Diabetic ketoacidosis (DKA) is a serious and potentially life-threatening complication of diabetes that results in a very high glucose level. It typically occurs in those with type 1 diabetes but can also develop in patients with type 2 diabetes.
When the body doesn’t have enough insulin to allow glucose into the cells for energy, fats will be broken down instead, producing ketones. Ketones make the blood dangerously acidic.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Decreased Cardiac Output
- Ineffective Tissue Perfusion
- Risk For Deficient Fluid Volume
- Risk For Unstable Blood Glucose
Nursing Process
DKA requires prompt treatment and close monitoring as deterioration can lead to coma and death. Priority treatment includes the administration of IV insulin and fluids which must be titrated correctly so as not to cause secondary complications. Nurses must also educate patients and family members on how to recognize symptoms of DKA as well as prevent recurrences.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to diabetic ketoacidosis.
Review of Health History
1. Inquire about the patient’s general symptoms.
The following are DKA warning signs and symptoms:
- General: unintended weight loss in patients newly diagnosed with type 1 diabetes (related to dehydration), generalized weakness, fatigue, drowsiness
- CNS: Altered consciousness, headache, blurred vision
- GI: nausea and vomiting, diffuse abdominal pain, decreased appetite
- GU: increased urination
- Integumentary: dry skin
- Musculoskeletal: myalgia, muscle stiffness
2. Interview the patient about their use of insulin.
Those with type 1 diabetes do not produce insulin or very little of it, so if they are not administering enough insulin or at incorrect frequencies, this can cause hyperglycemia. Determine if the following barriers are present:
- A history of nonadherence to insulin therapy
- Missed insulin injections due to nausea or varied mealtimes
- Inability to self-administer medication due to physical or mental limitations
- History of mechanical insulin infusion pump failure
3. Investigate for an infection.
Ask the patient about a history of UTIs, pneumonia, recent surgery, or other possible infectious sources. Infections increase blood glucose levels, and illnesses causing vomiting and a lack of appetite will also make glucose levels hard to manage.
4. Review the patient’s medication list.
Oral antidiabetic drugs (particularly SGLT2 inhibitors) are linked to an increase in DKA. Some corticosteroids and antipsychotic medications can result in DKA. It is also essential to determine whether the patient has a substance abuse disorder, as this can increase the rate of nonadherence to insulin regimens.
Physical Assessment
1. Monitor vital signs.
Patients with diabetic ketoacidosis will display a fever or hypothermia in the presence of an infection, tachycardia, tachypnea, and Kussmaul breathing (rapid and deep respirations).
2. Perform a physical examination.
Physical examination findings will reveal signs of dehydration, cerebral edema, or infection, including:
- General: ill appearance, weakness, weight loss, fever
- CNS: decreased mentation, drowsiness, decreased reflexes (hyporeflexia), headache, confusion
- Integumentary: dry skin, dry mucous membranes, poor skin turgor, flushed skin
- Respiratory: labored, deep, rapid breathing (Kussmaul breathing), fruity-scented breath odor (indicative of the presence of acetone), cough
- Cardiovascular: poor capillary refill
- GI: vomiting, abdominal tenderness upon palpation
- Genitourinary: Decreased urine output (with severe volume depletion)
3. Assess for the presence of ketones.
The body cannot utilize glucose to produce the necessary energy without insulin. This results in hormones breaking down fat for the body to use as fuel which generates acids known as ketones. When ketones accumulate in the blood, they eventually leak into the urine (ketonuria) and breath (fruity scent).
4. Look for the presence of cerebral edema.
The brain swells if blood sugar levels change too quickly. Children are more prone to cerebral edema, particularly those who have just been diagnosed with diabetes. Symptoms of cerebral edema include:
- Fluctuations in consciousness
- Sustained heart rate deceleration
- Incontinence
- Abnormal responses to pain
- Decorticate and decerebrate posturing
- Lethargy
Diagnostic Procedures
1. Obtain blood for testing.
The following blood results will diagnose DKA:
- Blood sugar levels of more than 250 mg/dL
- Arterial pH below 7.3
- Serum bicarbonate level below 15 mEq/L
- Presence of ketonemia (ketones in the blood)
- Anion gap more than 10 in mild DKA and greater than 12 in moderate or severe DKA. (Note: These numbers distinguish DKA from HHS (hyperosmolar hyperglycemic syndrome), which is a blood sugar level higher than 600 mg/dL, a pH higher than 7.3, and a serum bicarbonate level above 15 mEq/L.)
