Hey everyone, it's Sarah with RegisteredNurseAriene.com and in this video I'm going to be going over diabetic ketoacidosis, also called DKA. This video is... part of an endocrine series that I've been doing on the diabetic patient.
So if you haven't seen those videos, a card should be popping up so you can access that link. In those videos, I've been talking about the pathophysiology of diabetes, the pharmacological aspect of it, and all that. So what I'm going to be doing in this video is I'm going to be going over DKA, specifically the patho, the nursing interventions, the causes and the signs and symptoms, and I'm going to hit on the things that you need to know for NCLEX and for your nursing lecture exam. Now in the next video, I'm going to be going over the... complication that is similar to DKA, which is hyperglycemic hyperosmolar non-ketotic syndrome, which is HHNS.
And then I'm going to take it a step further in another video, and I'm going to compare DKA versus HHNS. So be sure to check out those videos. Now after this video, be sure to go to my website, registerednurserin.com, and take the free quiz that's going to test your knowledge on the patient with DKA. And a card should be popping up so you can access that quiz.
So let's... Let's get started! Okay, first let's define what DKA is. What in the world is DKA?
DKA is a life-threatening condition that patients with diabetes mellitus can suffer from. And what it is, in a nutshell, is that there is absolutely no insulin in the body. And insulin plays a role in using glucose. And glucose fuels our cells, but the body can't get to the glucose. So it starts breaking down fats for energy.
And when it breaks down fats, it releases... ketones. And ketones in the diabetic patient can cause major problems.
So what you're going to be seeing in this patient, the three things, I would remember this because everything else will make sense, you're going to be seeing hyperglycemia, you're going to be seeing ketosis, and you're going to be seeing acidosis. And all that plays a role in why you see these certain signs and symptoms and why you're doing these certain nursing interventions for this patient. But first let's talk about the key players, the pathophysiology, about what's going on in this DK.
patient. The first key player is glucose. What is glucose? Glucose is sugar and your cells love sugar and it fuels the cell with energy. However, in diabetic ketoacidosis, the body cannot get to that glucose.
It just stays in the blood because there is no insulin. So these patients'blood sugars are going to be running about greater than 300 mg per deciliter. Which leads into our next question. Next key player is insulin. Remember there's no insulin in DKA.
Insulin's role is to take glucose into the cell so your cell can use it for energy. Now with DKA there's none so the body can't get to it. So the body's like, hey we need some fuel.
We can't get to this glucose so we need something to help fuel these cells so they don't die. So the liver and glucagon start to say, hey the body doesn't have any energy so it must be in a hypoglycemic. state.
There must not be any sugar in the body for the body to use because it doesn't know that your body can't get to it. So in turn, what it tries to do is it releases those glucose stores in the liver. So it releases glucagon, which turns into glycogen, and those glycogen turns into glucose.
So you're elevating the glucose even more, which is horrible in the diabetic patient. Now, the body's still like, hey, the liver didn't do its job, still couldn't get to that sugar, so hey. we need to release and start breaking down fats.
So the body starts breaking down fats. And what happens whenever the body breaks down fats, it turns into ketones. And ketones is a byproduct of fat breakdown. And whenever ketones break down, you get acids into the body because ketones are very acidic. And the body decides to use those.
And the diabetic patient cannot tolerate the excessive ketones in the body. And whenever it does that, because it can't, it starts causing... causing the blood pH to drop and it will typically get less than 7.35 and then you're going to start entering into metabolic acidosis because of this. Now the next key player is the kidneys.
The poor little kidneys are also affected by this as well. And what happens is that your kidneys play a normal role in reabsorbing glucose in the renal tubules but here in DKA remember you have high blood pressure. high glucose. The kidneys cannot help with this.
What happens is that whenever the glucose is going through the body and the renal tubules, it's like, hey, we cannot reabsorb this glucose. It starts to leak the glucose into the urine and you start having osmotic diuresis. And with osmosis, you know, things like to move, water will move to wherever a higher concentration is.
So you start seeing polyuria. You're going to see that frequent urination because of that glucose causing the osmotic diuresis whenever it leaks into the urine. you're going to get the excretion of sodium, potassium, and chloride. So you're going to start to get electrolyte imbalances.
