Diabetic

ketoacidosis
(DKA)
 Learning objectives
● Define diabetic ketoacidosis
● Get to know the affected organs of the condition and its
pathophysiology
● Identify its signs and symptoms
● Get to know how to properly assess patients with DKA
● Identify appropriate medical, pharmacological, and
nursing interventions for patients with DKA.
T 1
 CONTENTS
01 02
Introduction on Anatomy
diabetic &
ketoacidosis physiology
03 04
pathophysiology ASSESSMENT

T 0
 CONTENTS

05
5 PRIORITY
NURSING DIAGNOSIS

06
INTERVENTIONS

T 0
01
WHAT IS
DKA?

T 1
 DEFINITION OF TERMS

DIABETES - is a chronic, metabolic disease HYPERGLYCEMIA - high blood glucose

characterized by elevated levels of blood glucose (or
blood sugar), which leads over time to serious
damage to the heart, blood vessels, eyes, kidneys
and nerves.
KETOSIS - a metabolic state that occurs when your
body burns fat for energy instead of glucose.
KETONES - chemicals made by the liver
METABOLIC ACIDOSIS - characterized by an
increase in the hydrogen ion concentration in the
systemic circulation that results in an abnormally
low serum bicarbonate level
OSMOTIC DIURESIS - increased urination due to the
presence of certain substances in the fluid filtered
by the kidneys

KETOACIDOSIS - a metabolic state associated with

pathologically high serum and urine concentrations
of ketone bodies.

T 1
What is dka?
uncontrolled catabolism associated with insulin
deficiency seen in patients with Type 1 Diabetes
resulting in hyperglycemia , ketosis that causes
metabolic acidosis, and osmotic diuresis resulting in
profound dehydration. - is a life-threatening problem
that affects people with diabetes.

T 1
What is the cause of
dka?
DKA develops when the body doesn’t have enough
insulin to allow blood sugar into cells for use as
energy.

T 1
02
Anatomy and
physiology of the
affected organs
Pancreas
Kidneys
Liver
lobe
03

pathophysiology
T 4
 Lack of Insulin Cells cannot utilize glucose

Cell starvation Hyperglycemia

250- 600+ mg/dl

Liver Lipolysis
Fat Breakdown

kidney

Glycogenolysis Fatty acid

Stored glycogen in
the liver is Osmotic diuresis
converted to Formation of Glucose leaks into urine
glucose along with electrolytes
ketones (k+, na+)

Ph acetone
Increased
blood sugar polyuria polydipsia
levels Metabolic
acidosis Fruity
breath dehydration

Kussmaul breathing
 04
ASSESSMENT

T 5
 SIGNS & SYMPTOMS OF Dka:
DEHYDRATION NAUSEA &
POLYDIPSIA
VOMITING

ABDOMINAL
POLYURIA
PAIN

T 2
 SIGNS & SYMPTOMS OF DKA:
ACETONE
SMELL OF KETONES
TACHYCARDIA
BREATH
“FRUITY”
HYPOTENSION,
KUSSMAUL
CONFUSION,
BREATHING
FATIGUE

T 2
 RISK FACTORS:
Type 1 Diabetes

Not taking prescribed

insulin

Stomach Illness

Infections

Heart disease (heart attack)

Recent stroke
T 6
 RISK FACTORS:
Blood clot in your lungs

Serious illness or any trauma

Pregnancy

Surgery
Medicines (steriods or
antipsychotics)

Using illegal drugs (cocaine)

T 6
 Diagnostic test
the following tests to diagnose DKA:

● Blood glucose test. (Normal Value: 70-100mg/dL)

● Ketone testing (through a urine or blood test).
Normal Value:under 0.6mmol/L
● Arterial blood gas.
pH (7.35-7.45), PaCO2 (35-45 mmHg), HCO3 (22-26 mEq/L)
● Blood pressure check (Normal Value: 120/80)
T 3
 Diagnostic test
The following tests to diagnose DKA:
● Basic metabolic panel.
BUN : 6 to 20 mg/dL (2.14 to 7.14 mmol/L)
CO2 (carbon dioxide) : 23 to 29 mmol/L.
Creatinine : 0.8 to 1.2 mg/dL (70.72 to 106.08 micromol/L)
Glucose : 64 to 100 mg/dL (3.55 to 5.55 mmol/L)
Serum chloride : 96 to 106 mmol/L.
Serum potassium : 3.7 to 5.2 mEq/L (3.7 to 5.2 mmol/L)
● Osmolality blood test.
(Normal Values 275 to 295 mmol/kg)

T 3
 PreventioN

How can I prevent DKA?