2. Collect urine for urinalysis.
The urinalysis or urine dipstick test is positive for glucose and ketones in patients with DKA.
3. Check for the presence of infection.
Leukocytosis is a common finding in DKA. Depending on the circumstances, additional tests may be required, including chest X-rays, serum lipase tests, and cultures of the urine, sputum, and blood. The most frequent conditions that lead to DKA are pneumonia and urinary tract infections.
4. Perform an ECG.
An ECG can assist in identifying ischemia changes related to hypo- or hyperkalemia. Peaked T waves can indicate hyperkalemia, while low T waves with U waves indicate hypokalemia.
5. Assist the patient in imaging scans as ordered.
A CT scan can identify DKA caused by acute pancreatitis if liver enzymes are elevated. Cerebral edema can be identified by MRI and CT imaging of the head.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with diabetic ketoacidosis.
Reverse Diabetic Ketoacidosis
1. Manage diabetic ketoacidosis.
The cornerstones of management in diabetic ketoacidosis are fluid resuscitation and maintenance, insulin therapy, electrolyte restoration, and supportive care.
2. Promote hydration.
Patients with DKA may lose 10% to 15% of their body weight in fluid. Immediate fluid resuscitation is essential to reverse hypovolemia, restore tissue perfusion, and eliminate ketones. Regardless of insulin, hydration improves glycemic control. 0.9% normal saline is the IV fluid of choice for initial hydration.
3. Administer insulin as ordered.
IV short-acting insulin by continuous infusion is recommended until the glucose level is below 200 mg/dL, plus two of the following:
- Serum bicarbonate level ≥ 15 mEq/L
- pH > 7.3
- Anion gap ≤ 12 mEq/L
4. Correct the electrolytes.
Insufficient insulin levels might deplete various electrolytes in the blood. Administer electrolytes intravenously as prescribed to keep the heart, muscles, and nerve cells functioning normally.
5. Replenish potassium as ordered.
Potassium levels may appear elevated or normal with DKA, but insulin will cause potassium to shift into the cells, causing severe hypokalemia. If the patient presents with hypokalemia, this must be addressed before administering insulin to prevent life-threatening cardiac arrhythmias. Monitor potassium closely to maintain a range of 4.0 – 5.0 mEq/L.
6. Monitor the laboratory findings.
Explain to the patient the need for routine laboratory testing.
- Point-of-care testing (POCT) for glucose should be done every hour.
- Reassess serum glucose and electrolyte levels every two hours until they are stable, and then every four hours.
- Obtain blood urea nitrogen (BUN) at baseline.
- Monitor ABG levels as necessary.
7. Maintain acid-base balance.
When decompensated acidosis becomes life-threatening, especially when accompanied by sepsis or lactic acidosis, sodium bicarbonate is given. Bicarbonate may cause cerebral edema in children, so administer with caution.
Treat or Prevent Complications
1. Treat concurrent infections.
Use the outcomes of culture and sensitivity studies as a guide to administering the right antibiotics in the presence of infection. Empiric antibiotics can be started when there is a suspicion of infection until culture results are available.
2. Infuse mannitol for cerebral edema.
Cerebral edema is rare but carries a significant mortality risk. Mannitol is commonly utilized as the initial treatment. It is crucial to frequently perform mental status and neurological examinations to intervene if symptoms arise.
3. Prevent overhydration.
If the patient has a history of renal failure or congestive heart failure, take caution when administering large amounts of intravenous fluids. Diuretics may also be necessary to manage pulmonary edema.
4. Prevent hypoglycemia.
Overcorrection of hyperglycemia may result in hypoglycemia if glucose levels are not carefully monitored.
Provide Education to Prevent Recurrences
1. Ask the patient to demonstrate using a glucose monitoring device.
Prior to discharge, the nurse should review glucose monitoring and have the patient demonstrate using their glucometer.
