Diabetic Ketoacidosis
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Rapid identification, treatment, and education can improve
survival rates.
By Gordon Lee Gillespie, BSN, CEN, and Melody Campbell, MSN, CEN, CCRN
T
he rescue squad arrives at the emergency
department (ED) with Chad Smith, 72
years old, who was found unconscious
on the basement floor of his home. En
route to the hospital, Mr. Smith’s respi-
rations became very shallow. An endotracheal tube
was inserted, and its placement was confirmed by
end-tidal CO2 detection. Since arriving at the ED,
he has remained comatose and is not assisting the
ventilator. His vital signs are blood pressure, 80/48
mmHg; heart rate, 112 beats per minute; and tem-
perature, 91.8°F. He has a sinus tachycardia with-
out ectopy. The glucometer indicates a finger stick
blood sugar (FSBS) reading of “panic high.”
Mr. Smith is among the 5.9% of people in the
United States with diabetes.1 A significant percentage
of them will experience diabetic ketoacidosis (DKA),
a state of hyperglycemia, hyperketonemia, and meta-
bolic acidosis.2,3 DKA typically affects those with type
1 diabetes, although patients with type 2 diabetes
who suffer from hyperglycemic hyperosmolar nonke-
totic syndrome also experience DKA, and with
increasing incidence.4,5 In January 2002, the
American Diabetic Association (ADA) reported that
there are approximately 100,000 hospitalizations for
DKA annually.6 It’s also the leading cause of death
among children with diabetes, nearly 40% of whom
present with DKA in addition to new-onset diabetes.7
The ability of emergency nurses to learn and rec-
ognize the signs and symptoms of DKA profoundly
affects outcome and survival rate. In 1980, the age-
adjusted death rate among patients with diabetes
was 30.8 per 100,000 patients, with DKA listed as
the cause of death. By 1996, this number had
Gordon Lee Gillespie is an emergency nurse at Mercy Franciscan
Hospital-Mount Airy, Cincinnati, OH. His mentor, Melody Campbell,
is critical care CNS and trauma coordinator at the Upper Valley
Medical Center, Troy, OH.
ajn@lww.com
dropped to 20.4, a change attributed to streamlined
care and modern treatment modalities.8
PATHOPHYSIOLOGY
DKA is initiated by trauma or conditions such as
new-onset diabetes or congestive heart failure,
which place the body under stress and increase the
levels of catecholamines, cortisol, growth hor-
mones, and glucagon. Excesses of these hormones
decrease the effectiveness of insulin.4,9 In the pres-
ence of insulin resistance or deficiency, hyperglycemia
occurs, decreasing the movement of glucose from the
intravascular spaces to the intracellular spaces. With
the cells then starving from lack of glucose, the
body starts metabolizing its own fats and pro-
teins. As fats are broken down, a process called
lipolysis occurs, in which free fatty acids form and
travel to the liver, where they become keto acids
that place the body in a state of hyperketonemia.10
When the body’s glucose level rises, fluid shifts
from the intracellular to the intravascular spaces.
Subsequently, when the kidneys’ ability to filter
the hyperglycemic blood is overcome, they begin
spilling the extra glucose into the renal system.