Now, DKA mainly occurs in the type 1 diabetic. So remember that because with HHNS, which we'll talk about in the next video, the next video, that's mainly occurring in your type 2 diabetic. But DKA can occur in the type 2 diabetic. It's rare. If the type 2 is having a severe illness, they can have it.
But it's mainly in type 1. Now let's talk about the causes, the signs and symptoms of nursing interventions. What in the world causes DKA? Number one, undetected diabetes.
This is usually the first sign in someone who doesn't know that they have diabetes. They are having excessive thirst, urination, everything like that. They go to the doctor.
The doctor looks at their urine. It's positive for ketones. They look at their blood glucose, and they're like, oh, you are diabetic. Another cause is the body needs more insulin than normal. And what can cause the body to actually need more insulin than it normally would?
Illnesses, stress, or medications like corticosteroids or thiazide diuretics. I would remember that. Okay, another thing that can cause it is not eating or skipping meals. Usually whenever you get sick, you have no appetite and it's the same for the diabetic patient. So they may start not eating, not skipping meals and the body goes into starvation mode which is not good for the diabetic patient.
So in turn because it can't help correct itself it starts burning down burning those fats which is going to turn into ketones which is going to start getting a lot of problems with that. Or the diabetic patient is not taking their insulin as scheduled. Maybe they're not compliant, maybe they don't understand the importance of having to take it.
So their glucose is not controlled. When the glucose is not controlled, the body can't get to the glucose and the body starts looking for something else for energy. So it turns to the ketones and then you have that vicious cycle of DKA that starts happening. Okay, so how do these patients present with diabetic ketoacidosis? How are they going to look to you as the nurse?
So let's recap. Okay, remember, what we have going on in the body, we have hyperglycemia, we have ketones in the blood, and we have metabolic acidosis going on. So whenever you have that, the signs and symptoms make sense because with hyperglycemia, what's happening? You have a high amount of glucose in the blood.
And what happens is that inside the cell, that water and everything's like, hey, I want to move where all the glucose is at through that osmosis law. So what happens is that that water... moves from the intracellular to the extracellular and also it pulls electrolytes with it. So you start getting polyuria, you become dehydrated, which we'll go over in depth here in a second. Then ketones in the blood.
And what happens is that your blood pH drops less than 7.35. The patient starts getting weight loss because they're burning all those fats and acidosis also causes electrolytes to shift and you get metabolic acidosis and that fruity breath, smell the acetone, breath. Then you get the acidosis, which again is your pH of less than 7.35. You get a bicarb less than 15 and you're going to start seeing that cosmo breathing where they're taking those rapid deep breaths where the respiratory system is trying to compensate for all that acid.
So all these symptoms that you're seeing are going to happen suddenly. Remember that because HHNS, those symptoms with those patients are going to happen over time gradually. But DK they happen suddenly.
And there will be the patient, if they are monitoring their blood sugar, a lot of times they're not, they may have some little warning sign where their blood sugar is just running really high, greater than 300 milligrams per deciliter. Okay, so what you're going to see is you're going to see polyuria and this is due to that osmotic diuresis and there's too much glucose for the kidneys to reabsorb. So you're getting dehydration and you're excreting that sodium and potassium and chloride.
Polydipsia, this is the body's way of trying to make up for all that frequent urination. The body's like, well, we need to keep drinking water because we're dehydrated, but it doesn't work because the body just dumps it out. Next, they're going to present with dehydration again because all of that urinating.
So they're going to have dry mucous membranes, their face may be flushed, decreased skin tartar. They may also have nausea and vomiting and abdominal pain. Abdominal pain is really present in your pediatric patients and this is due to the increase in blood sugar and the ketones, the acids present in the body, just wreaking havoc, making them feel horrible. The Cosmo breathing, again, this is that rapid, deep breathing as a side effect of the metabolic acidosis.
We talked about that in our acid base imbalance videos. This is where your body is trying to compensate by blowing off all that carbon dioxide because the body's like, well, we have way too much acid in the body, so we need to blow off this carbon dioxide, which is an acid, to help hopefully bring down those acid levels. Then you may have the acetone smell of the breath, that's that fruity smell of the breath and that is as a result of the breakdown of the ketones. Also you'll have positive ketones in the urine, tachycardia, hypotension.