● Check your blood sugar often
● Take your insulin and/or medication regularly
● Check for ketones
● Check your insulin pump

T 3
 05
5 primary
Nursing
Diagnosis

T 4
 NURSING DIAGNOSIS
1. FLUID VOLUME DEFICIT
Due to excessive urination, vomiting, and dehydration in DKA, the patient is at risk
for fluid volume deficit. Nursing interventions should focus on closely monitoring
intake and output, administering prescribed intravenous fluids, assessing for signs
of dehydration, and ensuring proper fluid balance.

Related to excess urination, vomiting and

dehydration secondary to Diabetic Ketoacidosis.

T 3
 NURSING DIAGNOSIS
As evidenced by:

● Elevated heart rate (tachycardia)

● Low blood pressure (hypotension)
● Increased respiratory rate (tachypnea)
● Elevated body temperature (due to dehydration
● Poor skin turgor and elasticity
● Dry and cool skin
● Delayed capillary refill time
● Dry and sticky mucous membranes (dry mouth)

T 3
 NURSING DIAGNOSIS
EXPECTED OUTCOMES

● Patient will maintain balanced fluid intake and output.

● Vital signs will return to baseline values, with normal blood pressure,
heart rate, and respiratory rate.
● Urine output will be within the normal range.
● Skin turgor and elasticity will improve, indicating better hydration.
● Mucous membranes will be moist and pink, indicating improved
hydration.
● Capillary refill time will be within the expected range.

T 3
 NURSING DIAGNOSIS
ASSESSMENT:

● Monitor vital signs regularly, including blood pressure, heart rate,

respiratory rate, and temperature.
● Assess skin turgor, mucous membranes, and capillary refill time to
identify signs of dehydration.
● Monitor intake and output to evaluate fluid balance.

T 3
 NURSING DIAGNOSIS
INTERVENTIONS:
1. Fluid Replacement:
- Administer intravenous fluids as prescribed by the healthcare provider (e.g.,
normal saline) to restore and maintain fluid balance.
1. Monitor Vital Signs:
- Regularly monitor blood pressure, heart rate, and respiratory rate. A drop in
blood pressure and an increase in heart rate may indicate severe volume
depletion.
1. Monitor Blood Glucose Levels: -Regular monitoring of blood glucose
levels is essential. The goal is to reduce the glucose levels slowly and
steadily. Insulin therapy will be necessary, but be careful to avoid a rapid
decrease in blood glucose which can lead to cerebral edema.
T 3
 NURSING DIAGNOSIS
INTERVENTIONS:
1. Monitor Electrolyte Levels: Electrolyte imbalance is common in
DKA. Potassium is especially important to monitor as insulin therapy
can lead to hypokalemia (low potassium levels).
2. Monitor Urine Output: Ensure adequate urine output (0.5-1
ml/kg/hr) as this is a sign that the kidneys are functioning, and the
fluid volume is being restored.
3. Monitor Mental Status: Changes in mental status can indicate
cerebral edema, a life-threatening complication.
4. Administer Insulin: Continuous intravenous insulin infusion is usually
required to correct hyperglycemia and ketoacidosis.
T 3
 NURSING DIAGNOSIS
2. Imbalanced Nutrition: Less Than Body
Requirements

Nausea, vomiting, and altered appetite can lead to inadequate nutritional

intake. The nurse should monitor the patient's nutritional status, provide
antiemetics as prescribed, offer small, frequent meals, and collaborate
with dietitians to create a suitable meal plan.

