE
    2. UNTIL URINE OUTPUT IS 30 TO 60 mL per hour
  2. ADMINISTER INSULIN VIA IV (AS PER ORDERS)
    1. dose: 0.1mg/kg/hr
  3. ADMINSTER IV POTASSIUM FOR HYPOKALEMIA (AS PER ORDERS)
    1. REPLENISH OTHER ELECTROLYTES IF INDICATED (AS PER PATIENT ORDERS)
  4. IF PATIENT HAS A pH LESS THAN 7.0
    1. ADMINISTER IV SODIUM BICARBONATE (AS PER ORDERS)
  5. SWITCH TO D5W WHEN BLOOD GLUCOSE NEARS 14 mmol/L
    1. PREVENTS HYPOGLYCEMIA
3. OBTAIN VITAL SIGNS
4. ADMINISTER O2 (AS PER ORDERS)
5. COMPLETE A THOROUGH HEAD TO TOE ASSESSMENT
6. MONITOR LEVELS
  1. BLOOD GLUCOSE
  2. BICARBONATE
  3. KETONES
  4. pH
  5. ELECTROLYTES
  6. BLOOD GASES
7. ASSESS
  1. LEVEL OF CONSCIOUSNESS
    1. COMPLETE GLASGOW COMA SCALE EVERY 1-2 HOURS
  2. CARDIAC and RESPIRATORY STATUS
8. PREVENTION
  1. DIABETES EDUCATION
    1. DKA EDUCATION
      1. SIGNS AND SYMPTOMS
      2. WHAT TO DO
  2. DENSIIIA
    1. DIAGNOSE EARLY
    2. NEVER STOP INSULIN
    3. INCREASE INSULIN APPROPRIATELY
Etiology
1. TYPE 1 DIABETES MELLITUS (DM)
  1. STRESS, INFECTION/ILLNESS, SURGERYTRAUMA
    1. Pancreas unable to meet insulin demand
  2. UNDIAGNOSED DM, INSULIN OMISSION, INSUFFICIENT INSULIN DOSAGE
    1. All lead to ↑ levels of blood glucose that cannot be used for energy because of insufficient insulin
  3. EXERCISE REGIMEN
    1. Muscles use glucose for energy -> exercise burns glucose -> liver releases glucose into blood stream -> insufficient insulin supply means muscles cannot use glucose for energy -> glucose is not used and remains in the blood stream
  4. PREGNANCY
    1. Placental hormones cause insulin resistance --> ↑ insulin requirements
      1. CAUTION: Ketones harmful to fetus
  5. DRUGS (CORTICOSTEROIDS, SYMPATHOMIMETICS, ATYPICAL ANTIPSYCHOTICS)
    1. Stimulate the liver to secrete glucose, impair glucose metabolism, and make it difficult for cells to use insulin aka insullin resistance
Clinical Manifestations
1. DEHYDRATION
  1. DRY MUCOUS MEMBRANES
  2. ORTHOSTATIC HYPOTENSION
  3. RATE (ALSO, PERIPHERAL PULSES MAY BE WEAK)
  4. SKIN TURGOR
  5. INCREASED THIRST
2. NAUSEA and VOMITING
3. INCREASED URINATION
4. KUSSMAUL RESPIRATIONS (LABOURED BREATHING)
5. BREATH THAT SMELLS LIKE
6. ABDOMEN PAIN/TENDERNESS
7. Neurological Signs/Symptoms
  1. LEVEL OF CONSCIOUSNESS
  2. CONFUSION & LETHARGY
  3. HEADACHES/MIGRAINES
  4. AGITATED/IRRITABLE
8. PALE SKIN
Complications
1. DEHYDRATION
  1. Result of: 1. OSMOTIC DIURESIS 2. ELECTROLYTE LOSS/IMBALANCE 3. VOMITING
    1. 3. Acidosis from DKA can induce vomiting = loss of more fluid and electrolytes
    2. 2. When ketones (anion) are excreted electrolytes such as sodium (Na) and potassium (K+) (cation) are excreted leading a loss of electrolytes
      1. Most affected electrolyte = K+... H+ ions (acidic) from lipolysis and proteolysis push K+ out of cell, K+ excreted in urine
    3. 1. Result of hyperglycemia and lipolysis, glucose and ketones excreted in urine (GLUCOSURIA, KETONURIA)
2. HYPOVOLEMIA
  1. Result of: PROLONGED FLUID LOSS
    1. HYPOVOLEMIC SHOCK IF NOT TREATED
3. RENAL FAILURE
  1. Result of: ↓ GLOMERULAR FILTRATION RATE, VITAL ORGANS NO LONGER ABLE TO COMPENSATE
    1. Kidneys can no longer excrete ketones or glucose, body becomes even more acidotic
4. COMA
  1. Result of: DEHYDRATION, ELECTROLYTE LOSS, ACIDOSIS
5. DEATH
MEDICAL EMERGENCY
By: Destinee Shepherd & Katherine Schlorff
NORMAL PANCREATIC FUNCTION
1. PANCREAS
  1. ISLET OF LANGERHANS
    1. BETA CELL
      1. RELEASES INSULIN
        Blood sugar DECREASES
    2. ALPHA CELL
      1. RELEASES GLUCAGON
        Blood sugar INCREASES

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Diabetic Ketoacidosis (DKA)

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	Created by Destinee Shepherd over 6 years ago