Hypotension and tachycardia go together because you have dehydration, fatigue and confusion. Nursing interventions, what are you going to be doing for this patient as a nurse and what you need to know for NCLEX and nursing lecture exams. You need to know the education parts and the medication management, how you're going to be giving insulin things like that I want to cover all those okay so education the key with our patients we always want to teach them how to monitor this and how to prevent this so teaching aspects tell the patient that they need to monitor their glucose and urine ketones every four hours when they're sick because they are a high vulnerability of getting dka whenever they're experiencing illness so they need to monitor that and if they can't eat or drink at all they need to notify their doctor for further treatment because dehydration makes this absolutely worse and if they can drink, try to drink every hour to keep hydrated.
Next, monitor those blood sugars regularly and if their blood sugar is running greater than 300 mg per deciliter to notify the doctor and if it's consistently doing that. Next, notify the doctor if you have ketones present in the urine or if you're having excessive urination, thirst, abdominal pain, nausea, or if you have a high blood pressure nausea, vomiting, or the fruity breath. Now let's look over the pharmacological aspects of DKA.
The pharmacological goals for the patient with DKA is to hydrate them, decrease their blood sugar, monitor the potassium levels and the patient-forced cerebral edema, which I'll go into here in a second, and to correct the acid-base imbalance, which is going on because remember they're in an acidotic state right now. So as a nurse you're going to be administering IV fluids, whatever the doctor's doctor writes. Typically, they start out with 0.9% normal saline, which is an isotonic solution. Then, depending on the severity of the dehydration, what's going on with the patient, they may progress to a hypotonic solution, which is 0.45% half normal saline to hydrate those cells. Remember, what hypotonic solutions do, they go in and they rehydrate those cells, but you've got to watch out because you can overhydrate those cells, which you could get some cerebral edema going on.
And again, this depends on how dehydrated the patient is. Sometimes 5% dextrose with half normal saline is added on as well. Whenever the glucose level is reading between 250 to 300, whenever you sort of have gone it down from where it was. And the reason for this is to gradually decrease the blood sugar.
Because you don't all of a sudden, because whenever they're on these IV fluids, they're also on an insulin drip. And you don't want to just drop their blood sugar out. Because the brain...
brain cannot cope with this. And what will happen is that water will move from the blood into the spinal fluid and you'll get cerebral edema and increased intracranial pressure. So you want to monitor and watch out for that.
Now insulin, you're going to be given insulin to this patient and typically what you give, only what you give with intravenously, the only insulin that can be given IV is regular insulin. Remember that. And before you even start insulin, you want to monitor the potassium level.
Check and see what that potassium level was. Remember this, very important, and you want a level greater than 3.3 because normally in DKA your potassium levels are either normal or elevated and the reason is is because remember everything moved out from the inside of that cell into the blood which included potassium. So you either have normal or elevated potassium because it moved out of the cell.
But whenever you start putting the potassium on insulin, insulin is going to start causing the potassium to move back into the cell and whenever it moves back into the cell it's left the blood so you can get hypokalemia so you want to make sure your potassium levels good and monitor it throughout the insulin time you're giving them insulin so typically what you give is an IV bolus of the regular insulin whatever the doctor orders then you'll start an insulin drip and this drip you will titrate this drip based on what those glucose readings are. You'll be checking those glucoses a lot with your bedside unit with the glucose monitor. Insulin checks can be like every 15 minutes.
It's a lot so you're going to be with this patient in and out of their room all the time. One thing you need to remember is that whenever you are priming that tubing to start your insulin drip, insulin absorbs into the plastic lining of the tubing. So waste between 15 minutes.
to 100 cc's of insulin depending on whatever your institution says and to prevent from all that insulin getting into that tubing and then it'll throw off how much the patient will get. So do that before administering and other meds the patient may be on is potassium and IV solution. Again that's just to keep the potassium nice and level while you're administering the insulin because potassium goes back into the cell with insulin and with potassium you want to watch out for phlebitis because potassium is very hard on veins.
EKGs, you want to make sure you're monitoring their EKG for any changes and make sure that renal function is good because patients with renal issues cannot clear potassium as someone who has good renal function. So that is about DKA. Now take that quiz on my website, registernurserin.com and be sure to check out the next video covering HHNS syndrome.
And thank you so much for watching and please consider subscribing to this YouTube channel.