Related to: Hyperglycemia

Insulin Deficiency
Increased Metabolic Rate

T 3
 NURSING DIAGNOSIS
As evidence by:

● Unintentional Weight Loss

● Poor Skin Turgor
● Dry Mucous Membranes
● Muscle Wasting
● Decreased Strength and Endurance
● Hypoglycemia
● Elevated Blood Ketone Levels
T 3
 NURSING DIAGNOSIS
EXPECTED OUTCOMES

● Patient will acquire adequate hydration.

● Maintain or gain weight within an acceptable range for their
age, height, and individual health needs.
● Improved Nutritional Status where laboratory values related to
nutrition will be in normal limits.
● Normal Blood Glucose Levels
● Adequate Energy Levels
Adequate Muscle Mass
T 3
 NURSING DIAGNOSIS
ASSESSMENT:
● Obtain a detailed medical history, including the duration and
management of diabetes.
● Document symptoms related to DKA, such as nausea, vomiting,
abdominal pain, fruity breath odor, and altered mental status.
● Monitor the patient's fluid intake and output, noting any changes
that might indicate dehydration.
● Review laboratory results, including blood electrolytes (sodium,
potassium, chloride), blood urea nitrogen (BUN), creatinine, and
arterial blood gases (ABGs).

T 3
 NURSING DIAGNOSIS
INTERVENTIONS:
1. Fluid Replacement:
- Administer intravenous fluids as prescribed to correct dehydration and
restore electrolyte balance.
1. Blood Glucose Management:
- Administer insulin therapy as prescribed to manage hyperglycemia and prevent
further breakdown of nutrients for energy.
1. Oral Hydration: -Offer oral fluids regularly to maintain adequate hydration
and prevent dehydration.

T 3
 NURSING DIAGNOSIS
INTERVENTIONS:
4. Monitor Ketone Levels:
- Continuously monitor blood ketone levels to assess the effectiveness of
treatment and nutritional intake

5. Educate the Patient and Family:

-Teach the patient how to manage their blood glucose levels, carbohydrate
counting, and the importance of regular meals and snacks.

T 3
 NURSING DIAGNOSIS
3. Risk for Electrolyte
Imbalance

DKA can lead to imbalances in electrolytes such as potassium, sodium, and

bicarbonate. Nurses must monitor electrolyte levels, administer replacement
electrolytes as ordered, and educate the patient about the importance of
maintaining electrolyte balance.

Related to :
● Hyperglycemia due to elevated blood
glucose levels.
● Accumulation of ketones in the blood due to
insulin deficiency
● Fluid Loss due to hyperglycemia

T 3
 NURSING DIAGNOSIS
As evidence by:
● Elevated blood glucose levels (hyperglycemia).
● Presence of ketones in blood and urine.
● Abnormal electrolyte levels, such as high potassium (hyperkalemia), low sodium
(hyponatremia), or altered chloride and bicarbonate levels.
● Abnormal heart rate (tachycardia or bradycardia).
● Changes in blood pressure.
● Dry mucous membranes.
● Decreased skin turgor.
● Presence of fruity breath odor (acetone smell).
● Signs of dehydration, such as sunken eyes or poor capillary refill.
T 3
 NURSING DIAGNOSIS
Expected outcomes:
● The patient's electrolyte levels, including sodium, potassium, chloride,
bicarbonate, and phosphorus, will remain within the normal range.
● The patient's blood glucose levels will gradually decrease and be maintained
within the target range.
● The patient's acid-base balance will improve, and the presence of ketones in the
blood and urine will decrease.
● The patient's blood pressure, heart rate, and respiratory rate will remain within
acceptable ranges.
● The patient will receive and tolerate appropriate nutritional support to prevent
further electrolyte disturbances.
● The patient will report feeling better overall, with relief from symptoms such as
nausea, vomiting, and weakness.
T 3
 NURSING DIAGNOSIS
ASSESSMENT:

● Monitor vital signs regularly, including blood pressure, heart rate,

respiratory rate, and temperature.
● Assess skin turgor, mucous membranes, and capillary refill time to
identify signs of dehydration.
● Monitor intake and output to evaluate fluid balance.

T 3
 NURSING DIAGNOSIS
interventions

1. Frequent Monitoring of Patient:

- Monitor blood glucose levels regularly to guide insulin therapy and prevent
extreme fluctuations.
2. Fluid Replacement:
- Administer intravenous fluids as prescribed to correct dehydration and
support electrolyte balance.
3. Insulin Administration:
- Administer insulin therapy as prescribed to manage hyperglycemia
and ketosis.