2. Teach the patient how to avoid DKA.
The nurse can instruct the patient on adjusting their insulin regimens on sick days and self-testing for urine ketones when their blood sugar is over 250 mg/dL. Educate the patient to increase monitoring when ill or under stressful circumstances.
3. Maintain blood glucose levels within normal limits.
Educate the patient on their recommended glucose range. Encourage the patient to adhere to their insulin or antidiabetic regimen.
4. Refer the patient to a diabetologist or endocrinologist.
Diabetologists are endocrinologists with advanced training in the management of diabetes. If not under the care of an endocrinologist, refer the patient to receive more specialized care and diabetes management instruction.
5. Instruct on signs and symptoms of DKA.
DKA is a medical emergency that requires intervention to prevent deterioration. Educate the patient and family on signs to monitor for, such as:
- More than one unexplained episode of vomiting
- Abdominal pain
- Excessive diarrhea
- Difficulty breathing
- Glucose levels sustained over 300 mg/dL
6. Refer the patient to DSMES.
Refer the patient to a diabetes self-management education and support (DSMES) program. DSMES services are essential for managing and coping with diabetes while maintaining good health.
7. Collaborate with a diabetic educator.
The diabetes educator can assist the patient and their caregivers in gaining the knowledge, skills, motivation, and confidence needed to manage DM.
8. Consider a nurse case manager referral.
If the patient cannot safely manage their diabetes independently or is struggling to afford diabetic supplies and medications, a nurse case manager or social worker can direct them to community and financial resources.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for diabetic ketoacidosis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for diabetic ketoacidosis.
Acute Confusion
Severe DKA may result in confusion or agitation. Cerebral edema is a rare but serious complication of DKA.
Nursing Diagnosis: Acute Confusion
Related to:
- Delirium
- Cerebral edema
- Metabolic encephalopathy
As evidenced by:
- Confusion
- Agitation
- Fluctuation in cognition
- Headache
- Lethargy
- Increased intracranial pressure
Expected outcomes:
- Patient will remain alert and oriented to person, place, and time.
- Patient will not experience seizures, cerebral edema, or coma from DKA.
Assessment:
1. Assess cognition.
Monitor closely for changes in cognition and consciousness. The Glasgow Coma Scale (GCS) may be used in some settings.
2. Monitor lab work.
All electrolyte levels should be monitored along with pH levels, ketones, and plasma glucose.
3. Review imaging scans.
CT scans or MRIs can be used to assess for dilated ventricles in the brain. Treatment should not be delayed for suspected cerebral edema.
Interventions:
1. Administer insulin.
IV insulin is the standard treatment for DKA as the patient needs insulin rapidly to decrease glucose and ketone levels.
2. Avoid overhydration.
Fluid replacement is another priority intervention though overhydration can lead to cerebral edema so nurses must carefully rehydrate.
3. Consider magnesium.
Magnesium deficits can contribute to cognitive symptoms such as tremors, agitation, and seizures. Magnesium levels should be checked and corrected.
4. Wear a medical alert bracelet.
In the event that DKA occurs when no one is around or the patient is too confused to verbalize, a medical alert bracelet can be lifesaving.
Decreased Cardiac Output
Inadequate heart pumping ability due to expansive myocardial dysfunction caused by elevated blood glucose levels leading to acidosis and electrolyte imbalances.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Hyperglycemia
- Hypovolemia
- Acidosis
- Hypokalemia
- Hyperkalemia
- Myocardial injury
As evidenced by:
- Tachycardia
- Tachypnea
- Dyspnea
- Reduced oxygen saturation
- Hypotension
- Decreased central venous pressure (CVP)
- Increased pulmonary artery pressure (PAP)
- Chest pain
- Abnormal heart sounds
- Dysrhythmia
- Fatigue
- Change in level of consciousness
- Anxiety/Restlessness
- Abnormal electrolyte levels
- Abnormal ABGs
- Elevated cardiac biomarkers
Expected outcomes:
- Patient will manifest adequate cardiac output as evidenced by the following:
- Systolic BP within 20 mmHg of baseline
- Heart rate: 60 to 100 beats/min with a regular rhythm
- Respiratory rate: 12 to 20 breaths/min
- Patient will demonstrate potassium levels within a range of 4.0-5.0 mEq/L.
