Diabetic Ketoacidosis

Salma Ghassan Nassr-U20103958

OBJECTIVES
By the end of this presentation, we will be able to:-
1. Know about the case through assessment and
health history.
2. Understand anatomy and physiology of body Click icon to add picture
systems associated with diabetes mellitus and
DKA.
3. Learn risk factors, pathophysiology of DKA.
4. Learn the diagnostic tests done to diagnose with
DKA.
5. Know the medical and surgical management od
DKA
6. Understand the nursing management and role in
treatment of DM and DKA

2
OUTLINE
2.ANATOMY AND
PHYSIOLOGY

1.CASE INFORMATION
Assessment and health history

3.ETIOLOGY AND
PATHOPHYSIOLOGY
Signs and symptoms of DKA

5.NURSING MANAGEMENT
4.DIAGNOSTICS AND Nursing care plan
MEDICAL MANAGEMENT
1. CASE
INFORMATION
 ABOUT THE CASE

A previously healthy 8-month-old male patient,

came to the ER with history of fever, vomiting
and diarrhea. Upon presentation in the ER
patient looked drowsy, blood glucose in the
triage room showed very high it was unreadable
by glucometer.

5
 PATIENT INFORMATION
Date of admission 24/4/2023

Date of birth/ age 22/8/2022. 8 months old

Gender Male

Nationality and
Pakistani. Muslim
religion
Allergies and
No known allergies. Vaccination record up-to-date.
vaccinations

Medical diagnosis Diabetic ketoacidosis and type 1 diabetes mellitus.

6
ASSESSMENT AND
HEALTH HISTORY
1)Health history:
History of fever, vomiting, diarrhea that lasted 4 days prior to admission.
Increased thirst with increased urinary output. History of chest infection while
out of country with father (in Pakistan) treated with regular nebulization.
2)Birth history:
Born term, via c-section. No NICU admissions.
3) Developmental history:
Patient’s development is appropriate/ within normal to age/ developmental
stage. No delayed development or reports of concerns. Babbles and sits alone.
Active child, interacted well with other nurse staff.
4)Diet/ nutritional history: breast milk + formula milk. Soft/ mashed food, eats
with family.

7
PHYSICAL ASSESSMENT
1-Vital signs  BP: 112/57 HR: 132 RR: 36 Temp:37.2 pain: 0 (FLACC).
2-Growth measurements  height: 72 cm weight: 8.4kg (weight loss of 0.6kg 9-8.4
is 1 day) head circumference: 43.6 cm chest circumference: 41.3 cm.
3-review of systems:
*head and neck  fontanelles closed, dry lips noticed. All normal findings. Mucous
membrane moist.
*neurological  on admission was drowsy (GCS 13/15). As of data collected on
25/4 patient is alert and responsive (GCS 15/15). Is calm and cooperative, no history
of seizures or numbness.
*cardiovascular  tachycardia noted rate of 168 bpm regurlar rhythm and no
murmur or chest pain reported.
*respiratory  cough, kussmaul breathing, no sob.
*musculoskeletal  normal range of motion.
*gastrointestinal  vomiting, diarrhea, increased thirst and urinary output. Normal
feeding (formula milk, as of 25/4 started mashed diabetic diet).
*integumentary  skin is warm to touch, no dehydration noticed, normal turgor and
capillary refill.

8
2.ANATOMY
AND
PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
Diabetes mellitus is a metabolic disorder, in which the body
is unable to regulate the level of blood sugars or glucose.
Due to insufficient insulin production by the pancreas, poor
sensitivity to insulin or both causes, that result in increase
blood glucose. The pancreas is the organ that produces the
hormone insulin to regulate/ control blood glucose levels.
Through its cells (alpha and beta cells, each have function)
that are activated either when blood glucose is elevated to
release insulin, or when BG is low to release glucagon. Any
insufficiency of the mentioned functions, will result in DM.

10
3.PATHOPHYSIO
LOGY
PATHOPHYSIOLOGY AND RISK
FACTOR
DKA or diabetic ketoacidosis is a serious complication that effects people with
type 1 DM, defined as a state of insulin deficiency that is accompanied with
hyperglycemia (increased blood sugar) that results in abnormal metabolism of
carbohydrates, fats and protein. High levels of ketones are produced by affected
organs in response to low insulin levels and high levels of counterregulatory
hormones and to create alternative source of energy.
Signs and symptoms/ manifestation: polyuria, polydipsia, blurred vision,
weakness, headache, anorexia, abdominal pain, nausea vomiting, acetone
breath, hyperventilation with Kussmaul respirations, and mental status changes.
Clinical features: dehydration, hyperglycemia, acidosis and ketonuria.
 For this patient, he presented with vomiting, diarrhea, polyuria, polydipsia,
weakness/ drowsiness and kussmaul breathing. This patient condition was acute
with no history of previous attacks, family history of type 1 (grandfather).