T 3
 NURSING DIAGNOSIS
interventions

4. Electrolyte Replacement:
- Administer electrolyte replacement solutions as prescribed to restore and
maintain appropriate electrolyte levels.
5. Renal Function Assessment:
- Monitor renal function tests, such as creatinine and blood urea nitrogen
(BUN), to assess kidney health and filtration.
6. Patient Education:
- Educate the patient and family about the risk for electrolyte imbalance, signs of
imbalance, and the importance of adherence to prescribed treatment.

T 3
 NURSING DIAGNOSIS
4. Risk for infection

Elevated blood glucose levels in DKA can impair the immune response
and increase the risk of infection. Nursing interventions might involve
monitoring for signs of infection, maintaining good hygiene practices,
and educating the patient about infection prevention.
Related to :
● Decreased Tissue Oxygenation
● Altered Skin Integrity
● Immune System Impairment: due to
hyperglycemia
● Glycosuria due to elevated blood sugar
levels.
● Poor Nutritional Status:
T 3
 NURSING DIAGNOSIS
As evidence by:
● Elevated blood glucose levels (hyperglycemia).
● Presence of ketones in blood and urine.
● Altered Immune Function as the Laboratory results indicating impaired immune
function.
● Documentation of slow or impaired wound healing.
● Presence of non-healing wounds or ulcers.
● Presence of multiple puncture sites due to frequent blood glucose monitoring.
● Dry mucous membranes.
● Decreased skin turgor.
● Documentation of dysuria, frequency, urgency, or cloudy urine.
● Positive urine culture indicating the presence of pathogens.
T 3
 NURSING DIAGNOSIS
Expected outcomes:
● The patient will show no signs or symptoms of infection, such as fever, localized
pain, or increased white blood cell count.
● Blood glucose levels will gradually decrease and be maintained within the target
range, reducing the favorable environment for microbial growth.
● Acidosis will improve, leading to a less favorable environment for bacterial
growth.
● Immune function will become more effective as blood glucose levels normalize.
● Any existing wounds or ulcers will show signs of healing without signs of
infection.
● The patient's skin will remain intact without new breaks or cracks that could serve
as entry points for pathogens.
● The patient will feel comfortable and safe in the healthcare environment, reducing
stress-related immunosuppression.T 3
 NURSING DIAGNOSIS
ASSESSMENT:

● Document symptoms of DKA, such as polyuria (excessive urination),

dehydration, fruity breath odor, and altered mental status.
● Review recent blood glucose levels to determine the extent of
hyperglycemia.
● Note patterns of hyperglycemia that can increase infection risk.
● Inspect the skin for any existing wounds, ulcers, cuts, or breaks in skin
integrity that could serve as entry points for infection.
● Note any signs of dry, cracked skin due to dehydration.
● Assess for signs of dehydration, such as dry mucous membranes,
decreased skin turgor, and low urine output.
T 3
 NURSING DIAGNOSIS
interventions

1. Instruct Hand Hygiene:

- Educate the patient, family, and healthcare providers about the importance of frequent
and thorough handwashing with soap and water or using alcohol-based hand
sanitizers.
2. Demonstrate Strict Aseptic Technique:
- Ensure that all invasive procedures, such as IV line insertion, catheterization, or wound
care, are performed using strict aseptic technique to prevent introducing pathogens.
3. Establish Wound Care:
- Monitor and properly care for any existing wounds, ulcers, or cuts to prevent infection.

T 3
 NURSING DIAGNOSIS
interventions

4. Provide Patient Comfort:

- Promote patient comfort, as stress and discomfort can weaken the immune
system.

5. Promote Adequate Rest:

- Encourage the patient to get adequate rest to support immune function and
overall recovery.
.

T 3
 NURSING DIAGNOSIS
5. Impaired gas exchange
Metabolic acidosis in DKA can result in respiratory distress and impaired gas
exchange. Nursing interventions include monitoring respiratory status,
administering oxygen as needed, encouraging deep breathing exercises, and
observing for signs of respiratory compromise.

