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DKA is caused when the body has little or no insulin to use. The blood glucose level keeps rising to dangerous levels. This is called hyperglycemia. DKA most often starts from infection. Hormonal changes lead to increased liver and renal glucose production and decreased glucose use in peripheral tissues. Increased production of counterregulary hormones leads to the production of ketoacids and resultant ketonemia and metabolic acidosis. DKA most commonly occurs in a person with type 1 diabetes. The lack of insulin leads to mobilization of fatty acids from adipose tissue because of the unsuppressed adipose cell lipase activity that breaks down triglycerides into fatty acids and glycerol. b. What are commonly seen blood glucose levels? The definitive diagnosis of DKA consists of blood glucose levels >250 mg/d, but is usually much higher. c. What fluid and electrolyte disturbances commonly occur? Typical overall electrolyte loss includes 200-500 mEq/L of potassium, 300-700 mEq/L of sodium, and 350-500 mEq/L of chloride. The combined effects of serum hyperosmolarity, dehydration, and acidosis result in increased osmolarity in brain cells that clinically manifests as an alteration in the level of consciousness. d. What causes the fluid and electrolyte disturbances? Hyperglycemia leads to osmotic diuresis, dehydration, and a critical loss of electrolytes. Hyperosmolality of extracellular fluids from hyperglycemia leads to a shift of water and potassium from the intracellular to the extracellular compartment. Extracellular sodium concentration frequently is low or normal despite enteric water losses because of the intracellular-extracellular fluid shift. Serum potassium levels may be normal or elevated, despite total potassium depletion resulting from protracted polyuria and vomiting. Metabolic acidosis is caused by the excess ketoacids that require buffering by bicarbonate ions; this leads to a marked decrease in serum bicarbonate levels. e. What acid-base disturbances are commonly seen? Serum pH <7.35. f. Why do the acid-base disturbances occur? When the accumulated ketones exceed the body's capacity of extracting them, they overflow into urine (ie, ketonuria). If the situation is not treated promptly, more accumulation of organic acids leads to frank clinical metabolic acidosis (ie, ketoacidosis), with a drop in pH and bicarbonate1 serum levels. Respiratory compensation of this acidotic condition results in rapid shallow breathing (Kussmaul respirations).
then at least every 2 hours thereafter. which can occur when serum osmolarity declines too rapidly. d. Usually. During the first 24 hours of treatment. .45% saline. usually 0. a second liter is given in the next hour. In patients with poor renal function and excess fluid volume. Temperature may be elevated. Check the clinical indicators of fluid imbalance. heart. Subcutaneous insulin is started when the patient can take oral fluids and ketosis has stopped. c. regular insulin by continuous IV infusion is the treatment of choice. For the patient receiving a continuous IV insulin infusion. This solution prevents hypoglycemia and cerebral edema. Edema occurs with excess interstitial fluid and often is not apparent until interstitial volume increases by 2 to 3 L. Effective blood insulin levels are reached quickly when an IV bolus dose is given at the start of the infusion. How are blood glucose levels monitored? How often? Hourly blood glucose measurements using a blood glucose meter. increasing blood pressure and pulse volume. Orthostatic hypotension may indicate volume depletion. This may be as much as 6 to 10 L. and orthostatic hypotension. Fluid overload can cause hypertension. How are elevated blood glucose levels corrected? The outcome of insulin therapy is to lower serum glucose by about 75 to 150 mg/dL/hr. Watch for signs of fluid replacement by monitoring blood pressure and urinary intake and output. the patient needs enough fluids to replace the actual volume deficit and ongoing losses. a. increasing abdominal girth.1 unit/kg/hr. The second goal of fluid therapy. How is the fluid status monitored in the acute stage of DKA? The dehydrated patient s lips and mouth may be dry and the tongue furrowed. b. Unless the episode of DKA is mild. Infuse 1 L of isotonic saline over 30 to 60 minutes. When blood glucose levels reach 250 mg/dL give 5% dextrose in 0. Describe the medical management of a patient in DKA. An initial IV bolus dose of 0. If a patient exhibits clinical symptoms of hyperglycemia that do not reflect the bedside blood glucose measurement. In severe volume depletion. replacing total body fluid losses. assess for edema around the eyes and in the limbs.45% saline. jugular venous distention.1 unit/kg is followed by an IV drip of 0. a lab glucose measurement is obtained. is achieved more slowly. How is hypovolemia corrected? How rapidly is fluid volume replaced? Why? The first goal of fluid therapy is to restore volume and maintain perfusion to the brain.2. Daily weights are good indicators of fluid status because 1 kg of body weight equals 1 L of fluid. bedside blood glucose is measured hourly for first 8 hours after initiation. the jugular venous pulsation may not be visible even with the patient lying flat. and kidneys. Jugular venous pressure increases with volume overload. Continuous insulin infusion is used because of the 4-minute half-life of IV insulin.
