1. Describe the pathophysiologic changes in DKA.

- A is a complication of diabetes where blood glucose is uncontrollably high, metabolic

acidosis is caused, and a very large amount of ketones is produced.
a. Why do blood glucose levels increase?
- BGL increases because this condition is a combination of insulin deficiency and an
elevation in hormone release that increases glucose production.
b. What are commonly seen blood glucose levels?
- Commonly seen BGLs are at >300mg/dL.
c. What fluid and electrolyte disturbances commonly occur?
- Dehydration and electrolytes loss specifically potassium but others as well, usually
occurs with DKA.
d. What causes the fluid and electrolyte disturbances?
e. Dehydration and electrolyte loss are caused by osmotic diuresis. Symptoms include
increased urination, thirst, extreme hunger, rotting fruit breath smell, vomiting
abdominal pain, dehydration, weakness, confusion, shock, and coma. Sodium levels
may be low as well.
f. What acid-base disturbances are commonly seen?
- DKA usually leads to a pH of less than 3.5 which is acidosis and is mainly metabolic
because of all the symptoms of DKA.
g. Why do the acid-base disturbances occur?
- As ketones increase, the blood pH lowers. Kussmaul respirations try to correct the
metabolic acidosis by blowing off some CO2.
2. Describe the medical management of a patient in DKA.
- They have to manage blood glucose and the fluid and electrolytes disturbances.
They have to manage the symptoms of DKA, assess the airway, LOC, fluid status,
electrolytes, and BGLs.
a. How is fluid status monitored in the acute stage of DKA?
- They assess for weight at the same time every day, dry mucous membranes,
decreased skin turgor, and decreased urine output. They assess for weak and rapid
pulse, flat neck veins, increased temperature, decreased central venous pressure,
muscle weakness, orthostatic hypotension, and cool, clammy, and pale skin.
b. How is hypovolemia corrected? How rapidly is fluid volume replaced? Why?
- Hypovolemia should be corrected by administer 1 L NS over 30-60 min and add a
second L if needed. Then 1/2NS should be administered. D5 1/2NS should be
administered when BG is 250 mg/dL or higher. The first goal is to restore fluid
volume and Infusion rates are normally 15 to 20 mL/kg/hr. The next goal is
replenishing fluid volume more slowly. These types are hypotonic and infused at 4-
14mL/kg/hr. after first bolus. They monitor if it is working by looking at BP, intake
and output, and weight at the same time every day.
c. How are blood glucose levels monitored? How often?
- The first thing to assess is the airway, LOC, hydration, electrolytes, and blood
glucose. They check the BP, pulse, and RR every 15 minutes. They also check urine
output, temperature, and mental status every hour. When a CVAD is placed it needs
to be assessed every 30 minutes.
 d. How are elevated blood glucose levels corrected?
- They administer normal saline, or isotonic fluid. They assess if it is working and if it
is not then they change to 5% dextrose in 0.45 saline. They also use insulin It is
usually fixed by IV bolus of insulin and then IV continuous infusion. Subcutaneous
insulins are used when the patient can take PO fluids and ketosis is controlled.
e. How quickly is blood glucose corrected? Why?
- Therapy to lower blood glucose by 50-75 mg/dL/hr. It is considered corrected when
blood glucose is at 250 mg/dL. Hypoglycemia may develop rapidly with correction of
ketoacidosis due to improved insulin sensitivity so BGL must be continuously
monitored.
3. What electrolytes are monitored in the acute stage of DKA? Why?
- Potassium is monitored because insulin use, correcting the metabolic acidosis, and
increasing fluid volume almost always decreases serum potassium.
a. How are electrolyte imbalances corrected? How rapidly is this accomplished? Why?
- To prevent this potassium decrease, potassium is replaced after the serum levels fall
below 5.0mEq/L. Signs of decreased potassium are fatigue, malaise, confusion,
muscle weakness, shallow respirations, abdominal distention, paralytic ileus, and a
weak pulse. These signs are always monitored for decreased potassium.
b. How are acid-base disturbances monitored? How often?
-
c. How are acid-base disturbances corrected? How quickly is this accomplished? Why?
- Bicarbonate is for severe acidosis. It is given very slowly by IV over many hours. This
is done when pH is 7.0 or lower. It is also given when sodium bicarb level is less than
5mEq/L.
4. Describe the nursing management of a patient in DKA.
a. How is fluid status assessed? How often?
b. What are the complications of fluid replacement and how are they prevented?
c. How are blood glucose levels assessed? How often?
d. What are the complications of lowering blood glucose levels and how are they
prevented?
e. How are electrolyte disturbances assessed? How often?
f. What are the complications of electrolyte replacement and how are they prevented?
g. How are acid-base disturbances assessed? How often?
h. What are the complications of acid-base correction and how are they prevented?
i. Define anion gap, serum osmolality and venous CO2.
j. How are serial anion gaps, serum osmolalities and venous CO2 results used?