Related to :
● Electrolyte Imbalances due to
hyperkalemia
● Respiratory Acidosis
● Dehydration: due to thickened respiratory
secretions
● Hyperviscosity due to accumulation of
Hyperglycemia
T 3
 NURSING DIAGNOSIS
As evidence by:
● Tachypnea (rapid breathing) or bradypnea (slow breathing) as a
compensatory response to metabolic acidosis.
● The patient may exhibit shallow, ineffective respirations due to muscle fatigue
or altered respiratory drive.
● Decreased Oxygen Saturation (SpO2):
● Rapid breathing that leads to excessive elimination of carbon dioxide,
potentially causing respiratory alkalosis.
● Patient verbalizes experiencing difficulty breathing or shortness of breath.

T 3
 NURSING DIAGNOSIS
Expected outcomes:
● The patient's respiratory rate will become more regular and within the normal
range.
● Oxygen saturation (SpO2) levels will improve and remain within the target
range.
● Arterial blood gas values, including pH, PaO2, PaCO2, and HCO3, will
normalize as acidosis is corrected.
● Heart rate will become more stable as respiratory compensation improves.
● The patient will report a reduction in shortness of breath or difficulty
breathing.
● Adequate hydration will contribute to thinner respiratory secretions and
improved gas exchange.
T 3
 NURSING DIAGNOSIS
ASSESSMENT:
● Assess the patient's respiratory rate, rhythm, and pattern.
● Note any signs of rapid, shallow breathing (Kussmaul respirations) or other abnormal
breathing patterns.
● Auscultate lung sounds to identify any wheezing, crackles, or decreased breath sounds
that could indicate impaired gas exchange.
● Monitor oxygen saturation (SpO2) using pulse oximetry to assess the patient's
oxygenation status.
● Assess the patient's skin, lips, and nail beds for signs of cyanosis (bluish discoloration)
indicating poor oxygenation.
● Monitor trends in oxygen saturation levels over time to identify changes in oxygenation
status.
● Assess the patient's ability to perform activities without experiencing significant
shortness of breath or oxygen desaturation.

T 3
 NURSING DIAGNOSIS
interventions
1. Administer Oxygen to the Patient::
- Provide supplemental oxygen as prescribed to maintain oxygen saturation levels
within the target range.
2. Elevate Head of Bed:
- Position the patient in a semi-Fowler's or high-Fowler's position to improve lung
expansion and reduce the work of breathing.
3. Encourage Deep Breathing and Coughing:
- Teach the patient deep breathing exercises to promote lung expansion and
coughing to clear respiratory secretions.

T 3
 NURSING DIAGNOSIS
interventions

4. Provide Bronchodilator Therapy:

- Administer bronchodilators as prescribed to improve airway patency and
promote optimal gas exchange.

5. Education:
- Educate the patient about the importance of adhering to DKA treatment,
maintaining hydration, and practicing deep breathing exercises.
.

T 3
 Blood sugar chart
Fasting Value (mg/dl) Postprandial (mg/dl)
Category
Min. Value Max. Value Value 2h after eating glucose

Normal 70 100 Less than 140

Early
101 126 140 to 200
Diabetes

Established
More than 126 - More than 200
Diabetes

T 4
06

INTERVENTIONS
T 4
 Nursing interventions:
PATIENT EDUCATION:
Teach them prevention and the warning signs

Monitor glucose and ketones in

urine every 4 hours when sick

If can’t eat or drink, notify

physician, but if CAN, drink every
hour

T 6
 Nursing interventions:
PATIENT EDUCATION:
Teach them prevention and the warning signs

Notify physician if B.S. > 300 mg/dl

consistently
Ketones present in urine

Excessive urination and fruity breath

T 6
 Nursing interventions:
PATIENT EDUCATION:
Teach them prevention and the warning signs

T 6
 Nursing interventions:
PATIENT EDUCATION:
IF TRACE OR SMALL, it may indicate the
Teach them prevention and the warning signs
BEGINNING OF KETONE BUILD-UP. The
American Diabetes Association recommends to
test again after a few hours

IF MODERATE OR LARGE, take this as a

DANGER SIGN. Seek medical help or call your
healthcare provider immediately

Teach patient to keep a log of their urine

test, so that they can share to their HCP,
to aid in their management.

