4 Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome Nursing Care Plans

Diabetic ketoacidosis (DKA) is a life-threatening emergency caused by a relative or absolute deficiency of insulin. This deficiency in available insulin results in disorders in the metabolism of carbohydrate, fat, and protein. Main clinical features of DKA are hyperglycemia, acidosis, dehydration, and electrolyte losses such as hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, and hypophosphatemia.

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) is a condition characterized by the presence of hyperglycemia, hyperosmolarity, and dehydration. There is enough production of insulin to reduce ketosis but not to control hyperglycemia. Persistent hyperglycemia causes osmotic diuresis, which results in the fluid and electrolyte imbalances. The clients with HHNS may present with symptoms of hypotension, tachycardia, marked dehydration, and neurological manifestation such as seizures, hemiparesis, and alterations in the sensorium).

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Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes and, much less commonly, of type 2 diabetes. DKA happens when your blood sugar is very high and acidic substances called ketones build up to dangerous levels in your body.

Diabetic Ketoacidosis shouldn’t be confused with ketosis, which is harmless. Ketosis can occur as a result of an extremely low carbohydrate diet, known as a ketogenic diet, or fasting. Diabetic Ketoacidosis only happens when you don’t have enough insulin in your body to process high levels of glucose in the blood.

It’s less common in people with type 2 diabetes because insulin levels don’t usually drop so low; however, it can occur. Diabetic Ketoacidosismay be the first sign of type 1 diabetes, as people with this disease can’t make their own insulin.

What are the symptoms of diabetic ketoacidosis?

Symptoms of Diabetic Ketoacidosis can appear quickly and may include:

  • frequent urination
  • extreme thirst
  • high blood sugar levels
  • high levels of ketones in the urine
  • nausea or vomiting
  • abdominal pain
  • confusion
  • fruity-smelling breath
  • a flushed face
  • fatigue
  • rapid breathing
  • dry mouth and skin

Diabetic Ketoacidosis is a medical emergency. Call your local emergency services immediately if you think you are experiencing DKA.

If left untreated, Diabetic Ketoacidosis can lead to a coma or death. If you use insulin, make sure you discuss the risk of DKA with your healthcare team and have a plan in place. If you have type 1 diabetes, you should have a supply of home urine ketone tests. You can buy these in drug stores or online.

If you have type 1 diabetes and have a blood sugar reading of over 250 milligrams per deciliter (mg/dL) twice, you should test your urine for ketones. You should also test if you are sick or planning on exercising and your blood sugar is 250 mg/dL or higher.

Call your doctor if moderate or high levels of ketones are present. Always seek medical help if you suspect you are progressing to Diabetic Ketoacidosis.

How is diabetic ketoacidosis treated?

The treatment for DKA usually involves a combination of approaches to normalize blood sugar and insulin levels. If you’re diagnosed with DKA but haven’t yet been diagnosed with diabetes, your doctor will create a diabetes treatment plan to keep ketoacidosis from recurring.

Infection can increase the risk of Diabetic Ketoacidosis. If your DKA is a result of an infection or illness, your doctor will treat that as well, usually with antibiotics.

Fluid replacement

At the hospital, your physician will likely give you fluids. If possible, they can give them orally, but you may have to receive fluids through an IV. Fluid replacement helps treat dehydration, which can cause even higher blood sugar levels.

Insulin therapy

Insulin will likely be administered to you intravenously until your blood sugar level falls below 240 mg/dL. When your blood sugar level is within an acceptable range, your doctor will work with you to help you avoid DKA in the future.

Electrolyte replacement

When your insulin levels are too low, your body’s electrolytes can also become abnormally low. Electrolytes are electrically charged minerals that help your body, including the heart and nerves, function properly. Electrolyte replacement is also commonly done through an IV.

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What causes diabetic ketoacidosis?

DKA occurs when blood sugar levels are very high and insulin levels are low. Our bodies need insulin to use the available glucose in the blood. In Diabetic Ketoacidosis, glucose can’t get into the cells, so it builds up, resulting in high blood sugar levels.

