QUEENY MARIE MARTINEZ
BSN III – B
NURSING CASE STUDY
DIABETIC KETOACIDOSIS (DKA)
1. Introduction/description of the disease
DKA is caused by an absence or markedly inadequate amount of insulin. This deficit in
available insulin results in disorder in the metabolism of carbohydrate, protein and fat.
The three main clinical features/manifestations of Diabetic Ketoacidosis (DKA) are based on
the following concepts:
1) Hyperglycemia
2) dehydration and electrolyte loss
3) acidosis.
Blood glucose levels range from 300 to 800 mg/dL.
Low serum bicarbonate and a low pH are present.
It is a life-threatening complication of DM type I. this is due to severe insulin deficiency.
2. Risk factors
o Patient with Type I diabetes mellitus are at risk to develop DKA.
o Persons who are frequently stressed out or due to stress-induced by surgery and
o persons with frequent or severe illness/infection are also at risk of developing DKA.
3. Causes
Underdose or missed dose of insulin
Illness or infection
Overeating
Stress, surgery
Undiagnosed and untreated type I DM.
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4. Pathophysiology
Without insulin, the amount of glucose entering the cells is reduced, and production and
release of glucose by the liver is increased. Both factors lead to hyperglycemia. In an attempt
of the body to get rid of the excess glucose, the kidneys excrete the glucose along with water
and electrolytes. This osmotic diuresis, which is characterized by excessive urination
(polyuria), leads to dehydration and marked electrolytes loss.
Lack of insulin
Decreased utilization of Increased breakdown of
glucose by muscles, fat, and fats
liver
Increased production of
glucose by liver. Increased fatty acids
Hyperglycemia Acetone breath Increased
Poor appetite ketones bodies
nausea
Blurred vision Polyuria
Nausea
Vomiting Acidosis
Weakness Abdominal pain
Dehydration
Headache
Increasing rapidly
Increased thirst respirations
(polydipsia)
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5. Clinical manifestations
Acetone breath (fruity odor)
Anorexia, nausea, vomiting, abdominal pain
Polyuria
Polydipsia
Blurred vision, weakness and headache
Orthostatic hypotension (drop in systolic blood pressure of 20 mm Hg or more on
changing from reclining to standing position)
Frank hypotension with a weak, rapid pulse
Mental status changes
Kussmaul’s respirations
6. Diagnostic test specific to the disease
Fasting Blood Sugar (FBS)
– fasting is defined as no caloric intake for at least eight hours; this include no
food, juices, milk; only water is allowed (NPO).
Fasting Blood Sugar Values :
109 mg % - Normal
110-125 mg % - Impaired glucose Tolerance (IGT)
126 mg % - Possible Diabetes Mellitus
Two-hour blood sugar test – performed two hours after using 75 g glucose dissolved
in water or after a good meal. Oral Glucose Tolerance Test (OGTT) is not
recommended for routine clinical use nor screening purposes.
Blood glucose monitoring
Check for Electrolytes imbalances
7. Medical Management
In addition to treating hyperglycemia, management of DKA is aimed at correcting
dehydration, electrolyte loss, and acidosis.
Rehydration
Treat dehydration with NSS 0.9% or 0.45% rapid IV as prescribed.
D5NS or 5% dextrose in 0.45% saline when the blood glucose level reaches 250 to 300 mg/dL.
Restoring electrolytes
Administer Potassium replacements
Reversing acidosis
Ketone bodies (acids) accumulates as a result of fat breakingdown. It is reversed by
insulin. Infuse intravenously at a slow continuous rate.
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8. Pharmacologic management (drug study)
Regular insulin
Potassium replacement (KCl)
Metoclopramide (Plasil)
9. Nursing management and Non-pharmacologic treatments
Monitoring fluid, electrolyte and hydration status
Monitor blood glucose level
Administer fluids, insulin, and other medications
Prevent fluid overload
Monitor intake and output accurately
Vital signs monitoring
ABG results monitoring and reporting to the attending physician
Assess mental status and breath sounds
Check ECG reading and make sure that there are no signs of hyperkalemia (tall and
peaked or tented T waves)
Make sure that laboratory values of potassium are normal or approaching normal.
Make sure that the patient is urinating. (no renal shutdown)
Initiate referrals for home care and outpatient diabetes education to ensure patient
continued recovery.
10. Collaborative management
Maintain patent airway
Administer Oxygen therapy as prescribed
Treat dehydration with 0.9% NSS or 0.45% rapid as prescribed.
11. Nursing Care Plan
Risk for fluid volume deficit related to polyuria and dehydration
Imbalanced nutrition related to imbalance of insulin, food, and physical activity
Fatigue related to decreased metabolic energy production and insufficient
insulin as evidenced by overwhelming lack of energy, decreased performance
and disinterest in surrounding.
12. Diet
Collaborate with the dietician and the physician.
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13. Methods of Prevention and Contro
For prevention of DKA related to illness patients must be taught “SICK DAY” rules for
managing their diabetes when ill.
o Guidelines to Follow During Periods of Illness (“SICK DAY RULES”)
Take insulin or oral antidiabetic agents as usual.
Test blood glucose and test urine ketones every 3 to 4 hours.
Report elevated glucose level (>300 mg/dL[16.6mmol/L] or as
otherwise specified) or urine ketones to your health care provider.
If you take insulin, you may need supplemental doses of regular
insulin every 3 to 4 h.
If you cannot follow your usual meal plan, substitute soft foods six
to eight times per day.
If vomiting, diarrhea, or fever persists, take liquids every ½ to 1
hour to prevent dehydration and to provide calories.
Report nausea , vomiting, and diarrhea to your health care
provider, because extreme fluid loss may be dangerous.
If you are unable to retain oral fluids, you may require
hospitalization to avoid diabetic ketoacidosis and possible coma.
The most important concept to teach patients is not to eliminate insulin doses when
nausea and vomiting occur.
Blood glucose and urine ketones must be frequently assessed.
