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Diabetic Ketoacidosis is a serious complication of Diabetes Mellitus Type 1. The problem in Diabetes Mellitus Type 1 is the absolute lack of insulin. Without insulin, glucose will not be transported to the cells. Consequently, a person feels hungry despite of eating adequately and the level of glucose in the body is increasing because cell transportation is impossible.

Consequently, as a response to cell hunger, the body will begin to breakdown proteins. If not managed promptly, the break down will continue and this time, it’s the fats. These will give rise to a high level of ketones in the blood. Ketones are blood acids and will result to Diabetic Ketoacidosis. If left untreated, this is fatal.

Causes

  1. Decreased or missed dose of insulin – deficient insulin supply
  2. Illness or infection – causes resistance to insulin
  3. Undiagnosed and untreated diabetes
  4. Error in drawing up or injecting insulin – common in patients with visual impairment
  5. Intentional skipping of insulin doses – common in adolescents and those who have difficulty coping with the disease
  6. Equipment problems – example is occlusion of insulin pump tubing

Clinical Manifestations

  1. Hyperglycemia – leads to polyuria, polydipsia, blurred vision, weakness, and headache
  2. Orthostatic hypotension – a decrease of 20 mmHg or more in systolic blood pressure caused by marked intravascular volume depletion; weak, rapid pulse is noted
  3. Ketosis and acidosis – lead to gastrointestinal symptoms such as anorexia, nausea, vomiting, and abdominal pain, acetone (a fruity odor) breath
  4. Kussmaul respirations – hyperventilation with very deep, but not labored, respirations
  5. Mental status varies widely. Patient may be alert, lethargic, or comatose

Assessment and Diagnostic Findings

  1. Blood glucose level is between 300-800 mg/dL
  2. Ketoacidosis  – low serum bicarbonate value of 0-15 mEq/L and low blood pH of 6.0-7.3
  3. Low partial pressure of CO2 as respiratory compensation (10-30 mmHg)
  4. Accumulation of ketones reflected in blood and urine ketones measurements
  5. Patient can lose up to 6.5L and 500 mEq each of sodium, potassium, and chloride
  6. Increased hematocrit, BUN, and creatinine because of dehydration

Medical Management:

  1. Rehydration – patient may need 6-10 L of IV fluid
  2. Restoring electrolytes – major focus is given to controlling potassium
  3. Reversing acidosis – this is achieved through insulin therapy

Nursing Interventions:

  • Educate client about importance of strict adherence to diet. Recommended diet should be composed of 50% carbohydrates, 30% fats, and 20% protein. Also, client should have small frequent feedings instead of having three heavy meals a day.
  • Instruct client to do brisk walking for 30 minutes thrice a week. Exercise helps in controlling blood sugar.
  • Emphasize with the client the importance of taking insulin on time.
  • Test blood glucose and test urine ketones every 3 to 4 hours.
  • Instruct client to report blood glucose level higher than 300 mg/dL
  • If vomiting, instruct client to take liquids (e.g. cola, orange juice, broth, Gatorade) every ½ to 1 hour to prevent dehydration and to provide calories.
  • Address client’s confusion and safety by orienting and giving client information as well as raising side rails up and seeing to it that one significant other is present at the room.
  • Measure client’s intake and output accurately.
  • Be alert for signs and symptoms of electrolyte imbalance.
  • Refer client and family for counselling or therapy if difficulty in coping is observed.

Pathophysiology of Diabetic Ketoacidosis

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Iris is the recipient of Florence Nightingale Award in her class. She has genuine passion and interest in Endocrinology, Renal Nursing, and Nursing Research. Decided that the Nursing profession called her, she is serving the nursing community through writing or blogging for health-related educational websites and assisting students with their undergraduate thesis.