DEFINITION:

DKA is caused by an absence or markedly inadequate amount of insulin, resulting in

disorders in the metabolism of carbohydrate, protein, and fat.

CAUSES:
▪ Decreased Or Missed Dose of Insulin
▪ Illness or Infection
▪ Undiagnosed and Untreated Diabetes

PATHOPHYSIOLOGY:
Insulin deficiency

Reduction in amount of glucose, entering the cells

Increased Glucose Production in the Liver

Excretion of glucose in water and electrolytes by kidney

Osmotic diuresis

Dehydration and Marked Electrolyte Loss

V
Lipolysis into free fatty acids and glycerol

Conversion of fatty acids into ketone bodies

Excessive production of ketone bodies

DKA
CLINICAL MANIFESTATIONS:
The three main clinical features of DKA are:
• Hyperglycaemia
• Dehydration and electrolyte loss
• Acidosis
Other features could be:
• Polyuria
• Polydipsia
• Blurred Vision
• Weakness
• Headache
• Orthostatic Hypotension
• Frank Hypotension with A Weak, Rapid Pulse
• Anorexia
• Nausea And Vomiting
• Abdominal Pain
• Acetone Breath (a fruity odour)
• Kussmaul Respirations

DIAGNOSTIC FINDINGS:
▪ Blood glucose levels may vary from 300 to 800 mg/dl.
▪ Evidence of ketoacidosis is reflected in low serum bicarbonate (0 to 15 mEq/L) and
low pH (6.8 to 7.3) values.
▪ A low PCO2 level (10 to 30 mm Hg) reflects respiratory compensation (Kussmaul
respirations) for the metabolic acidosis.
▪ Accumulation of ketone bodies (which precipitates the acidosis) is reflected in blood
and urine ketone measurements.
▪ Sodium and potassium levels may be low, normal, or high, depending on the amount of
water loss (dehydration).
▪ Elevated levels of creatinine, blood urea nitrogen (BUN), haemoglobin, and haematocrit
may also be seen with dehydration.

PREVENTION:
▪ The most important issue to teach patients is not to eliminate insulin doses when nausea
and vomiting occur.
▪ Rather, they should take their usual insulin dose and then attempt to consume frequent
small portions of carbohydrates.
▪ Drinking fluids every hour is important to prevent dehydration.
▪ Blood glucose and urine ketones must be assessed every 3 to 4 hours.
 ▪ Diabetes self-management skills (including insulin administration and blood glucose
testing) should be assessed to ensure that an error in insulin administration or blood
glucose testing did not occur.

MEDICAL MANAGEMENT:
▪ Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis.
▪ In dehydrated patients, rehydration is important for maintaining tissue perfusion.
▪ Fluid replacement enhances the excretion of excessive glucose by the kidneys.
▪ Monitoring fluid volume status involves frequent measurements of vital signs, lung
assessment, and monitoring intake and output.
▪ Monitoring for signs of fluid overload is especially important for older patients, those
with renal impairment, or those at risk for heart failure.
▪ Initially, 0.9% sodium chloride (normal saline) solution is administered at a rapid rate,
usually 0.5 to 1 L per hour for 2 to 3 hours.
▪ Plasma expanders may be necessary to correct severe hypotension that does not respond
to IV fluid treatment.

NURSING MANAGEMENT:
➢ Nursing care of the patient with DKA focuses on monitoring fluid and electrolyte
status as well as blood glucose levels; administering fluids, insulin, and other
medications; and preventing other complications such as fluid overload.
➢ Urine output is monitored to ensure adequate renal function before potassium is
administered to prevent hyperkalaemia.
➢ The electrocardiogram is monitored for dysrhythmias indicating abnormal potassium
levels.
➢ Vital signs, arterial blood gases, and other clinical findings are recorded on a flow
sheet.
➢ The nurse documents the patient’s laboratory values and the frequent changes in
fluids and medications that are prescribed and monitors the patient’s responses.
➢ As DKA resolves and the potassium replacement rate is decreased, the nurse makes
sure that:
• There are no signs of hyperkalaemia on the electrocardiogram (tall, peaked T
waves).
• The laboratory values of potassium are normal or low.
• The patient is urinating (i.e., no renal shutdown).
➢ As the patient recovers, the nurse reassesses the factors that may have led to DKA
and teaches the patient and family about strategies to prevent its recurrence.