In response, the body starts breaking down fat into a useable fuel that doesn’t require insulin. That fuel is called ketones. When too many ketones build up, your blood becomes acidic. This is diabetic ketoacidosis.

The most common causes of Diabetic Ketoacidosis are:

  • missing an insulin injection or not injecting enough insulin
  • illness or infection
  • a clog in one’s insulin pump (for people who are using one)

Who is at risk for developing diabetic ketoacidosis?

Your risk of DKA is higher if you:

  • Have type 1 diabetes
  • Are under the age of 19
  • Have had some form of trauma, either emotional or physical
  • Are stressed
  • Have a high fever
  • Have had a heart attack or stroke
  • Smoke
  • Have a drug or alcohol addiction

Although DKA is less common in people who have type 2 diabetes, it does occur. Some people with type 2 diabetes are considered “ketone prone” and are at a higher risk of DKA. Some medications can increase the risk of DKA. Talk to your doctor about your risk factors.

How is diabetic ketoacidosis diagnosed?

Testing for ketones in a sample of urine is one of the first steps for diagnosing DKA. They will likely also test your blood sugar level. Other tests your doctor may order are:

  • Basic blood work, including potassium and sodium, to assess metabolic function
  • Arterial blood gas, where blood is drawn from an artery to determine its acidity
  • Blood pressure
  • If ill, a chest X-ray or other tests to look for signs of an infection, such as pneumonia

Preventing diabetic ketoacidosis

There are many ways to prevent DKA. One of the most important is proper management of your diabetes:

  • Take your diabetes medication as directed.
  • Follow your meal plan and stay hydrated with water.
  • Test your blood sugar consistently. This will help you get in the habit of making sure your numbers are in range. If you notice a problem, you can talk to your doctor about adjusting your treatment plan.

Although you can’t completely avoid illness or infection, you can take steps to help you remember to take your insulin and to help prevent and plan for a DKA emergency:

  • Set an alarm if you take it at the same time every day, or download a medication reminder app for your phone to help remind you.
  • Pre-fill your syringe or syringes in the morning. That will help you easily see if you missed a dose.
  • Talk to your doctor about adjusting your insulin dosage levels based on your activity level, illnesses, or other factors, such as what you’re eating.
  • Develop an emergency or “sick day” plan so you will know what to do if you develop DKA symptoms.
  • Test your urine for ketone levels during periods of high stress or illness. This can help you catch mild to moderate ketone levels before they threaten your health.
  • Seek medical care if your blood sugar levels are higher than normal or ketones are present. Early detection is essential.

Takeaway

DKA is serious, but it can be prevented. Follow your treatment plan and be proactive about your health. Tell your doctor if something isn’t working for you or if you’re having trouble. They can adjust your treatment plan or help you come up with solutions for better managing your diabetes.

Nursing Care Plan (NCP): Guide and Complete List” href=”https://nursingessays.us/nursing-care-plans/” target=”_self” rel=”noopener noreferrer” data-ail=”41475″>Diabetic Ketoacidosis Nursing Care Plans

The nursing care plan for clients with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome includes provision of information about disease process/prognosis, self-care, and treatment needs, monitoring and assistance of cardiovascular, pulmonary, renal, and central nervous system (CNS) function, avoiding dehydration, and correcting hyperglycemia and hyperglycemia complications.

Here are four (4) nursing care plans (NCP) and nursing diagnosis for patients with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome:

  1. Risk For Fluid Volume Deficit
  2. Risk For Infection
  3. Deficient Knowledge
  4. Imbalanced Nutrition: Less Than Body Requirements

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Risk For Fluid Volume Deficit

Nursing Diagnosis

Risk Factors

Possibly evidenced by

  • [not applicable].

