help prioritizing with DKA...due WED 2/8

Esme12, ASN, BSN, RN · Feb 7, 2012

What is DKA......Diabetic KetoAcidosis. Know the pathophysiology first. Then know your patient assessment. Your problems are patient oriented and not every patient is the same. What are the patient's labs? If the patient is in the ED it would be the most acute phase with minimal treatment. The prevailing issues with DKA is fluid and electrolyte imbalance and elevated glucose.

The two most common life-threatening complications of diabetes mellitus include diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS).

http://emedicine.medscape.com/article/118361-overview requires free registration but is a valuable resource for you.

The symptoms of an episode of diabetic ketoacidosis usually evolve over the period of about 24 hours. Predominant symptoms are nausea and vomiting, pronounced thirst, excessive urine production and abdominal pain that may be severe. Those who measure their glucose levels themselves may notice hyperglycemia (high blood sugar levels). In severe DKA, breathing becomes labored and of a deep, gasping character (a state referred to as "Kussmaul respiration"). The abdomen may be tender to the point that an acute abdomen may be suspected, such as acute pancreatitis, appendicitis or gastrointestinal perforation. Coffee ground vomiting (vomiting of altered blood) occurs in a minority of patients; this tends to originate from erosion of the esophagus. In severe DKA, there may be confusion, lethargy, stupor or even coma (a marked decrease in the level of consciousness).

The physical examination will usually show clinical evidence of dehydration, such as a dry mouth and decreased skin turgor. If the dehydration is profound enough to cause a decrease in the circulating blood volume, tachycardia (a fast heart rate) and low blood pressure may be observed. Often, a "ketotic" odor is present, which is often described as "fruity", often compared to the smell of pear drops whose scent is a ketone. If Kussmaul respiration is present, this is reflected in an increased respiratory rate.

DKA is characterized by hyperglycemia, metabolic acidosis, and increased circulating total body ketone concentration. Ketoacidosis results from the lack of, or ineffectiveness of, insulin with concomitant elevation of counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). Hyperglycemia results from increased hepatic and renal glucose production (gluconeogenesis and glycogenolysis) and impaired glucose utilization in peripheral tissues. Both hyperglycemia and high ketone levels cause osmotic diuresis (increased urine output) that leads to hypovolemia. Dehydration can be and usually is very profound in DKA.

The clinical presentation of DKA usually develops rapidly, over a period of

http://spectrum.diabetesjournals.org/content/15/1/28/F1.large.jpg treatment algorhythm

I hope this helps.

nurseprnRN, BSN, RN · Feb 7, 2012

:yeah:

locslady · Feb 7, 2012

Thanks Esme. My patient did display many but not all of these symptoms. As far as metabolic acidosis, I am surprised that ABGs were not ordered for her.

You are right though every patient is different, just because a disease or condition is the same doesn't mean the plan of care is always the same. Good look.