Because of the molecular size of glucose and its
osmotic pressure, fluid follows the glucose
through the renal system and into the bladder,
causing the patient to experience polyuria.2 This
leads to intracellular as well as generalized dehy-
dration, which, along with the body’s inability to
rid itself entirely of the ketones, leads to metabolic
acidosis.3,9 During early DKA, the glomerular fil-
tration rate decreases as kidney function becomes
impaired. Coupled with a shift of potassium (K+)
from the cells into the extracellular spaces, this
causes elevated K+ levels. And as DKA progresses,
profound diuresis occurs, causing a drop in serum
K+ level. Once rehydration is initiated, K+ begins
AJN ▼ September 2002 ▼ Supplement 13
 shifting back into the cells, causing severe levels. As rehydration and insulin therapy take effect,
hypokalemia.2, 4 these levels will begin decreasing. If the initial K+
level is less than 5.5 mEq/L, 20 mEq potassium chlo-
IDENTIFICATION ride should be added to the primary fluid. If the K+
The symptoms of this condition are polyuria, poly- level is less than 3.3 mEq/L, 40 mEq potassium chlo-
dipsia, and polyphagia.4 Because of Mr. Smith’s ride should be added.3 As the acidosis increases, the
coma, the nurses were unable to assess him for these pH continues to drop. However, the acidosis isn’t
symptoms. During his physical assessment, how- treated until pH drops to less than 7.0. Treating the
ever, he demonstrated hypother- acidosis when pH is higher than 7.0
mia, tachycardia, hypotension, and increases the risk of hypokalemia
vomiting, all of which are associ- and cardiac arrhythmia and brings
ated with DKA. Other symptoms about a shift in the oxyhemoglo-
associated with the condition bin dissociation curve that causes
include Kussmaul respirations (rapid decreased tissue oxygenation.3,4 If
and deep respiratory pattern), car- Maintain urinalysis, radiographs, or CBC
diac arrhythmia, altered mental sta- show signs of infection, start antibi-
tus, an acetone or fruity breath, otic therapy after cultures have
nausea, weakness, weight loss, continuous been obtained. Maintain continu-
blurred vision, flushed face, and leg ous cardiac monitoring to check for
cramps.2,4 Patients presenting with cardiac arrhythmia that may result from
typical symptoms of DKA, an changes in K+ levels.
altered level of consciousness, or monitoring to
several of the additional symptoms MANAGEMENT
should have a FSBS test performed check for Once DKA is identified, manage-
to rule out hyperglycemia and pos- ment of the patient is twofold. The
sible DKA. It’s important to note, arrhythmia that precipitating stressors must be iden-
however, that FSBS values can be tified and treated, as must the
erroneously low if the patient is serum glucose level and the addi-
severely dehydrated or hypoten-
may result from tional significant symptoms.
sive.11 Therefore, serum glucose lev- Precipitating stressors include
els should always be compared changes in K+ infection, trauma, myocardial in-
with the initial FSBS value. This is farction, congestive heart failure,
especially important if FSBS level levels. cerebrovascular accident, gastroin-
will be used to evaluate the effec- testinal bleeding, and new-onset
tiveness of subsequent treatment. diabetes. Other stressors include
Hematocrits below 20% and above emotional stress, cocaine use, mis-
70% may also cause lower FSBS management of insulin or of oral
values. diabetic agents, and concurrent use
of medications such as corti-
DIAGNOSIS AND INTERVENTION costeroids, thiazide diuretics, and phenytoin.4,10
When Mr. Smith arrived at the ED, an electrocar- Mr. Smith was immediately started on a 0.9%
diogram, chest radiograph, and routine urinalysis normal saline (NS) IV fluid bolus for hypotension
were performed, and FSBS, complete blood count and hyperglycemia. He was also given 10 units of
(CBC), chemistry panel, and serum ketone level regular insulin via intravenous push (IVP).
were assessed. These diagnostic tests are typically Patients with DKA typically need 3 to 6 L NS
used to confirm the presence of DKA and to deter- during the first few hours after onset.10 The ADA
mine its severity in patients with signs and symp- recommends that 0.9% NS be administered intra-
toms. Further diagnostic tests, such as urine, venously at 15 to 20 mL/kg/hr for 60 to 90 min-
sputum, wound, and blood cultures, as well as utes.6 Others have recommended that 0.9% NS be
assessment of arterial blood gas, cardiac enzyme, given intravenously at 15 mL/kg/hr for one hour,
amylase, and lipase levels will help identify the then at 7.5 mL/kg/hr for 2 hours, then at 3.75
cause of DKA. Also, consider administering preg- mL/kg/hr for the next 24 to 36 hours as long as the
nancy tests to women of childbearing age.2 corrected serum sodium isn’t elevated.12 Once the
Intervention will vary depending on test results. hypovolemia and hypotension are corrected, the
Patients with DKA usually present with elevated K+ 0.9% NS should be changed to 0.45% NS.10

14 AJN ▼ September 2002 ▼ Supplement http://www.nursingcenter.com

 Routine treatment includes administering regular then confirming its placement with an end-tidal
insulin 0.1 to 0.15 units per kg IVP followed by a CO2 detector, auscultation of breath sounds, and a
0.1 unit/kg/hr IV infusion.10 An insulin infusion is pre- portable chest radiograph.2,6 Assess circulation, ob-
pared by adding regular insulin to 0.9% NS to reach tain vascular access, and start a 0.9% NS infusion.
