Diabetic

ketoacidosis
(DKA)
 CONTENTS
01 02
Anatomy
Introduction on diabetic
&
ketoacidosis
physiology
03 04
pathophysiology ASSESSMENT

T 0
 DEFINITION OF TERMS
DIABETES - is a chronic, metabolic disease HYPERGLYCEMIA - high blood glucose
characterized by elevated levels of blood glucose (or
blood sugar), which leads over time to serious damage METABOLIC ACIDOSIS - characterized by an
to the heart, blood vessels, eyes, kidneys and nerves. increase in the hydrogen ion concentration in the
systemic circulation that results in an abnormally low
KETOSIS - a metabolic state that occurs when your serum bicarbonate level
body burns fat for energy instead of glucose.
OSMOTIC DIURESIS - increased urination due to
KETONES - chemicals made by the liver the presence of certain substances in the fluid filtered
by the kidneys
KETOACIDOSIS - a metabolic state associated with
pathologically high serum and urine concentrations of
ketone bodies.

T 1
01
WHAT IS
DKA?

T 1
 DEFINITION OF TERMS
DIABETES - is a chronic, metabolic disease HYPERGLYCEMIA - high blood glucose
characterized by elevated levels of blood glucose (or
blood sugar), which leads over time to serious damage METABOLIC ACIDOSIS - characterized by an
to the heart, blood vessels, eyes, kidneys and nerves. increase in the hydrogen ion concentration in the
systemic circulation that results in an abnormally low
KETOSIS - a metabolic state that occurs when your serum bicarbonate level
body burns fat for energy instead of glucose.
OSMOTIC DIURESIS - increased urination due to
KETONES - chemicals made by the liver the presence of certain substances in the fluid filtered
by the kidneys
KETOACIDOSIS - a metabolic state associated with
pathologically high serum and urine concentrations of
ketone bodies.

T 1
What is dka?
defined as uncontrolled catabolism associated with
insulin deficiency seen in patients with Type 1 Diabetes
resulting in hyperglycemia l, ketosis that causes
metabolic acidosis, and osmotic diuresis resulting in
profound dehydration. - is a life-threatening problem
that affects people with diabetes.

T 1
What is the cause of dka?

DKA develops when the body doesn’t have enough

insulin to allow blood sugar into cells for use as energy.

T 1
02
Anatomy and physiology
of the affected organs

Pancreas
Liver
Kidneys
03

pathophysiology
T 4
 Lack of Insulin Cells cannot utilize glucose

Cell starvation Hyperglycemia

250- 500+ mg/dl

Liver Lipolysis
Fat Breakdown

kidney
Fatty acid
Glycogenolysis
Stored glycogen in the liver is Osmotic diuresis
converted to glucose Formation of Glucose leaks into urine along with
electrolytes
ketones (k+, na+)

Ph acetone
Increased blood sugar polyuria polydipsia
levels
Metabolic acidosis Fruity
breath dehydration

Kaussmaul breathing
 04
ASSESSMENT

T 5
 SIGNS & SYMPTOMS OF Dka:
DEHYDRATION NAUSEA &
POLYDIPSIA
VOMITING

ABDOMINAL
POLYURIA
PAIN

T 2
 SIGNS & SYMPTOMS OF DKA:
ACETONE
SMELL OF KETONES
TACHYCARDIA
BREATH
“FRUITY”
HYPOTENSION,
KUSSMAUL
CONFUSION,
BREATHING
FATIGUE

T 2
 RISK FACTORS:
Type 1 Diabetes

Not taking prescribed insulin

Stomach Illness

Infections

Heart disease (heart attack)

Recent stroke
T 6
 RISK FACTORS:
Blood clot in your lungs

Serious illness or any trauma

Pregnancy

Surgery

Medicines (steriods or antipsychotics)

Using illegal drugs (cocaine)

T 6
 Diagnostic test
the following tests to diagnose DKA:

● Blood glucose test.

● Ketone testing (through a urine or blood test).
● Arterial blood gas.
● Basic metabolic panel.
● Blood pressure check.
● Osmolality blood test.

T 3
 PreventioN

How can I prevent DKA?