Desired Outcomes

  • Client will remain normovolemic as evidenced by urinary output greater than 30 ml/hr, normal skin turgor, good capillary refill, normal blood pressure, palpable peripheral pulses, and blood glucose levels between 70-200 mg/dL.
Nursing Interventions Rationale
Assess precipitating factors such as other illnesses, new-onset diabetes, or poor compliance with treatment regimen. These will provide baseline data for education once with resolved hyperglycemia. Urinary tract infection and pneumonia are the most common infections causing DKA and HHNS among older clients.
Assess skin turgor, mucous membranes, and thirst. To provide baseline data for further comparison. Skin turgor will decrease and tenting may occur. The oral mucous membranes will become dry, and the client may experience extreme thirst.
Monitor hourly intake and output. Oliguria or anuria results from reduced glomerular filtration and renal blood flow.
Monitor vital signs:
Decreased blood volume may be manifested by a drop in systolic blood pressure and orthostatic hypotension.
  • Monitor respirations, e.g., acetone breath, Kussmaul’s respirations.
Acetone breath is due to the breakdown of acetoacetic acid. Kussmaul’s respiration (rapid and shallow breathing) represent a compensatory mechanism by the respiratory buffering system to raise arterial pH by exhaling more carbon dioxide.
  • Monitor temperature.
Fever with flushed, dry skin may indicate dehydration.
  • Monitor heart rate.
Compensatory mechanism results in peripheral vasoconstriction with a weak, thready pulse that is easily obliterated.
  • Assess neurological status every two (2) hours.
Decreased level of consciousness results from blood volume depletion, elevated or decreased glucose level, hypoxia or electrolyte imbalances.
Weigh client daily. Provides baseline data of current fluid status and adequacy of fluid replacement. A weight loss of 2.2 lbs over 24 hours indicates a 1 liter of fluid loss.
Monitor laboratory studies:
  • Blood glucose levels
Diagnostic criteria:

DKA: blood glucose level greater than 250 mg/dL.

HHNS: blood glucose level greater than 600 mg/dL with serum osmolality >320 mOsm/kg.

  • Serum ketones
Elevated ketones is associated with DKA.
  • Potassium
Initially, hyperkalemia occurs in response to metabolic acidosis. As the fluid volume deficit progresses, potassium level decreases. Both DKA and HHNS result in hypokalemia.
  • Sodium
Increased blood sugar causes water to shift from intracellular into extracellular, resulting in serum sodium depletion.
Elevated BUN and creatinine indicate cellular breakdown from dehydration or a sign of an acute renal failure.
Monitor ABG for metabolic acidosis. Clients with DKA have metabolic acidosis with arterial a bicarbonate level less than 18 mEq/L, and a pH less than 7.30.
Insert indwelling urinary catheter as indicated. To provide accurate measurement of urinary output especially for clients with neurogenic bladder.
Administer fluid as indicated: Isotonic solution (0.9% NaCl). Initial goal of therapy is to correct circulatory fluid volume deficit. Isotonic normal saline will rapidly expand extracellular fluid volume without causing a rapid fall in plasma osmolality. Clients typically need 2 to 3 liters within the first 2 hours of treatment.
Administer succeeding IV therapy: Hypotonic solution such as 0.45% normal saline. Continuation of IV administration depends on the degree of fluid deficit, urinary output, and serum electrolyte values.
Add dextrose to IV fluid when serum blood glucose level is less than 250 mg/dL in DKA or less than 300 mg/dL in HHNS. Dextrose is added to prevent the occurrence of hypoglycemia and an excessive decline in plasma osmolality that can result in cerebral edema.
Administer IV potassium and other electrolytes as indicated. Potaasium is added to the IV once serum potassium drops below 5.5 mEq/L to prevent hypokalemia. The administration of insulin to lower blood glucose promotes the movement of potassium intracellularly.
Administer bicarbonate as indicated. This is given in clients with a severe hyperkalemia and severe acidosis with pH of less than 7.1.
Administer an IV bolus dose of regular insulin, followed by a continuous infusion of regular insulin. Regular insulin has a rapid onset and therefore immediately helps move glucose intracellularly. IV route is the initial route because subcutaneous injection of insulin may be absorbed unpredictably. While a continuous infusion is an optimal way to consistently administer insulin to prevent hypoglycemia.

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