PREPARED BY: ZYRINE M.

SALOMON

COMPREHENSIVE NURSING/MEDICAL MANAGEMENT OF DIABETIC KETOACIDOSIS

The therapeutic goals of DKA management include optimization of:
1) Volume status;
2) Hyperglycemia and ketoacidosis;
3) Electrolyte abnormalities;
4) Potential precipitating factors
Assessment of severity
The presence of one or more of the following may Indicate severe DKA :
Blood ketones over 6 mmol/L
Bicarbonate level below 5 mmol/L
Venous/arterial pH below 7.1
Hypokalaemia on admission (under 3.5 mmol/L)
GCS less than 12 or abnormal AVPU scale
Oxygen saturation below 92% on air (assuming
Normal baseline respiratory function)
Systolic BP below 90 mmHg
Pulse over 100 or below 60 bpm
Action 1 - Intravenous access and initial
Investigations

Rapid ABC (Airway, Breathing, Circulation)

Large bore IV cannulae and commence IV fluid
Replacement
Clinical assessment: Respiratory rate; temperature; blood pressure;
Pulse; oxygen saturation
Check Glasgow Coma Scale- a drowsy patient in the context of DKA is serious and the patient
requires critical care input. Consider NG tube with airway protection to prevent aspiration
Full clinical examination of the patient then report immediately to the attending physician if there
is untoward signs and symptoms
Initial investigations should include:
1. Blood ketones
2. Capillary blood glucose
3. Venous plasma glucose
4. Urea and electrolytes
5. Venous blood gases
6. Full blood count
7. Blood cultures
8. ECG
9. Chest radiograph
10. Urinalysis and culture
Continuous cardiac monitoring
Continuous pulse oximetry
Consider precipitating causes and treat

Appropriately
Establish usual medication for diabetes prescribed by the doctor

Action 2 Restoration of circulating volume

Assess the severity of dehydration using pulse and blood pressure. As a guide 90mmHg may be
used as a measure of hydration but take age, gender and concomitant medication into account.

NURSING CONSIDERATIONS: Systolic BP (SBP) on admission below 90mmHg Hypotension is likely to

be due to low circulating volume, but consider other causes such as heart failure, sepsis, etc.

Give 500 ml of 0.9% sodium chloride solution over 10-15 minutes. If SBP remains below
90mmHg this may be repeated as ordered. In practice most patients require between 500 to
1000 ml given rapidly.
If there has no clinical improvement consider other causes of hypotension and report
immediately to attending physician
Once SBP above 90mmHg follow fluid replacement as below:

Fluid Volume
0.9% sodium chloride 1L * 1000ml over 1st hour
0.9% sodium chloride 1L with potassium chloride 1000ml over next 2 hours
0.9% sodium chloride 1L with potassium chloride 1000ml over next 2 hours
0.9% sodium chloride 1L with potassium chloride 1000ml over next 4 hours
0.9% sodium chloride 1L with potassium chloride 1000ml over next 4 hours
0.9% sodium chloride 1L with potassium chloride 1000ml over next 6 hours
Re-assessment of cardiovascular status at 12 hours is mandatory, further fluid may be
Required

Monitor closely the following patients undergoing fluid replacement: Young people aged 18-25
years, Elderly, Pregnant, Heart or kidney failure and other serious co-morbidities.

Action 3 - Potassium replacement

Hypokalaemia and hyperkalaemia are life threatening conditions and are common in DKA. Serum
potassium is often high on admission (although total body potassium is low) but falls precipitously
upon treatment with insulin. Regular monitoring is mandatory.

Action 4 - Commence a fixed rate intravenous insulin infusion

B. 60 minutes to 6 hours, 6hours to 12hours and 12 hours to 24 hours
1. Re-assess patient, monitor vital signs
Consider urinary catheterization if incontinent or anuric (i.e. not passed urine by 60 minutes)
Consider naso-gastric tube if patient obtunded or if persistently vomiting
Continuous cardiac monitoring in those with severe DKA
2. Review metabolic parameters
3. Identify and treat precipitating factors
NURSES CARING FOR PATIENTS WITH DIABETIC KETOACIDOSIS SHOULD REMEMBER THESE:
1. Maintain patent airway
2. Administer oxygen therapy as prescribed
3. Treat dehydration with normal saline 0.9% and 0.45% rapid IV as prescribed
4. D5NS OR 5% DEXTROSE IN 0.45% SALINE when the blood glucose level reaches 250300mg/dl.
To prevent abrupt fall of blood glucose levels.