● Check your blood sugar often
● Take your insulin and/or medication regularly
● Check for ketones
● Check your insulin pump

T 3
 05
5 primary
Nursing
Diagnosis

T 4
06

INTERVENTIONS
T 4
 Nursing interventions:
PATIENT EDUCATION:
Teach them prevention and the warning signs

Monitor glucose and ketones in urine every

4 hours when sick

If can’t eat or drink, notify physician, but if

CAN, drink every hour

T 6
 Nursing interventions:
PATIENT EDUCATION:
Teach them prevention and the warning signs

Notify physician if B.S. > 300 mg/dl consistently

Ketones present in urine

Excessive urination and fruity breath

T 6
 Nursing interventions:
PATIENT EDUCATION:
Teach them prevention and the warning signs

T 6
 Nursing interventions:
PATIENT EDUCATION:
Teach them prevention and the warningIF TRACE OR SMALL, it may indicate the
signs
BEGINNING OF KETONE BUILD-UP. The
American Diabetes Association recommends to
test again after a few hours

IF MODERATE OR LARGE, take this as a

DANGER SIGN. Seek medical help or call your
healthcare provider immediately

Teach patient to keep a log of their urine test, so that

they can share to their HCP, to aid in their
management.

T 6
 Other nursing interventions:
PATIENT EDUCATION:
Teach them prevention and the warning signs

1. Monitor for and treat signs / symptoms

of infection

- DKA is often the result of an underlying infection such as a common

cold, flu or bacterial infection like pneumonia or urinary tract
infections. Assess for fever and other symptoms of infection and
administer antibiotics as necessary

T 6
PATIENT EDUCATION:
Teach
2. them prevention
Monitor vitaland the warning signs of
signs/symptoms
hypovolemia

- Vomiting and frequent urination can cause a deficiency in fluid

volume, thus leading to a decreased circulatory volume. This will be
evident by low blood pressure and tachycardia

T 6
PATIENT EDUCATION:
3. them
Teach Prevent injuryand
prevention and
the falls;
warningassist
signs with
ambulation

- Fatigue and weakness are common due to the cells inability to use
glucose to produce energy, also following vomiting, and in cases of
dehydration.

T 6
PATIENT EDUCATION:
4. Nutrition and lifestyle education:
Teach them prevention and the warning signs
- Avoid alcohol/illicit drug use
- Choose foods that are high in fiber and low in fats, sugars, and simple
carbs
- Eat regular meals and snacks, don’t miss meals
- Check for urine ketones when you have symptoms
- Do not exercise when urine shows positive for ketones
- Maintain compliance with medication insulin therapy

T 6
 PHARMACOLOGICAL INTERVENTIONS

AIMED AT :
REHYDRATION

RESTORING ELECTROLYTES

REVERSING ACIDOSIS

Before treating hyperglycemia with insulin.

Other goals for treatment are:

1. Lower blood sugar
2. Monitor K+ levels for cerebral edema
T 6
 REHYDRATION

- Rehydration is important for maintaining tissue perfusion

- Patient may need IV fluid to replace fluid losses caused by
POLYURIA, HYPERVENTILATION, DIARRHEA,
VOMITING

T 6
 REHYDRATION

1. Initially, 0.9% Sodium Chloride (Normal Saline) is given, or may

progress to 0.45%, depending on how dehydrated the patient is.
2. If BP is stable and sodium level is not low, 200 to 500 ml may be needed
for several hours
3. When blood glucose levels reach 300 mg/dl or less the IV solution may
be change to D5W

T 6
 RESTORING ELECTROLYTES

- Major electrolyte concern during treatment of DKA is POTASSIUM

- Initial plasma concentration of K+ is often high.
- Rehydration treats the affected potassium concentration. It leads to
increased urinary excretion of K+
- Frequent ECGs (2-4 hours initially) & lab measurements of K+ is
necessary during the first 8 hours

T 6
 REVERSING ACIDOSIS

- KETONE BODIES (acid) is a result of fat breakdown

- The acidosis can be reversed with insulin, which inhibits fat
breakdown, and ending ketone production and acid build-up.

REGULAR INSULIN IV
- Monitor K+ levels first (>3.5 meq/L)

T 6
 Other nursing interventions (Pharmacological):
PATIENT EDUCATION:
Teach them prevention and the warning signs
1. Monitor blood glucose levels and
administer insulin as appropriate

- Consistently high blood glucose levels, over 400 mg/dL, are the
primary indicator of ketone production. Monitor glucose and
intervene with prescribed insulin as appropriate to reduce
glucose levels and prevent further ketone production.

T 6
 2. Monitor fluid and electrolyte balance
PATIENT EDUCATION:
to prevent dehydration and
Teach them prevention andsuch
complications the warning signs
as decreased
sodium, potassium, calcium and
magnesium

- Excess blood glucose can cause nausea and vomiting resulting in

electrolyte imbalances. These electrolyte deficiencies can lead to
further complications and cardiac arrhythmias.

T 6
 2. Administer medications as appropriate
PATIENT EDUCATION:
- Teach them
Insulin prevention
as necessary, andInsulin,
Regular the warning
the only signs
type of insulin approved
for IV may be added to IV solutions

- IV fluids

T 6
 NURSING DIAGNOSIS
FLUID VOLUME DEFICIT
Related to excess urination, vomiting and
dehydration secondary to Diabetic Ketoacidosis.