Assessment:
1. Monitor respiratory rate, heart rate, and blood pressure.
DKA frequently causes tachypnea, tachycardia, and hypotension in relation to hypovolemia.
2. Monitor 12-lead ECG.
ECG provides information about dysrhythmias and the development of myocardial ischemia.
3. Monitor electrolytes, ABGs, and cardiac biomarkers.
Cardiac dysrhythmia occurs secondary to hypokalemia and/or acidosis in DKA and often resolves after proper treatment. The nurse should initially assess these lab results and redraw them as directed until resolution.
Interventions:
1. Correct electrolyte imbalances.
With DKA, insulin causes potassium to shift into cells which can cause rebound hypokalemia. If potassium levels are low, potassium should be replaced before administering insulin to prevent cardiac arrest and dysrhythmias.
2. Administer supplemental oxygen as needed.
Some patients with a history of congestive heart failure may be at risk for fluid overload since DKA requires aggressive fluid resuscitation. Provide supplemental oxygen to manage symptoms of pulmonary edema and to prevent hypoxia.
3. Consider sodium bicarbonate for acidosis.
If sepsis or lactic acidosis is observed, sodium bicarbonate can be infused to correct acidosis and prevent dysrhythmias.
4. Consult with cardiology.
Patients who continue to display dysrhythmias despite proper treatment should receive a cardiology consult.
Ineffective Tissue Perfusion
Diabetic ketoacidosis causes cerebral hypoperfusion, hypovolemia, and decreased renal perfusion.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Septic shock
- Acidosis
- Renal failure
- Vomiting
- Dehydration
- Hyperglycemia
- Cerebral edema
As evidenced by:
- Fever (>38.0 C) or hypothermia (< 36.0 C)
- Tachycardia
- Tachypnea
- Leukocytosis
- Hypotension
- Prolonged capillary refill time
- Change in level of consciousness
- Oliguria
- Nausea and vomiting
- Dry skin
- Poor skin turgor
Expected outcomes:
- Patient will maintain optimal perfusion as evidenced by the following:
- Temperature: 36.5 to 37.4C
- HR: 60 to 90 bpm
- RR: 12-20 breaths per min
- BP: SBP>90 to <140 mmHg / DBP >60 to <90 mmHg
- Urine output 0.5 to 1.5 cc/kg/hour
- WBC 4,000 to 12,000/mm3
- Capillary refill time <2 secs
- Patient will not experience any alterations in consciousness or orientation.
Assessment:
1. Monitor vital signs.
Elevated WBC count plus abnormal vital signs such as fever, tachycardia, and tachypnea are manifestations of sepsis. If these parameters are accompanied by hypotension and organ damage, septic shock is occurring.
2. Monitor complete blood count.
Even in the absence of infection, the CBC shows an increased WBC count in patients with DKA. Marked leukocytosis or leukopenia may suggest sepsis—a complication of DKA.
3. Assess blood urea nitrogen (BUN) and creatinine.
These lab tests should be drawn initially to obtain a baseline and reassessed as instructed to monitor for signs of impaired kidney function.
Interventions:
1. Administer IV fluid as ordered.
Fluid resuscitation is crucial in the management of patients with DKA. IV fluids replace extravascular and intravascular fluids and electrolyte losses. High glucose levels and counterregulatory hormones become diluted. 0.9% normal saline is the IV fluid of choice.
2. Prevent cerebral edema.
Rare and most common in children, cerebral edema is a serious complication often associated with ongoing hyponatremia. Monitor closely for alterations in cognition, posturing, and lethargy as signs of cerebral hypoperfusion. Mannitol or a hypertonic saline solution is the suggested treatment.
3. Monitor urine output.
Patients with DKA are also prone to acute renal failure due to hypovolemia and sepsis. Urine output is a helpful tool in assessing renal function.
4. Administer medications as ordered.
Infections are a common cause of DKA. Broad-spectrum antibiotics aid in controlling the source of infection until the pathogen is identified to prevent worsening perfusion.
