Dx Help: DM vs. DKA?

  1. For starters, hello everyone! This is my first post on here (though I have spent much time stalking the site for answers throughout my 14 months of nursing school so far LOL)

    Well I am now in the long stretch (will graduate in March) of my RN program and I have hit a wall, of sorts.

    Im doing some work for simulation lab tomorrow and the scenario they plan to run is DKA (yay...not)

    I have to formulate 3 nursing Dx along with 3 supporting interventions per Dx.

    The problem?

    While I COMPLETELY understand the differences in pathophysiology and expression of DM and DKA, I am wondering this: Are the nursing Dx for the two different? My thought is no since there are no SPECIFIC nursing Dx for metabolic imbalances. DKA is essentially metabolic acidosis but, if I am correct, the nursing Dx's would simply have to reflect the subcomplications of the condition, right?

    I hope this makes sense
    Last edit by Joe V on Aug 12, '12
  2. Visit Nursing_Mamacita profile page

    About Nursing_Mamacita

    Joined: Aug '12; Posts: 88; Likes: 79
    Registered Nurse; from US
    Specialty: 1 year(s) of experience in Cardiac/Respiratory/PCU


  3. by   SHGR
    I think you are working under some incorrect assumptions, so go back to the beginning, and review DKA patho... think it through:
    What body systems would DKA affect? What would this patient look like, what will your assessment likely show? Think respiratory, fluid and electrolytes, mentation. How critical might he or she be?
    Also, knowledge deficit is my absolute most-used nursing dx. Is this a newly diagnosed patient, or one that has had DM for a long time?
    Ineffective coping?
  4. by   all517
    They would be different DX. Think of the main things that are life threatening in DKA and how you treat it. DKA is an acute complication of DM.
  5. by   Nursing_Mamacita
    Hello hey_suz!

    The summary of the simulation client:
    36 y/o male
    Presents to ED confused and agitated
    Dx'd with DM I 12 months prior
    48 U of insulin daily
    Had "the flu" for 5 days with nausea, vomitting and anorexia
    Stopped taking insulin 2 days ago because he was not eating

    One of the biggest concerns with DKA is the respiratory system, correct? At that point the body has become acidotic and the respiratory system tries to compensate by exaggerating respirations. Fluid and electrolytes wise, the client in this senario is likely to have a low sodium because of fluid loss so my priority Dx would be Deficient Fluid Volume, correct?

    I guess, even this late in the program I have a hard time prioritzing my Dx's. I mean, I know airway is always first, then you have worries such as injury, infection, fluid volume, and the list goes on.

    My brain hurts! hah
    Am I on the right track?
  6. by   SHGR
    You are absolutely on the right track!! So, yes, safety, correcting the imbalances, and think too about the effects the fluctuating K+ may have and what you are going to do to monitor and help him compensate for that.

    Hard work, yes, but sooo worth it!

    Is there an "alteration in fluid/electrolyte" dx? I don't know them all offhand. They have changed some since I graduated!
  7. by   all517
    You need to hydrate, hydrate, hydrate! A dehydrated DKA patient will give you a falsified blood glucose reading because the blood is so concentrated. Before treating glucose priorities, you need to know what you're working with!
  8. by   Nursing_Mamacita
    Haha! YESSS! Go me! :P
    No specific Dx speaks on electrolytes, if I am correct
    But I do know that with Deficient Fluid Volume being my top priority, my interventions can reflect correcting the fluid/electrolyte imbalance since I would be giving a client with DKA 0.9% NS (: Anddd I know that within 2hrs they need to have had at least 2L infused, so it's likely the infusion rate would be 1L/hr.

    My next priority is correcting the blood glucose since he has been off of his insulin for 2 days and probably looks something like this -->

    So the Dx would be unstable blood glucose. And in the case of DKA, isn't IV Humulin R admin'd?

    Thirdly, due to his altered mental status, I know that I need to addess safety! BUT I cannot decide if this should take priority over everything else or what...

    Because, here is my thought: If I do not correct the fluid volume and the glucose, the DKA state is going to exacerbate and he is at risk for falling into a coma, correct?

    Can I get a hint? LOL
  9. by   Nursing_Mamacita
    AHH! Brilliant!
    Yes indeedyy! So should I change Unstable Blood Glucose to RISK FOR Unstable Blood Glucose?
  10. by   all517
    If your patient is in DKA, they already have unstable blood glucose!
  11. by   Nursing_Mamacita
    I mean OBV!! (-_-)
    Before treating glucose priorities, you need to know what you're working with!
    Obv labs are going to be ordered and reviewed because we don't treat blindly!
    But I as saying before that it is obv that he is most definitely going to be unstable because he has been off of insulin for the past 2 days...and that is what caused him to go into DKA.
  12. by   SHGR
    I think you pretty well have it. Remember the difference between T1DM and T2DM, too.
  13. by   Nursing_Mamacita
    Got cha!
    Thank you SO SO SO much! (:
  14. by   Nursing_Mamacita
    By the way, here is what I went with:

    1.) Deficient Fluid Volume
    a. monitor VS: noting orthostatic BP changes, respiratory pattern, RR & quality, peripheral pulse quality
    b. measure strict I&O
    c. administer 0.9% NS as ordered

    2.) Unstable Blood Glucose
    a. perform blood glucose testing as ordered
    b. administer fast acting insulin if indicated as ordered
    c. monitor labs (i.e serum glucose, acetone, k, pH, HCO3-)

    3.) Risk for Injury
    a. follow facility protocol for safety measures (i.e bed in lowest position, call bell within reach, etc)
    b. assess LOC qh; orient as needed
    c. appoint sitter as necessary (SO, family member, volunteer)