Diabetic Ketoacidosis (DKA) & Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

Main Causes of DKA

•Illness or infection (insulin resistance)

•Undiagnosed/untreated diabetes

•decreased or missed dose of insulin

•Patient error

•Intentional skipping of insulin doses

•Equipment problems

•Stress

if a patient has AMS with a sugar of 40 what do you do

-give glucagon: helps it not get worse

-IV push 50% dextrose

-recheck glucose 15-30 mins later

DKA: Pathophysiology

•Insulin deficiency→ decreased amount of glucose entering the cell

•Gluconeogenesis (release of glucose by the liver) increases→ leads to hyperglycemia

•Kidneys excrete glucose along with water and electrolytes (sodium, potassium)→ osmotic diuresis (may lose up to 6.5 L of water/day)

•Insulin deficiency or deficit causes lipolysis breakdown of fat) into free fatty acids

•Free fatty acids converted into ketone bodies→ leads to metabolic acidosis

when pt is on a insulin drip you must monitor

potassium

how often do you do accucheck for DKA

-q30 for the first hour

-once stable qhr

DKA: Prevention

-teach them to

-follow up

-go to ER when they feel sick

-teach them to do accucheck

-teach them to be compliant to meds

DKA: Clinical Manifestations

•Polyuria

•Polydipsia

•Fatigue

•Blurred vision

•Weakness

•Headache

•Orthostatic hypotension

•Volume depletion→ frank hypotension

-sunken eyes

•Ketosis leads to

•Anorexia

•Nausea/vomiting

•Abdominal pain

•Acetone breath

•Hyperventilation (Kussmaul's respirations)

•Mental status changes

DKA p symptoms

polyuria and polydipsia

DKA overall vague symptoms

•Fatigue

•Blurred vision

•Weakness

•Headache

DKA volume sx

Orthostatic hypotension

•Volume depletion→ frank hypotension

-sunken eyes

DKA ketosis sx

•Anorexia

•Nausea/vomiting

•Abdominal pain

•Acetone breath

•Hyperventilation (Kussmaul's respirations)

DKA neuro changes

•Mental status changes

DKA blood glucose reading will be

vary from 300-800 mg/dL

DKA serum bicarb will be

•low serum bicarbonate (0-15 mEq/L)

DKA PH is

low pH (pH 6.8-7.3)

DKA has ____ CO2 related to _______

•low PCO2 reflects respiratory compensation (10-30 mm Hg)

DKA leads to renal _____

insufficiency which leads to increased BUN/CRT

patients with DKA will have _____ in their blood and urine which leads to _________

-ketones

-increased HCT

severity of DKA is not related to

blood glucose

how do you manage DKA?

-REHYDRATE

-CORRECT ACIDOSIS

-CORRECT ELECTROLYTE IMBALANCE

DKA management: rehydration

•Initially with 0.9% NS (may need 6-10L of IV fluid)

•Followed by 0.45% NS

•D5W after blood glucose is < 300 mg/dL (if patients anion gap is not closing we change it from D5 to D10 IF GLUC drops too low)

•rehydration leads to increased plasma volume and decreased K+, insulin enhances the movement of K+ from extracellular fluid into the cells (patient must be on the EKG)

rehydration leads to increased plasma volume and decreased

-K

-insulin enhances the movement of K+ from extracellular fluid into the cells (patient must be on the EKG)

during rehydration potassium moves back into the cells so the patient must be on the

EKG monitor

before starting insulin drip what must you do

-check potassium and correct it because insulin drives potassium into cells

how do you give potassium for DKA

-IV pump (never override the pump)

-GIVEN with fluids

DKA: Management reversing Acidosis

•Ketone bodies accumulate as a result of fat breakdown

•Reversed with insulin

•Regular Insulin infused IV (5 units/hr) at the same time AS the rehydration fluids are going

•Do not stop the Insulin! we need to make sure the gap is closing

•Blood glucose levels are usually corrected before the acidosis is corrected

what labs do we need with DKA

-k

-BUN/ crt

-ABGs (will tell us acidosis)

-will be elevated with DKA

BUN and CRT DKA levels

BUN- > 30

CRT- > 1.5

for DKA sodium will be

-above, below, within the expected range

Bicarb and sodium bicarb levels for DKA

-Sodium Bicarb- 0-15

-bicarb-1-15

For PH for DKA it will be

less than 7.35

DKA patients are _____

-acute

-everything you do is acute

when patient comes off of insulin drip we have to switch to

-sliding scale SUB Q

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

•Secondary to lack of effective insulin (insulin resistance)

•Persistent hyperglycemia causes osmotic diuresis→ water and electrolyte losses

•Water shift from the intracellular fluid space to the extracellular fluid space

Predominating features of HHS

•Hyperosmolarity

•Hyperglycemia

•Minimal or absent ketosis

how do we fix HHS

FLUIDS

-dilutes the hyperosmotic blood

-stops the kidneys from osmotic diuresing

-lowers blood sugar

-replenishes electrolytes

HHS happens mostly with who

DM2

We check sugar and it says HI what do you do

-order a BMP

-ABG

-start fluids

HHNS: Etiology

•Occurs in older people; no known history of DM or type 2 DM.

•Can be traced to a precipitating even (acute illness; pneumonia, CVA, dialysis)

HHNS clinical manifestations

•Signs of profound dehydration

•Neurologic manifestations (cerebral dehydration)

Mortality rates: 10-40%

HHNS Assessment/Diagnostics

•Blood glucose = 600-1200 mg/dL

•Electrolytes

•BUN

•CBC

•Serum osmolality= > 350 mOsm/kg

•ABG- rule out DKA

HHS blood glucose level will be

•600-1200 mg/dL

HHS Serum osmolality

•> 350 mOsm/kg

can HHNS get insulin

-yes but it doesnt have to be AGRESSIVE

HHNS: Management

•Rehydration

•CVP monitoring

•Monitor fluid volume and electrolyte status

•Insulin administration

•Prevention

•BGSM

•Diagnosis and management of diabetes

Assess and promote self-care management skills

Insulin administartion is less important for HHS because

-it is not needed to reverse ketoacidosis

-may still be given after changing IVF to D5W once sugar drops

nursing diagnosis for DKA/HHS

•Risk for fluid deficit r/t polyuria and dehydration

•F & E imbalance r/t fluid loss or shifts

•Deficient knowledge about diabetes self-care skills

Collaborative problems for DKA/HHNS

•Fluid overload, pulmonary edema, heart failure

•Hyperglycemia/ketoacidosis

•Cerebral edema

•Hypoglycemia

•Hypokalemia

what are some things you need to monitor for during HHS/DKA and especially after a patient receives tx

•Hypoglycemia

•Hypokalemia

Nursing Interventions for DKA/HHNS

•Maintain fluid and electrolyte balance

•Increase knowledge about DM

•Monitoring & Managing potential complications

OUTCOMES OF TEACHING PATIENT SELF CARE

•Achieves fluid and electrolyte balance

•Absence of complications

•Demonstrates adequate knowledge

ph FOR HHNS

greater than 7.45

Bicarb for HHS

greater than 20

DKA main points

•Ketosis

•Acidosis

•No insulin present

•Breakdown of glucose, protein and fat→ leads to ketosis

HHNS main points

•Minimal to no ketosis

•Minimal to no acidosis

•Insulin level is too low to prevent hyperglycemia, but high enough to prevent fat breakdown

•No ketosis-related GI symptoms (do not seek care)

•Delays in therapy

•More severe: hyperglycemia, dehydration, hyperosmolarity