Assess for edema around eyes and in the limbs. increasing blood pressure and pulse volume. K supplementation can be withheld. Its use is therefore discouraged. although some guidelines recommend it for extreme acidosis (pH<6. It can also cause pulmonary edema and edema in extremities. insulin should be withheld and K given at 40 mEq/h until serum K is 3. K Hyper/Hypokalemia a. may be taken from a normal blood test taken from a vein. . especially in patients with kidney failure. as there is little difference between the arterial and the venous pH. How is fluid status assessed? Daily weights are good indicators of fluid status. How quickly is blood glucose corrected? Why? Slowly lower blood glucose to prevent hypokalemia. Subsequent measurements (to ensure treatment is effective).0) 4. if serum K is > 5 mEq/L. Assess mucous membrane and skin turgor. Assess urine concentration.3 mEq/L. Check the clinical indicators of fluid imbalance.3 mEq/L. b. a. What are the complications of fluid replacement and how are they prevented? Fluid overload can cause hypertension. There is little evidence that it improves outcomes beyond standard therapy. What electrolytes are monitored in the acute stage of DKA? Why? Na. Monitor for fluid imbalance. and indeed some evidence that while it may improve the acidity of the blood. Assess vitals. increasing abdominal girth. and smaller amounts for severe acidosis (pH 6. b. How are acid-base disturbances monitored? How often? Arterial blood gas measurement is usually performed to demonstrate the acidosis. this requires taking a blood sample from an artery. How are electrolyte imbalances corrected? How rapidly is this accomplished? Why? Hypokalemia prevention requires replacement of 20 to 30 mEq K in each liter of IV fluid to keep serum K between 4 and 5 mEq/L. The serum CO2 test is performed to determine metabolic acid-base abnormalities.9 7. it may actually worsen acidity inside the body's cells and increase the risk of certain complications.9). Describe the nursing management of a patient in DKA. c.e. 3. If serum K is < 3. Every one hour. Use of electrolyte replacement solutions based on lab findings. How are acid-base disturbances corrected? How quickly is this accomplished? Why? The administration of sodium bicarbonate solution to rapidly improve the acid levels in the blood is controversial.
Anion gap. measured cations (sodium and potassium). The formula used is: Anion gap = (sodium + potassium) (chloride + bicarbonate). d. Monitor ECG for QRS spread and peaked T waves. then at least every 2 hours thereafter. Anion gap is the difference between the electrolytes. Respiratory alkalosis to compensate. Assess renal function. Define anion gap. A serum osmolality test measures the amount of chemicals dissolved in the liquid part (serum) of the blood. Keep accurate intake and output record. Anion gap measures cations (sodium and potassium) and anions (chloride and bicarbonate). serum osmolality and venous CO2. Serum osmolality is measured to check the balance between the . High potassium levels greater than 5. How are acid-base disturbances assessed? How often? Arterial blood gases are usually ordered to assess disturbances of acid-base balance. then metabolic alkalosis results. Chemicals that affect serum osmolality include sodium. g. What are the complications of lowering blood glucose levels and how are they prevented? Hypoglycemia can be avoided by assessing therapy effectiveness with hourly blood glucose measurements. What are the complications of electrolyte replacement and how are they prevented? Hyperkalemia. How are electrolyte disturbances assessed? How often? Every one hour. e. If a patient exhibits clinical symptoms of hyperglycemia that do not reflect the bedside blood glucose measurement.0 mEq/L should be reported. Urinalysis. a lab glucose measurement is obtained. proteins. What are the complications of acid-base correction and how are they prevented? If a bicarbonate excess is present. For the patient receiving a continuous IV insulin infusion.c. h. 7. Check specific gravity of urine to assess for hypernatremia. a decreased anion gap less than 10 mEq/l indicates metabolic alkalosis. An elevated anion gap greater than 17 mEq/l indicates metabolic acidosis. and sugar (glucose). Vital signs. i. How are blood glucose levels assessed? How often? Hourly blood glucose measurements using a blood glucose meter. a sign of hyperkalemia. Observe for edema and overhydration resulting from an elevated serum sodium level. bedside blood glucose is measured hourly for first 8 hours after initiation. f. bicarbonate.0 mEq/L or higher can cause cardiac arrest. A serum osmolality test is done on a blood sample taken from a vein. chloride. and measured anions (chloride and bicarbonate to determine the unmeasured cations and anions in the serum.
Serum osmolalities indicates dehydration or overhydration. . Anion gap indicates metabolic acidosis/alkalosis. The serum CO2 test is performed to determine metabolic acid-base abnormalities. Venous CO2 is the amount of carbon dioxide in the blood. j. How are serial anion gaps. serum osmolalities and venous CO2 results used? The serum CO2 test is performed to determine metabolic acid-base abnormalities.water and the chemicals dissolved in blood and Find out if severe dehydration or overhydration is present.
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