DIABETIC

KETOACIDOSIS
 DESCRIPTION
• Life threatening metabolic acidosis
resulting from persistent hyperglycemia
and breakdown 0f fats into glucose,
leading to presence of ketones in blood

• Can be triggered by emotional stress,

uncompensated exercise, infection,
trauma, or insufficient or delayed insulin
administration.
 ASSESSMENT
GENERAL ASSESSMENT
• Includes health history, vital signs, cognitive
function and mental status
• Glucose monitoring log
• Medication Administration
• Oral intake for past 48 hours
• Elimination pattern, Skin
• Oxygenation, breath sounds, respiratory effort
and pattern,
• Weight and hourly intake and output.
 ASSESSMENT
CLINICAL MANIFESTATIONS:
• Thirst, nausea vomiting
• Malaise, lethargy
• Polyuria
• warm dry skin
• flushed face
• Acetone (fruity) odor to
breath
• Kussmauls respirations (deep,
nonlabored, rapid respirations)
 ASSESSMENT
DIAGNOSTICS AND LABORATORY TEST
FINDINGS:

• Serum Glucose: >250 mg/dL;

• Plasma pH: <7.35
• Plasma bicarbonate: <15 mEq/L
• Serum ketones present
• Urine positive for glucose and ketones
• may have abnormal serum sodium and
chloride levels and hyperkalemia
 THERAPEUTIC MANAGEMENT

• Intravenous administration of fluids,

electrolytes, and regular insulin to
correct hyperglycemia and acidosis

• Supportive care as indicated such as

NPO status, vasopressors and
possible ventilator to respiratory
support
 THERAPEUTIC MANAGEMENT

A. INSULIN
1). A bolus of IV regular insulin is given followed by a
continous IV drip (0.1 unit/kg body weight) until the blood
glucose level drops to 250 mg/ 100 ml or the pH= 7.30

2.) Once this blood level is reached, regular insulin is given on

a sliding scale according to blood glucose.

3. As an alternative to IV infusion, IM administration of

insulin may be given hourly.

4. Bedside blood glucose monitoring is done q1 to 2 hrs. to

monitor the effectiveness of this therapy.
 THERAPEUTIC MANAGEMENT

FLUID THERAPY:
-Instituted to diminish the hyperglycemia
and to treat the large fluid deficit
(dehydration) that accompanies DKA
1.) Normal Saline Solution is usually
given at a rate of 1 to 2 L for the first hour,
then is decreased to 500 mL/hr as tolerated
by cardiac and respiratory systems.
 THERAPEUTIC MANAGEMENT

2.) When the blood glucose level reaches

250 to 300, a 5% glucose solution (D5 1/2NS) is
added to prevent hypoglycemia and to prevent
cerebral edema

3.) Central venous pressure or

hemodynamic monitoring may be necessary to
evaluate the effectiveness of the therapy
 THERAPEUTIC MANAGEMENT

C. POTASSIUM REPLACEMENT
-Always necessary in DKA

1.) The initial serum potassium (K+) level is

usually elevated

2.) with the reversal of the acidosis and the

administration of insulin, the K+ shifts into the
intracellular compartment and the serum level
can drop rapidly.
 THERAPEUTIC MANAGEMENT

3. Electro cardiographic monitoring is instituted

to monitor for cardiac changes and due to hyper
and hypokalemia and to monitor the effects of
therapy on the serum K+ level.

4. Another electrolytes such as phosphate will

also be replaces based on the result of laboratory
profiles; bicarbonate is not given routinely in DKA
because rapid correction of acidosis can cause
severe hypokalemia
 PRIORITY NURSING
DIAGNOSIS

• Deficient Fluid volume

• Risk for Injury
• Risk for impaired skin integrity
• Ineffective breathing pattern
• Disturbed Sensory Perception
• Knowledge deficit
• Anxiety
 PLANNING AND
IMPLEMENTATION
A.Restore Fluid, electrolyte and glucose with IV
infusions and medications
Analyze intake and output, blood glucose, urine
ketones, vital signs, oxygenation and breathing
pattern.

