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1. Introduction/description oI the disease

DKA is caused by an absence or markedly inadequate amount oI insulin. This deIicit in
available insulin results in disorder in the metabolism oI carbohydrate, protein and Iat.

The three main clinical Ieatures/maniIestations oI Diabetic Ketoacidosis (DKA) are based on
the Iollowing concepts:
) Hyperglycemia
2) dehydration and electrolyte loss
3) acidosis.
lood glucose levels range Irom 300 to 800 mg/dL.
Low serum bicarbonate and a low pH are present.

It is a liIe-threatening complication oI DM type I. this is due to severe insulin deIiciency.

2. Risk Iactors

4 !atient with Type I diabetes mellitus are at risk to develop DKA.
4 !ersons who are Irequently stressed out or due to stress-induced by surgery and
4 persons with Irequent or severe illness/inIection are also at risk oI developing DKA.

3. Causes

&nderdose or missed dose oI insulin
Illness or inIection
$tress, surgery
&ndiagnosed and untreated type I DM.


. !athophysiology

Without insulin, the amount oI glucose entering the cells is reduced, and production and
release oI glucose by the liver is increased. oth Iactors lead to hyperglycemia. In an attempt
oI the body to get rid oI the excess glucose, the kidneys excrete the glucose along with water
and electrolytes. This osmotic diuresis, which is characterized by excessive urination
(polyuria), leads to dehydration and marked electrolytes loss.

Lack of lnsulln
lncreased breakdown of
O ecreased uLlllzaLlon of
glucose by muscles faL
and llver
O lncreased producLlon of
glucose by llver
lncreased faLLy aclds
keLones bodles
O ceLone breaLh
O 9oor appeLlLe
O nausea
O -ausea
O IomlLlng
O bdomlnal paln
lncreaslng rapldly
8lurred vlslon
O Jeakness
O Peadache
lncreased LhlrsL


. Clinical maniIestations

Acetone breath (Iruity odor)
Anorexia, nausea, vomiting, abdominal pain
lurred vision, weakness and headache
rthostatic hypotension (drop in systolic blood pressure oI 20 mm Hg or more on
changing Irom reclining to standing position)
rank hypotension with a weak, rapid pulse
Mental status changes
Kussmaul`s respirations

6. Diagnostic test speciIic to the disease

asting lood $ugar ($)
Iasting is deIined as no caloric intake Ior at least eight hours; this include no
Iood, juices, milk; only water is allowed (N!).

asting lood $ugar Values :
109 mg - Normal
110-12 mg - Impaired glucose Tolerance (IGT)
126 mg - !ossible Diabetes Mellitus

Two-hour blood sugar test perIormed two hours aIter using 7 g glucose dissolved
in water or aIter a good meal. ral Glucose Tolerance Test (GTT) is not
recommended Ior routine clinical use nor screening purposes.
lood glucose monitoring
Check Ior Electrolytes imbalances

7. Medical Management

In addition to treating hyperglycemia, management oI DKA is aimed at correcting
dehydration, electrolyte loss, and acidosis.

Treat dehydration with N$$ 0.9 or 0. rapid IV as prescribed.
DN$ or dextrose in 0. saline when the blood glucose level reaches 20 to 300 mg/dL.

Restoring electrolytes
Administer !otassium replacements

Reversing acidosis
Ketone bodies (acids) accumulates as a result oI Iat breakingdown. It is reversed by
insulin. InIuse intravenously at a slow continuous rate.


8. !harmacologic management (drug study)

Regular insulin
!otassium replacement (KCl)
Metoclopramide (!lasil)

9. Nursing management and Non-pharmacologic treatments

Monitoring Iluid, electrolyte and hydration status
Monitor blood glucose level
Administer Iluids, insulin, and other medications
!revent Iluid overload
Monitor intake and output accurately
Vital signs monitoring
AG results monitoring and reporting to the attending physician
Assess mental status and breath sounds
Check ECG reading and make sure that there are no signs oI hyperkalemia (tall and
peaked or tented T waves)
Make sure that laboratory values oI potassium are normal or approaching normal.
Make sure that the patient is urinating. (no renal shutdown)
Initiate reIerrals Ior home care and outpatient diabetes education to ensure patient
continued recovery.

10.Collaborative management

Maintain patent airway
Administer xygen therapy as prescribed
Treat dehydration with 0.9 N$$ or 0. rapid as prescribed.

11.Nursing Care !lan

Risk for fluid volume deficit related to polyuria and dehydration

Imbalanced nutrition related to imbalance of insulin, food, and physical activity

atigue related to decreased metabolic energy production and insufficient
insulin as evidenced by overwhelming lack of energy, decreased performance
and disinterest in surrounding.


O Collaborate with the dietician and the physician.


13.Methods oI !revention and Contro

or prevention oI DKA related to illness patients must be taught '$ICK DAY rules Ior
managing their diabetes when ill.

4 Guidelines to ollow During !eriods oI Illness (~SICK DAY RULES)

O Take insulin or oral antidiabetic agents as usual.

O Test blood glucose and test urine ketones every 3 to hours.

O Report elevated glucose level (~300 mg/dL|16.6mmol/L| or as
otherwise speciIied) or urine ketones to your health care provider.

O II you take insulin, you may need supplemental doses oI regular
insulin every 3 to h.

O II you cannot Iollow your usual meal plan, substitute soIt Ioods six
to eight times per day.

O II vomiting, diarrhea, or Iever persists, take liquids every to 1
hour to prevent dehydration and to provide calories.

O Report nausea , vomiting, and diarrhea to your health care
provider, because extreme Iluid loss may be dangerous.

O II you are unable to retain oral Iluids, you may require
hospitalization to avoid diabetic ketoacidosis and possible coma.

The most important concept to teach patients is not to eliminate insulin doses when
nausea and vomiting occur.

lood glucose and urine ketones must be Irequently assessed.