Presentation

What is diabetic ketoacidosis (DKA)?

A life-threatening acute complication of diabetes characterized by:

• Hyperglycemia

• Ketosis

• Metabolic acidosis
  Caused by absolute or relative insulin deficiency

Why is DKA considered a medical emergency?

• Rapid onset

• Can progress to coma or death without prompt treatment

• Requires rapid recognition and intervention

Which patients are most commonly affected by DKA?

• Primarily Type 1 diabetes (absolute insulin deficiency)

• Can occur in Type 2 diabetes during:

  • Severe stress

  • Illness

  • Insulin non-adherence

What is the initiating problem in DKA pathophysiology?

Insulin deficiency

What metabolic state occurs due to lack of insulin in DKA?

• Catabolic state

• Breakdown of:

  • Fats

  • Proteins
    for energy

How does insulin deficiency lead to ketone production?

• Lipolysis releases free fatty acids

• Liver converts free fatty acids into ketone bodies:

  • Acetoacetate

  • β-hydroxybutyrate

Why does metabolic acidosis develop in DKA?

• Ketone levels exceed the body’s buffering capacity

• Results in metabolic acidosis

How does hyperglycemia worsen DKA?

• Causes osmotic diuresis

• Leads to:

  • Polyuria

  • Severe dehydration

  • Electrolyte losses

Which electrolytes are most affected in DKA?

• Potassium (K⁺)

• Sodium (Na⁺)

Which organ systems are most impacted by electrolyte shifts in DKA?

• Cardiac

• Renal

• Neurologic

What four processes define the critical nature of DKA?

• Insulin deficiency

• Hyperglycemia

• Ketogenesis

• Fluid and electrolyte derangements

What are the classic symptoms of DKA?

• Polyuria

• Polydipsia

• Nausea

• Vomiting

• Abdominal pain

• Fatigue

Why do patients with DKA develop GI symptoms?

• Severe hyperglycemia

• Ketone accumulation

• Metabolic acidosis

What is Kussmaul respiration and why does it occur in DKA?

• Deep, labored respirations

• Body attempts to blow off CO₂ to compensate for metabolic acidosis

What causes the fruity odor on the breath in DKA?

Acetone, a ketone produced from fat breakdown

What neurologic changes can occur in DKA?

• Mild confusion

• Altered mental status

• Coma (severe cases)

What vital sign changes may be seen as DKA progresses?

• Hypotension

• Tachycardia

• Decreased level of consciousness

What are the most common triggers of DKA?

• Infection

• Missed or inadequate insulin

• Physical or emotional stress

Which infections most commonly precipitate DKA?

• Respiratory infections

• Urinary tract infections

Why does infection increase the risk of DKA?

• Increases metabolic demand

• Increases insulin resistance

Why is insulin non-compliance a major cause of DKA?

Any interruption in insulin can rapidly lead to:

• Hyperglycemia

• Ketogenesis
  in insulin-dependent patients

What stress hormones contribute to DKA?

• Cortisol

• Epinephrine (catecholamines)

How do stress hormones worsen DKA?

• Counteract insulin

• Promote ketone production

What blood glucose level is typically seen in DKA?

> 250 mg/dL

What ketone findings support a diagnosis of DKA?

• Ketones in blood and urine

• Especially β-hydroxybutyrate

What acid–base changes occur in DKA?

• Metabolic acidosis

• Arterial pH < 7.3

• Serum bicarbonate < 18 mEq/L

Why must potassium be monitored closely in DKA?

• Insulin drives potassium into cells

• Risk for hypokalemia

• Can cause dangerous arrhythmias

Which renal labs are important in DKA and why?

• BUN and creatinine

• Assess dehydration and guide fluid replacement

What is the correct order of DKA treatment?**

1. Fluids

2. Electrolytes

3. Insulin

What is the first treatment priority in DKA?

Fluid resuscitation

What IV fluids are initially used in DKA?

Isotonic crystalloids:

• 0.9% normal saline

• Lactated Ringer’s

Why are fluids critical in DKA?

• Correct dehydration

• Improve renal perfusion

• Enhance glucose clearance

What complication must be monitored during fluid resuscitation?

• Fluid volume overload

• Especially in cardiac patients

Why must potassium be corrected before insulin therapy?

• Insulin shifts potassium into cells

• Can cause life-threatening hypokalemia

When is sodium bicarbonate used in DKA?

Only if arterial pH < 7.0

Why is bicarbonate used cautiously?

• Can worsen hypokalemia

• Has potential adverse effects

What is the gold-standard insulin therapy for DKA?

• Continuous IV regular insulin infusion

• ~0.1 units/kg/hr

Why must glucose be lowered slowly in DKA?

• Prevents cerebral edema

• Especially important in pediatric patients

What are signs of cerebral edema?

• Headache

• Dizziness

• Changes in level of consciousness

When should dextrose be added to IV fluids?

When blood glucose reaches ~250 mg/dL

Dextrose prevents hypoglycemia while insulin finishes fixing the DKA.

What IV fluids are used once dextrose is added?

• D5NS

• D5½NS

What monitoring responsibilities do nurses have in DKA?

• Vital signs

• Blood glucose

• Urine output

• Electrolytes

• Continuous trend assessment

What therapeutic interventions are nurses responsible for in DKA?

• Administer fluids → electrolytes → insulin

• Adjust therapy per protocol

• Manage potassium carefully

• Document responses

Why is nursing documentation critical in DKA?

• Ensures patient safety

• Guides treatment adjustments

• Supports effective interdisciplinary care

How much fluid should patients consume daily to prevent DKA?

2–3 liters/day unless contraindicated

What are sick-day rules for patients with diabetes?

• Continue insulin

• Monitor fever and vomiting

• Do not skip meals without carb replacement

How often should blood glucose be checked during illness?

Every 4 hours

When should urine ketones be tested?

• BG > 240–250 mg/dL

• During illness or stress

What ketone level requires immediate action?

Moderate to large ketones

What safety identification should all diabetic patients wear?

Medical alert bracelet

When should patients contact their healthcare provider?

• Symptoms > 24 hours

• BG > 250 despite insulin

• Persistent ketones

Is DKA preventable?

Yes, with proper education, monitoring, and adherence

What defines successful DKA management?

• Rapid recognition

• Structured treatment

• Nursing vigilance

• Patient empowerment