B. Maintain Skin integrity; promote healing of impaired

skin; prevent infection by turning and positioning
client q 2 hours; provide pressure relief as indicated.
Manage incontinence and perspiration with skin
protective barriers and cleansing; provide adequate
nutrition and oxygen support
 PLANNING AND
IMPLEMENTATION
C. Promote safety by analyzing vital signs,
client communication, LOC and emotional
response, and activity intolerance;
implement falls prevention measures.

D. Assist client to verbalize concerns and

cope effectively with illness and fears.
 MEDICATION THERAPY

• IV infusions of NS
• Regular insulin and
• electrolyte replacement
including potassium
replacement as previously
described.
 CLIENT EDUCATION

• Instruct Client about the nature

and causes of DKA (such as
excess glucose intake),
insufficient medications, or
physiology and/or psychological
stressors) and any new
medications.
 EVALUATION
A. Fasting blood glucose is within normal range
Serum pH is 7. 35 to 7.45
Urine is negative for ketones

B. Client’s LOC and perceptual function returns to normal;

elimination is normal
Skin is intact
Breathing pattern is normal
Fluids and electrolytes are balanced

C. Client verbalizes understanding f Diabetic Ketoacidosis, its

causes, methods of prevention and new medications
 Hyperglycemic
Hyperosmolar Non-
ketotic Coma
(HHNKC)
 DESCRIPTION

 Life-threatening metabolic
disorder of hyperglycemia usually
recurring with DM tyoe 2 and
triggered by a variety of situations:
Medications, infection, acute
illness, invasive procedures or a
chronic illness.
 ASSESSMENT
GENERAL ASSESSMENT
• Includes health history, vital signs, LOC,
cognitive and perceptual function
• Elimination pattern
• Skin, breathing pattern, breath sounds
• Reflexes, sensory and motor function
• I & O, weight
• ECG, communication, glucose monitoring log
• Nutrition pattern and meds taken within 7
days.
 ASSESSMENT

CLINICAL MANIFESTATIONS:
symptoms gradually occur over 24 hours to 2
weeks and include:
 decreased LOC
 dry mucous membranes
 polydipsia
 hyperthermia
 impaired sensory and motor function
 + Babinski’s sign and seizures
 ASSESSMENT
DIAGNOSTICS AND LABORATORY TEST
FINDINGS:
 Elevated serum sodium
 Serum osmolality: >340mOsm/L
 Serum Glucose: >600 mg/dL
 abnormal serum potassium and
chloride
 NO serum ketones
 Normal serum pH
 THERAPEUTIC MANAGEMENT

 Determine and treat triggering

situation
 Treat co existing health
deviations
 Provide fluid and electrolyte
replacement
 Provide regular insulin IV to
normalize serum glucose/
 PRIORITY NURSING
DIAGNOSIS
 Decreased cardiac output
 Deficient fluid volume
 Hyperthermia
 Disturbed Sensory perception
 Risk for impaired skin integrity
 Risk for aspiration
 Deficient knowledge
 PLANNING AND
IMPLEMENTATION
A. Provide normalized cardiac
output, sensory perceptual function,
fluid and electrolyte balance, Normal
body temperature by administering
fluids, medications and analyzing I &
O, weight, vital signs, lab values,
sensory and cognitive function.
 PLANNING AND IMPLEMENTATION

B.Maintain intact skin by turning q 2 hrs, use of

pressure relief aids, nutritional support, use
of skin moisturizers and barriers, and
management of incontinence.

C. Prevent aspiration using appropriate feeding

precautions, elevate head of bed15 to 30
degrees during and after feeding for 1 hour; if
BP too unstable to elevate HOB with feeding,
then withhold oral feedings.
 MEDICATION THERAPY

 IV infusion of NS to replace
fluids and sodium

 Regular insulin IV to manage

the hyperglycemia and
potassium to replace losses and
shifts.
 CLIENT EDUCATION

 Instruct client on
HHNK, symptoms to
report and
administration of new
medications.
 EVALUATION
A.Client returns to normal LOC and perceptual
function, elimination function and breathng
pattern
Fasting blood glucose id within normal range
skin is intact

B.Fluid and electrolyte levels are balanced

C. Client verbalizes understanding of HHNK,

symptoms to report and administration of
new medications.
 THE END… TNX FOR
CAREFULLY
LISTENING!!!!

BSN 4D- GROUP 3  