5. Treat hyperglycemia with regular insulin IV as prescribed. A dose of 5-10 units of regular insulin
by IV bolus may be prescribed followed by continuous infusion
6. Mix prescribed IV dose of insulin for continuous infusion in 0.9% and 0.45% saline or prescribed.
7. Small dose of albumin may be mixed with insulin and saline solution to prevent adherence of
insulin molecules to plastic IV infusion sets.
8. Always use infusion pump for insulin infusion
9. Monitor potassium levels, glucose levels, and urinary output and for signs of increased
intracranial pressure. If blood glucose severely drops too fast before the brain can equilibrate
water is pulled from the blood to the csf and the brain. This causes edema and increased ICP.
10. Correct electrolyte imbalances.
11. Potassium replacement may be required. Ensure adequate renal function; urine output of 30-60
ml per hour before administering potassium to prevent renal damage.
12. The maximum amount of potassium chloride that may be mixed with 1 liter of IV fluid is 40 meq.
13. The maximum amount of potassium supplement that maybe given per infusion is 10meq per hour
14. Always use IV infusion pump for potassium infusion,
15. Never administer potassium as bolus or IV push, cardiac arrest may occur if potassium is given
via bolus or IV push
DISCHARGE CARE

DISCHARGE INSTRUCTIONS:
WHAT YOU NEED TO KNOW:
Diabetic ketoacidosis (DKA) is a life-threatening condition caused by dangerously
high blood sugar levels. Your blood sugar levels become high because your body does not
have enough insulin. Insulin helps move sugar out of the blood so it can be used for energy.
The lack of insulin forces your body to use fat instead of sugar for energy. As fats are broken
down, they leave chemicals called ketones that build up in your blood. Ketones are
dangerous at high levels.
Seek care/ Contact health care provider immediately if:
You have a seizure.
You begin to breathe fast, or are short of breath.
You become weak and confused
You have fruity, sweet breath.
You have severe, new stomach pain and are vomiting.
You are more drowsy than usual.
Your blood sugar level is lower or higher than your healthcare provider says it
should be.
You have ketones in your blood or urine.
You have a fever or chills.
You are more thirsty than usual.
You are urinating more often than usual.
You have questions or concerns about your condition or care.
Medicines:
Insulin and diabetes medicine decreases the amount of sugar in your blood.Take
your medicine as directed. Call your healthcare provider if you think your medicine is not
helping or if you have side effects. Tell him if you are allergic to any medicine. Keep a list
of the medicines, vitamins, and herbs you take. Include the amounts, and when and why
you take them. Bring the list or the pill bottles to follow-up visits. Carry your medicine list
with you in case of an emergency.
Help prevent DKA:
Monitor your blood sugar levels closely if you have an infection, are stressed, or
experience trauma. Check your blood sugar levels often. You may need to check

at least 3 times each day. If your blood sugar level is too high, give yourself
insulin as directed by your healthcare provider
Manage your sick days. When you are sick, you may not eat as much as you
normally would. You may need to change the amount of insulin you give yourself.
You may need to check your blood sugar level more often than usual. Make a
plan with your healthcare provider about how to manage your diabetes when you
are sick.
Check your ketones as directed. Follow your healthcare provider's instructions
about when you should check your blood or urine for ketones. Your healthcare
provider may give you a machine to check your blood ketones. Urine ketones
can be checked with sticks you dip in your urine. Do not exercise if you have
ketones in your urine or blood.
Know how to treat DKA symptoms at home. If you have signs of DKA, drink more
liquids that do not contain sugar, such as water. Take your insulin as directed by
your healthcare provider and go to the nearest emergency room.
Healthy diet and Healthy lifestyle
Follow up with your health care provider
LEARNING INSIGHTS:

One of the most notorious complications of diabetes is diabetic ketoacidosis, or DKA.

DKA represented something close to the ultimate diabetes emergency: In just 24 hours,
people can experience an onset of severe symptoms, all leading to coma or death.

Diabetic ketoacidosis (DKA) is a life-threatening condition that develops when cells in the
body are unable to get the sugar (glucose) they need for energy because there is not
enough insulin. When the sugar cannot get into the cells, it stays in the blood. The
kidneys filter some of the sugar from the blood and remove it from the body through
urine.Because the cells cannot receive sugar for energy, the body begins to break down
fat and muscle for energy. When this happens, ketones, or fatty acids, are produced and
enter the bloodstream, causing the chemical imbalance (metabolic acidosis) called
diabetic ketoacidosis.

Ketoacidosis can be caused by not getting enough insulin, having a severe infection or
other illness, becoming severely dehydrated, or some combination of these things. It can
occur in people who have little or no insulin in their bodies (mostly people with type 1
diabetes but it can happen with type 2 diabetes, especially children) when their blood
sugar levels are high.

Keeping blood sugars in the normal range can help prevent DKA: 70-180 mg/dl is ideal.
Risk of DKA increases substantially when blood glucose levels exceed 240 mg/dl.
Sticking with healthy, regular eating patterns and taking medications at the right times are
also critical for preventing DKA

If ketone levels are high enough to put patient at risk of DKA, be prepared to act quickly
in getting emergency care. The treatment for DKA involves dealing with the various
symptoms, which means: Rehydration, Replacement of lost electrolytes and Regular
administration of insulin

DKA is very treatable, but only as long as its diagnosed promptly and patients
understand the risk.