the desired concentration, usually a 1:1 ratio. The If the patient is hypotensive, a fluid bolus must be
tubing needs to be primed and an extra 10 to 50 given.2 Finally, assess the patient’s neurologic status:
mL of fluid wasted through continuous priming Is he alert and responsive to verbal or painful stimuli?
to accommodate for the insulin being absorbed by Secondary assessment. Undress the patient,
polyvinyl chloride tubing.2,13 and if there’s hypothermia, control temperature
If the glucose level doesn’t drop by 50 to 100 using warmed blankets, overhead heating lamps,
mg/dL every hour, the insulin infu- and warmed IV fluids. Insert a
sion rate should be doubled.2,3,10 nasogastric tube if the patient is
Regardless of the initial FSBS read- vomiting, and insert an indwelling
ing, insulin therapy should be urinary catheter in order to moni-
maintained until electrolyte values tor output and obtain urinalysis.
have been obtained and K+ therapy If the patient has been intubated,
is initiated (if the K+ level is lower
Chronic vision place a nasogastric tube to decom-
than 5.5 mEq/L).6,12 Once the hourly press the stomach.4 Initiate cardiac
blood sugar measurements are less changes may monitoring to check for arrhyth-
than 250 mg/dL, the hourly rate of mia, which may result from elec-
intravenous insulin should be re- prevent elderly trolyte imbalances. Take steps to
duced by half. Start an infusion of make the patient comfortable, such
5% dextrose and 0.45% NS at 100 patients with as by administering antiemetics or
to 150 mL/hr to replace the 0.9% analgesia.
(or 0.45%) NS infusion. The insulin diabetes from Obtain a thorough history from
infusion should continue until at the patient and family in order to
least two of the following outcomes administering identify what may have precipitated
occur: the anion gap is less than the DKA episode. Perform a head-
14 mEq/L, the venous pH is 7.3 to-toe exam to identify abnormali-
or greater, or the bicarbonate level is
insulin on ties, establish a baseline assessment,
greater than 18 mEq/L.2,3,10 For and help identify root causes and
treating acidosis, if the pH is less their own. sequelae of the condition.
than 6.9, the ADA recommends The frequency of follow-up
adding 100 mmol of sodium bicar- assessments will vary depending on
bonate (NaHCO3) to 400 mL ster- the baseline assessment and stabil-
ile water and administering the ity of the patient. For example, alert
solution over two hours. If the pH patients may be able to report
is 6.9 to 7.0, 50 mmol of NaHCO3 should be symptom changes to nursing staff, whereas those
added to 200 mL sterile water and given over two who are unconscious will require assessment hourly
hours. Reevaluate the venous pH every two hours. (or more frequently, if necessary). Reassessment
When the pH reaches 7.0, no further NaHCO3 includes examination of ABC, and assessment of
need be administered. neurologic status and vital signs.2,4

NURSING CARE AND ONGOING ASSESSMENT EDUCATION

Nursing care of patients with DKA includes a
thorough nursing assessment as well as patient and
family education.