T 6
 Other nursing
interventions:
PATIENT EDUCATION:
Teach them prevention and the warning signs

1. Monitor for and treat signs / symptoms

of infection

- DKA is often the result of an underlying infection such

as a common cold, flu or bacterial infection like
pneumonia or urinary tract infections. Assess for fever
and other symptoms of infection and administer
antibiotics as necessary

T 6
PATIENT EDUCATION:
2. Monitor
Teach vital signs/symptoms
them prevention of
and the warning signs
hypovolemia

- Vomiting and frequent urination can cause a

deficiency in fluid volume, thus leading to a decreased
circulatory volume. This will be evident by low blood
pressure and tachycardia

T 6
PATIENT EDUCATION:
3. Prevent
Teach injury and and
them prevention falls;the
assist with signs
warning
ambulation

- Fatigue and weakness are common due to the cells

inability to use glucose to produce energy, also
following vomiting, and in cases of dehydration.

T 6
PATIENT EDUCATION:
4. Nutrition and lifestyle education:
Teach them prevention and the warning signs
- Avoid alcohol/illicit drug use
- Choose foods that are high in fiber and low in fats,
sugars, and simple carbs
- Eat regular meals and snacks, don’t miss meals
- Check for urine ketones when you have symptoms
- Do not exercise when urine shows positive for ketones
- Maintain compliance with medication insulin therapy

T 6
 PHARMACOLOGICAL INTERVENTIONS

AIMED AT :

REHYDRATION

RESTORING ELECTROLYTES

REVERSING ACIDOSIS

Before treating hyperglycemia with insulin.

Other goals for treatment are:

1. Lower blood sugar
2. Monitor K+ levels for cerebral edema
T 6
 REHYDRATION

- Rehydration is important for maintaining

tissue perfusion
- Patient may need IV fluid to replace fluid
losses caused by POLYURIA,
HYPERVENTILATION, DIARRHEA, VOMITING

T 6
 REHYDRATION

1. Initially, 0.9% Sodium Chloride (Normal Saline) is given,

or may progress to 0.45%, depending on how
dehydrated the patient is.
2. If BP is stable and sodium level is not low, 200 to 500 ml
may be needed for several hours
3. When blood glucose levels reach 300 mg/dl or less the
IV solution may be change to D5W

T 6
 RESTORING ELECTROLYTES

- Major electrolyte concern during treatment of DKA is

POTASSIUM
- Initial plasma concentration of K+ is often high.
- Rehydration treats the affected potassium
concentration. It leads to increased urinary excretion
of K+
- Frequent ECGs (2-4 hours initially) & lab measurements
of K+ is necessary during the first 8 hours

T 6
 REVERSING ACIDOSIS
- KETONE BODIES (acid) is a result of fat
breakdown
- The acidosis can be reversed with insulin, which
inhibits fat breakdown, and ending ketone
production and acid build-up.

REGULAR INSULIN IV
- Monitor K+ levels first (>3.5 meq/L)

T 6
 Other nursing interventions
(Pharmacological):
PATIENT EDUCATION:
Teach them prevention and the warning signs
1. Monitor blood glucose levels and
administer insulin as appropriate

- Consistently high blood glucose levels, over 400

mg/dL, are the primary indicator of ketone
production. Monitor glucose and intervene with
prescribed insulin as appropriate to reduce
glucose levels and prevent further ketone
production.

T 6
 2. Monitor fluid and electrolyte balance
to prevent
PATIENT dehydration and
EDUCATION:
Teachcomplications such
them prevention as the
and decreased
warning signs
sodium, potassium, calcium and
magnesium

- Excess blood glucose can cause nausea and vomiting

resulting in electrolyte imbalances. These electrolyte
deficiencies can lead to further complications and
cardiac arrhythmias.

T 6
 2. Administer medications as appropriate
PATIENT EDUCATION:
-Teach
Insulinthem prevention
as necessary, Regular and the
Insulin, thewarning
only type ofsigns
insulin approved for IV may be added to IV solutions

- IV fluids

T 6