T 3
 NURSING DIAGNOSIS
As evidence by:

● Elevated heart rate (tachycardia)

● Low blood pressure (hypotension)
● Increased respiratory rate (tachypnea)
● Elevated body temperature (due to dehydration
● Poor skin turgor and elasticity
● Dry and cool skin
● Delayed capillary refill time
● Dry and sticky mucous membranes (dry mouth)

T 3
 NURSING DIAGNOSIS
EXPECTED OUTCOMES

● Patient will maintain balanced fluid intake and output.

● Vital signs will return to baseline values, with normal blood pressure, heart
rate, and respiratory rate.
● Urine output will be within the normal range.
● Skin turgor and elasticity will improve, indicating better hydration.
● Mucous membranes will be moist and pink, indicating improved hydration.
● Capillary refill time will be within the expected range.

T 3
 NURSING DIAGNOSIS
ASSESSMENT:

● Monitor vital signs regularly, including blood pressure, heart rate,

respiratory rate, and temperature.
● Assess skin turgor, mucous membranes, and capillary refill time to
identify signs of dehydration.
● Monitor intake and output to evaluate fluid balance.

T 3
 NURSING DIAGNOSIS
INTERVENTIONS:
1. Fluid Replacement:
- Administer intravenous fluids as prescribed by the healthcare provider (e.g., normal
saline) to restore and maintain fluid balance.
1. Monitor Vital Signs:
- Regularly monitor blood pressure, heart rate, and respiratory rate. A drop in blood
pressure and an increase in heart rate may indicate severe volume depletion.
1. Monitor Blood Glucose Levels: -Regular monitoring of blood glucose levels is
essential. The goal is to reduce the glucose levels slowly and steadily. Insulin therapy
will be necessary, but be careful to avoid a rapid decrease in blood glucose which can
lead to cerebral edema.

T 3
 NURSING DIAGNOSIS
INTERVENTIONS:
1. Monitor Electrolyte Levels: Electrolyte imbalance is common in DKA.
Potassium is especially important to monitor as insulin therapy can lead to
hypokalemia (low potassium levels).
2. Monitor Urine Output: Ensure adequate urine output (0.5-1 ml/kg/hr) as
this is a sign that the kidneys are functioning, and the fluid volume is being
restored.
3. Monitor Mental Status: Changes in mental status can indicate cerebral
edema, a life-threatening complication.
4. Administer Insulin: Continuous intravenous insulin infusion is usually required to
correct hyperglycemia and ketoacidosis.

T 3
 NURSING DIAGNOSIS
FLUID VOLUME DEFICIT
Due to excessive urination, vomiting, and dehydration in DKA, the patient is at risk for
fluid volume deficit. Nursing interventions should focus on closely monitoring intake and
output, administering prescribed intravenous fluids, assessing for signs of dehydration, and
ensuring proper fluid balance.

Related to excess urination, vomiting and

dehydration secondary to Diabetic Ketoacidosis.

T 3
 NURSING DIAGNOSIS
Imbalanced Nutrition: Less Than Body Requirements

Nausea, vomiting, and altered appetite can lead to inadequate nutritional intake.
The nurse should monitor the patient's nutritional status, provide antiemetics as
prescribed, offer small, frequent meals, and collaborate with dietitians to create a
suitable meal plan.

Related to: Hyperglycemia

Insulin Deficiency
Increased Metabolic Rate

T 3
 NURSING DIAGNOSIS
As evidence by:

● Unintentional Weight Loss

● Poor Skin Turgor
● Dry Mucous Membranes
● Muscle Wasting
● Decreased Strength and Endurance
● Hypoglycemia
● Elevated Blood Ketone Levels
T 3
 NURSING DIAGNOSIS
EXPECTED OUTCOMES

● Patient will acquire adequate hydration.

● Maintain or gain weight within an acceptable range for their age,
height, and individual health needs.
● Improved Nutritional Status where laboratory values related to
nutrition will be in normal limits.
● Normal Blood Glucose Levels
● Adequate Energy Levels
Adequate Muscle Mass
T 3
 NURSING DIAGNOSIS
ASSESSMENT:
● Obtain a detailed medical history, including the duration and
management of diabetes.
● Document symptoms related to DKA, such as nausea, vomiting,
abdominal pain, fruity breath odor, and altered mental status.
● Monitor the patient's fluid intake and output, noting any changes that
might indicate dehydration.
● Review laboratory results, including blood electrolytes (sodium,
potassium, chloride), blood urea nitrogen (BUN), creatinine, and arterial
blood gases (ABGs).