Primary assessment involves evaluation of air-
way, breathing, and circulation (ABC), as well as
neurologic status. First, assess airway patency. If the
patient is not able to breathe on his own insert an
oral or nasopharyngeal airway.6 If vomiting occurs,
oral suctioning may be required. If breathing is inef-
fective or the patient is vomiting and comatose, pro-
tect the airway by inserting an endotracheal tube
Once the patient is extubated, he will need educa-
tion in diabetes management in order to prevent
recurrence and sequelae. Patients who don’t believe
they have diabetes (as reported by family members)
pose a particular challenge to nurses, who will need
to tailor education accordingly.
Management during concurrent illness and daily
FSBS monitoring are of the utmost importance,
even if the disease is well controlled by oral agents.
Signs and symptoms of DKA need to be reviewed
with the patient and family during each ED visit for

ajn@lww.com AJN ▼ September 2002 ▼ Supplement 15

 hyperglycemia and whenever diabetes is identified
in the ED.4 Also, urge patients to get annual
influenza vaccines to prevent sepsis and pneumo-
nia—common stressors that precipitate acute DKA
episodes.13
Sick-day management. Advise patients to seek
professional medical assistance for uncontrolled
fevers, urinary frequency or discomfort, persistent
cough, or ulcerations. If antibiotics have been pre-
scribed for these illnesses, explain the importance of
using the entire prescription, even after symptoms
have improved or subsided. This will ensure that
these illnesses are appropriately treated and will
reduce the incidence of resistant bacterial strains.
Encourage patients to continue their insulin therapy
and medications even when they’re experiencing
nausea and vomiting from other illnesses.13 To pre-
vent DKA and dehydration, instruct patients to
drink liquids containing carbohydrates (such as
sodas, juices, and gelatins) and salt (such as bouil-
lon).3,9,13 If patients can’t keep these fluids down, or
if nausea and vomiting persist for more than a day,
they will need to consult a health care professional.
When patients with diabetes become ill with a
cold or flu, they should check their urine for ketones
with each void—or at least daily—using urine ketone
strips from the pharmacy.13 Patients also should
increase the frequency of FSBS monitoring to
make sure the levels remain under 200 mg/dL. If
readings exceed 200 mg/dL, they should contact
the health care professional.9 Encourage them to
get extra rest.13 Finally, remind patients to tell
family members or friends when they become ill,
and to ask family members to check on them
every four hours to make sure the condition has-
n’t worsened.3,13
Consultations. If patients don’t adhere to their
medical regimen, it’s important to identify the rea-
sons why. Patients often deny having a chronic ill-
ness, and therefore don’t follow medical advice or
take their medications. Those who struggle to cope
with diabetes may benefit from a psychiatric con-
sultation, which may help them accept the condi-
tion. A spiritual guide or a chaplain can also be
helpful, especially when there’s a threat of death,
severe illness, or life-changing complication.
If patients aren’t following the prescribed regi-
men because they can’t afford the cost of medica-
tions or diabetes monitoring equipment, arrange a
social service consultation as soon as possible. A
social worker may be able to help patients to
either obtain these supplies or apply for Medicare
or Medicaid insurance. Provide literature describ-
ing community services.
Furthermore, a registered dietitian can rein-
16 AJN ▼ September 2002 ▼ Supplement
force the importance of proper diet planning and
self-management of diabetes. Patients may also
benefit from advice on how to accommodate
dietary modifications when grocery shopping or
dining out.
Chronic vision changes may prevent elderly
patients with diabetes from administering insulin on
their own. A registered diabetes educator can help
them choose alternative methods of measuring and
administering insulin, such as teaching friends and
family members to administer the insulin for them,
using a magnifying glass when drawing the insulin,
or using an insulin pen.
Diabetes affects a significant percentage of the
population, and DKA is one of the most serious
health problems resulting from it. Rapid identifica-
tion is essential in order to improve patient out-
comes and overall quality of life. Once the stressors
have been identified, they must be treated. To pre-
vent further occurrence of DKA, educate patients
and their families so they can manage sick days
more effectively and know when to seek medical
assistance. ▼
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