12
4.DIAGNOSTIC
TESTS AND
MEDICAL
MANAGEMENT
LABARATORY STUDIES
Patients that present with signs of DKA are tested for the following studies:-

• Serum glucose levels

• Serum electrolyte levels (eg, potassium, sodium, chloride, magnesium, calcium, phosphorus)
• Bicarbonate levels. Amylase and lipase levels
• Urine dipstick
• Ketone levels
• Serum or capillary beta-hydroxybutyrate levels
• ABG measurements
• Complete blood count (CBC)
• BUN and creatinine levels
• Urine and blood cultures if infection is suspected

14
 Patient’s lab results
WBC 14.14 RBC 5.42 (High) Hgb 14.1 (High)

Hct 41.30 (High) Platelet 634.0 (High) Neutro % 52.7 (High)

Sodium 156 (High) Potassium 5.7 (High) CO2 6.6 (Low)

Creatinine 66 (High) Uric acid 765 (High) Glucose 20.4 (High)

Highest glucose 30.4 (critically

Urea 8.9 (High) pO2 cap 127.3 (High)*
reading high)
*Capillary blood gases are normal

15
Patient’s lab results
Urine analysis and blood culture:-
-urine and blood culture of the patient showed no abnormal growth.
-CRP result was normal.
-urine routine showed the following:-
*glucose  3+ (indicate high glucose levels in urine)
*ketones  3+ (indicate high ketone levels in urine)
*protein  1+ (indicate high protein levels in urine, which can be a sign of kidney
damage)
*WBC  3-5 (may indicate lower urinary tract infection, no leukocytes were counted).
*urine was clear and yellow, normal pH (6), no presence of bilirubin found, RBCs or
leukocytes.
16
IMAGING STUDIES
Radiologic studies that my be helpful for patients with DKA include the following:-

• Chest radiography - To rule out pulmonary infection such as pneumonia

• Head computed tomography (CT) scanning - To detect early cerebral edema; use low threshold in
children with DKA and altered mental status
• Head magnetic resonance imaging (MRI) - To detect early cerebral edema

 For this patient he had done chest x-ray, showed normal results.

17
MEDICAL MANAGEMENT OF DKA
If a patient was diagnosed with DKA, they would either be treated in the ER or admitted,
treatment involves the following measures:-
1. Fluids: to replace fluids lost as a result of increased urination and thin out blood sugars.
2. Electrolytes replacement: decreased insulin can result in lowering electrolytes.
3. Insulin therapy: insulin reverse the effects of ketoacidosis.

This patient is undergoing the following treatment:

1.fluids: 0.9% of normal saline 50mL (0.45 mL/hr)
2.insulin: *insulin aspart (rapid-acting)  TID, SC injection, using sliding scale.
*insulin glargine (long-acting)  Daily, SC injection, 4 units.
3.Monitoring: checking blood glucose levels before, 3hr after food. Urine I&O.

18
5.NURSING
MANAGEMENT
AND CARE
PLAN
NURSING MANAGEMENT
Nurses’ role in DKA management include the following:-
• Monitor vital signs.
• Check blood sugar and treat with insulin as ordered (sliding scale).
• Check electrolytes especially potassium levels, ECG and check renal
function (urinary output).
• Assess lung sounds for rales and crackles. And monitor
• Administer fluids as prescribed.
• Encourage patient/ family to adhere/ follow the prescribed treatment plan/
medication and diet.
• Assess mental status (drowsiness, GCS changes)

20
NURSING DIAGNOSIS
1. Deficient fluid volume related to excessive gastric losses due to diarrhea
and vomiting as evidenced by polyuria and sudden weight loss.
2. Risk for unstable blood glucose level related to insufficient diabetes
management.
3. Risk for infection related to diabetes mellitus (hyperglycemia, poor tissue
perfusion).
4. Imbalanced nutrition: less than body requirements related to insufficient
insulin as evidence by diarrhea, nausea and weight loss.
5. Deficient knowledge related to unfamiliarity with the condition, risk factors
and treatment as evidenced by request of information and verbalization of
lack of exposure to such disease.