T 3
 NURSING DIAGNOSIS
INTERVENTIONS:
1. Fluid Replacement:
- Administer intravenous fluids as prescribed to correct dehydration and restore
electrolyte balance.
1. Blood Glucose Management:
- Administer insulin therapy as prescribed to manage hyperglycemia and prevent further
breakdown of nutrients for energy.
1. Oral Hydration: -Offer oral fluids regularly to maintain adequate hydration and
prevent dehydration.

T 3
 NURSING DIAGNOSIS
INTERVENTIONS:
4. Monitor Ketone Levels:
- Continuously monitor blood ketone levels to assess the effectiveness of treatment and
nutritional intake

5. Educate the Patient and Family:

-Teach the patient how to manage their blood glucose levels, carbohydrate counting,
and the importance of regular meals and snacks.

T 3
 NURSING DIAGNOSIS
Risk for Electrolyte Imbalance

DKA can lead to imbalances in electrolytes such as potassium, sodium, and bicarbonate.
Nurses must monitor electrolyte levels, administer replacement electrolytes as ordered, and
educate the patient about the importance of maintaining electrolyte balance.

Related to :
● Hyperglycemia due to elevated blood
glucose levels.
● Accumulation of ketones in the blood due to
insulin deficiency
● Fluid Loss due to hyperglycemia

T 3
 NURSING DIAGNOSIS
As evidence by:
● Elevated blood glucose levels (hyperglycemia).
● Presence of ketones in blood and urine.
● Abnormal electrolyte levels, such as high potassium (hyperkalemia), low sodium
(hyponatremia), or altered chloride and bicarbonate levels.
● Abnormal heart rate (tachycardia or bradycardia).
● Changes in blood pressure.
● Dry mucous membranes.
● Decreased skin turgor.
● Presence of fruity breath odor (acetone smell).
● Signs of dehydration, such as sunken eyes or poor capillary refill.
T 3
 NURSING DIAGNOSIS
Expected outcomes:
● The patient's electrolyte levels, including sodium, potassium, chloride, bicarbonate, and
phosphorus, will remain within the normal range.
● The patient's blood glucose levels will gradually decrease and be maintained within the
target range.
● The patient's acid-base balance will improve, and the presence of ketones in the blood and
urine will decrease.
● The patient's blood pressure, heart rate, and respiratory rate will remain within acceptable
ranges.
● The patient will receive and tolerate appropriate nutritional support to prevent further
electrolyte disturbances.
● The patient will report feeling better overall, with relief from symptoms such as nausea,
vomiting, and weakness.
T 3
 NURSING DIAGNOSIS
ASSESSMENT:

● Monitor vital signs regularly, including blood pressure, heart rate,

respiratory rate, and temperature.
● Assess skin turgor, mucous membranes, and capillary refill time to
identify signs of dehydration.
● Monitor intake and output to evaluate fluid balance.

T 3
 NURSING DIAGNOSIS
interventions

1. Frequent Monitoring of Patient:

- Monitor blood glucose levels regularly to guide insulin therapy and prevent
extreme fluctuations.
2. Fluid Replacement:
- Administer intravenous fluids as prescribed to correct dehydration and support
electrolyte balance.
3. Insulin Administration:
- Administer insulin therapy as prescribed to manage hyperglycemia and
ketosis.

T 3
 NURSING DIAGNOSIS
interventions

4. Electrolyte Replacement:
- Administer electrolyte replacement solutions as prescribed to restore and maintain
appropriate electrolyte levels.
5. Renal Function Assessment:
- Monitor renal function tests, such as creatinine and blood urea nitrogen (BUN), to
assess kidney health and filtration.
6. Patient Education:
- Educate the patient and family about the risk for electrolyte imbalance, signs of
imbalance, and the importance of adherence to prescribed treatment.

T 3
 NURSING DIAGNOSIS
fatigue

DKA can lead to imbalances in electrolytes such as potassium, sodium, and bicarbonate.
Nurses must monitor electrolyte levels, administer replacement electrolytes as ordered, and
educate the patient about the importance of maintaining electrolyte balance.

Related to :
● Hyperglycemia due to elevated blood
glucose levels.
● Accumulation of ketones in the blood due to
insulin deficiency
● Fluid Loss due to hyperglycemia

T 3
 Blood sugar chart
Fasting Value (mg/dl) Postprandial (mg/dl)
Category
Min. Value Max. Value Value 2h after eating glucose

Normal 70 100 Less than 140

Early Diabetes 101 126 140 to 200

Established
More than 126 - More than 200
Diabetes

T 4