Risk For Deficient Fluid Volume
Dehydration and electrolyte imbalances can result from fluid losses.
Nursing Diagnosis: Risk For Deficient Fluid Volume
Related to:
- Vomiting
- Kussmaul respirations
- Polyuria
- Glycosuria and osmotic diuresis
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred. Nursing interventions are directed at prevention.
Expected outcomes:
- Patient will identify causes and related symptoms causing fluid loss.
- Patient will remain normovolemic as evidenced by urine output, electrolyte levels, and vital signs within normal limits.
Assessment:
1. Assess vital signs and respirations.
Dehydration will cause tachycardia and low blood pressure. Kussmaul respirations are another common finding. These rapid, shallow breaths are a result of the body’s attempt to correct acidosis in the blood. A fruity odor on the breath is a classic accompanying sign.
2. Monitor electrolytes.
Potassium levels will typically be elevated initially but will drop as fluid volume decreases while magnesium and sodium levels will be deficient. All electrolytes should be replaced and may resolve simply with fluid or insulin administration.
3. Assess kidney function urine output.
Acute kidney injury can result due to osmotic polyuria and volume depletion. Progression to chronic kidney disease is a concern and increases mortality. Urine output should stabilize with treatment. Monitor serum creatinine levels and eGFR decline.
Interventions:
1. Administer isotonic solutions initially.
Fluid replacement alone will begin to lower blood glucose. Initial isotonic therapy of 0.9% saline is recommended. A transition to a hypotonic solution such as 0.45% saline may be used as long as sodium levels remain normal.
2. Give dextrose once glucose levels stabilize.
Once glucose levels reach 250 mg/dL, dextrose should be given to prevent further ketosis.
3. Offer oral fluids.
If the patient is alert and oriented and can safely swallow, or if their DKA is mild, oral fluid resuscitation is also advised.
4. Educate on symptoms for prevention.
To prevent a recurrence of DKA or when to seek prompt treatment, educate the patient on symptoms such as polydipsia, polyuria, (early signs) nausea and vomiting, flushed skin, weakness, and fatigue.
Risk For Unstable Blood Glucose
Knowledge deficits, illnesses, injuries, stress, and incorrect insulin dosing can result in DKA.
Nursing Diagnosis: Risk For Unstable Blood Glucose
Related to:
- Lack of diabetic diagnosis
- Poor diabetes management
- Illness causing unstable glucose levels
- Nonadherence to insulin regimen
- Physical injury such as a motor vehicle accident
- Alcohol or drug use
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred. Nursing interventions are directed at prevention.
Expected outcomes:
- Patient will verbalize factors causing unstable blood glucose.
- Patient will verbalize the correct administration of insulin.
- Patient will maintain blood glucose levels within an acceptable range.
Assessment:
1. Assess understanding of diabetes diagnosis.
DKA often presents as the first sign of diabetes in patients who have yet to be diagnosed. In patients who are aware of their diagnosis, assess their understanding of the relationship between diabetes and insulin.
2. Review lab work.
Reviewing Hgb A1C levels can assess for a new diagnosis or poor long-term glucose control.
3. Assess their understanding of insulin.
Patients with type 1 diabetes require insulin as their pancreas does not make any. Assess the patient’s understanding and adherence to their prescribed insulin regimen.
Interventions:
1. Observe the patient using their glucometer.
Have the patient demonstrate using their glucose monitoring device. The nurse can also calibrate the device to ensure accuracy.
2. Use a ketone test kit.
Patients can be advised to purchase over-the-counter ketone testing kits. When cells don’t get adequate glucose the body breaks down fat for energy, producing ketones. High ketones can poison the body and cause DKA. Patients can test for ketones in their urine when their blood sugar is >240.
3. Educate on the causes of DKA.
Provide education on instances that affect insulin and may lead to DKA such as illnesses affecting fluid or food intake, alcohol intake, and medications.
4. Coordinate with a diabetes educator.
Patients who struggle with managing their diabetes may need education by a diabetes educator. These are usually nurses trained to help patients manage and understand their diabetes and medications.
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