21
 Assessment Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective Data: -by the end of the -nurse will assess vital signs and - dehydration can cause -achieved when
“he has vomited 3 times 1.Deficient fluid
volume related to shift, patient will assess renal function (UO). tachycardia and kassmaul patient reached
yesterday, it was yellow in excessive gastric become breathing (shallow and electrolytes
color, he is passing loose losses due to normovolemic as -nurse will monitor electrolyte levels rapid). DKA can result is balance (Na:
stools and he’s been diarrhea and evidenced by and give dextrose once glucose AKI/ CKD, monitoring 143, K:4.56),
urinating more frequently vomiting as
evidenced by balanced I&O/ UO, reached 250mg/dL. creatinine and GFR is vitals within
and asking for water polyuria and electrolytes and vital important. normal.
more”. -Parents of pt. sudden weight signs within normal - potassium levels are
Objective Data: loss. limits. -nurse will administer fluids as initially elevated but with
Patient appears drowsy, prescribed. fluid replacement will be
pale. Has increased dropped to normal.
urinary output with -nurse will teach family on early electrolyte levels should be
increased thirst, passing signs of DKA for prevention. replaced and are resolved by
frequent loose stools administration of fluids and
brown in color. Father insulin. Dextrose can
reported that in clinic prevent further ketosis.
weight measured was 9kg, -isotonic fluid/ solution
today it measures 8.4 (0.6 replacement initially will
kg loss in one day). lower blood glucose
Noticed tachycardia of HR -to prevent reoccurrence of
168 bpm DKA patient/ family
education on symptoms like
polydipsia, polyuria, N/V,
weakness and fatigue.

22
 Assessment Nursing Planning Implementation Rationale Evaluation
Diagnosis

Subjective Data: -during hospital stay, -nurse will assess parent’s -DKA is often the first sign of diabetes -yet to be
2. Risk for patient will display understanding of disease and for undiagnosed patients, so educating achieved as
unstable blood
glucose level blood glucose levels treatment/ insulin. and assessing understanding between patient still
related to within acceptable diabetes and insulin is important. suffers from
insufficient range, and parents -nurse will observe patient/ parents -having the patient/ parents perform hyperglycemia
diabetes will verbalize and as they use the glucometer to ensure blood glucose self-check increases and is still
management.
demonstrate accurate accuracy and documentation. their confidence and understanding of improving/
Objective Data: administration of treatment/ procedure. recovering. And
RBS reached a high insulin. -nurse will perform blood glucose -adherence to treatment regimen help parents need
of 30.4 as charted on testing, at ordered times (before and in faster recovery period. Studies show more education
the system, and after food), and administer insulin as that frequent regular checking and participation
lowest reading was ordered (using insulin sliding scale). decreases the risk of developing DKA in management
14.3 (same day. as high readings are reported earlier. of diabetes and
24/4). -nurse will educate patient/ family (Bradley & Tobias, 2008) DKA.
about insulin administration using -to increase participation in providing
either the pen or vail. care as DM is a chronic condition and
patients often discharged after days of
staying in hospital, so education and
providing instructions about insulin
administration will help maintain
blood glucose levels within range.

23
 Assessment Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective Data: -during hospital stay, -nurse will assess signs of infection/ -infection is a common cause of DKA. -achieved when
3. Risk for
infection related patient will be free inflammation. Among the symptoms of DKA patient showed
to diabetes from infection or associated recurrent infection are fever no signs of
mellitus signs of infection. -nurse will auscultate lung sounds. , dysuria, coughing, malaise, infection.
(hyperglycemia, chest pain, shortness of breath.
poor tissue -nurse will obtain blood and urine (Hamdy & Khardori, 2021).
perfusion).
culture as ordered.
Objective Data: - Rhonchi indicate accumulation of
Patient is still -nurse will encourage adequate oral secretions possibly related to
maturing, immune intake of fluids as prescribed. pneumonia or bronchitis that may have
system not fully precipitated DKA. (Aprilia et al.,
adequate to fight in 2019).
presence of chronic
illness. - Urine and blood culture findings help
to identify any possible infectious
organisms in clients diagnosed with
DKA. This will help identify the
appropriate treatment regimen or
antibiotic therapy (Hamdy &
Khardori, 2021).
-increasing oral fluid intake reduces
the susceptibility to infection, increase
urination which gets rid of toxins in
UT.

24
REFRENCES
o Marilyn J. Hockenberry, and David Wilson ,Wong's
Nursing Care of Infants and Children, 10th Edition,
Mosby. 2015.
o Doenges, Moorhouse, Murr, Nursing care plans,
guidelines for individualizing client care across the
life span, 10th edition, F A Davis Company. 2019.
o mayoclinic.org
o emedicine.medscape.com
o ncbi.nlm.nih.gov
o nurseslabs.com

25
thank you