In a patient with diabetic ketoacidosis, the nurse should expect which laboratory finding?

Diabetic ketoacidosis (DKA) is a serious and potentially life-threatening complication of diabetes that results in a very high glucose level. It typically occurs in those with type 1 diabetes, but can also develop in those with type 2 diabetes. 

When the body doesn’t have enough insulin to allow glucose into the cells for energy, fats will be broken down instead which produces ketones. Ketones make the blood more acidic which is dangerous. 

Major causes of DKA include illness and inadequate insulin. Infections increase blood glucose levels and illnesses causing vomiting and a lack of appetite will also make glucose levels hard to manage. Those with type 1 diabetes do not produce insulin or very little of it, so if they are not administering enough insulin or at incorrect frequencies, this can cause hyperglycemia. 

The Nursing Process  

DKA requires prompt treatment and close monitoring as deterioration can lead to coma and death. Priority treatment includes the administration of IV insulin and fluids which must be titrated correctly so as not to cause secondary complications. Nurses must also educate patients and family members on how to recognize symptoms of DKA as well as prevent recurrences. 

Nursing Care Plans Related to Diabetic Ketoacidosis 

Risk For Unstable Blood Glucose Care Plan 

Knowledge deficits, illnesses, injuries, stress, and incorrect insulin dosing can result in DKA.

Nursing Diagnosis: Risk For Unstable Blood Glucose

Related to: 

• Lack of diabetic diagnosis 
• Poor diabetes management 
• Illness causing unstable glucose levels 
• Nonadherence to insulin regimen 
• Physical injury such as a motor vehicle accident 
• Alcohol or drug use 

Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred. Nursing interventions are directed at prevention. 

Expected Outcomes: 

• Patient will verbalize factors causing unstable blood glucose 
• Patient will verbalize the correct administration of insulin 
• Patient will maintain blood glucose levels within an acceptable range 

Risk For Unstable Blood Glucose Assessment

1. Assess understanding of diabetes diagnosis.
DKA often presents as the first sign of diabetes in patients who have yet to be diagnosed. In patients who are aware of their diagnosis, assess their understanding of the relationship between diabetes and insulin.

2. Review lab work.
Reviewing Hgb A1C levels can assess for a new diagnosis or poor long-term glucose control.

3. Assess their understanding of insulin.
Patients with type 1 diabetes require insulin as their pancreas does not make any. Assess the patient’s understanding and adherence to their prescribed insulin regimen.

Risk For Unstable Blood Glucose Interventions

1. Observe the patient using their glucometer.
Have the patient demonstrate using their glucose monitoring device. The nurse can also calibrate the device to ensure accuracy.

2. Use a ketone test kit.
Patients can be advised to purchase over-the-counter ketone testing kits. When cells don’t get adequate glucose the body breaks down fat for energy, producing ketones. High ketones can poison the body and cause DKA. Patients can test for ketones in their urine when their blood sugar is >240.

3. Educate on the causes of DKA.
Provide education on instances that affect insulin and may lead to DKA such as illnesses affecting fluid or food intake, alcohol intake, and medications.

4. Coordinate with a diabetes educator.
Patients who struggle with managing their diabetes may need education by a diabetes educator. These are usually nurses trained to help patients manage and understand their diabetes and medications.

Acute Confusion Care Plan 

Severe DKA may result in confusion or agitation. Cerebral edema is a rare but serious complication of DKA.

Nursing Diagnosis: Acute Confusion

Related to: 

• Delirium 
• Cerebral edema 
• Metabolic encephalopathy 

As evidenced by: 

• Confusion 
• Agitation 
• Fluctuation in cognition 
• Headache 
• Lethargy 
• Increased intracranial pressure 

Expected Outcomes: 

• Patient will remain alert and oriented to person, place, and time 
• Patient will not experience seizures, cerebral edema, or coma from DKA 

Acute Confusion Assessment

1. Assess cognition.
Monitor closely for changes in cognition and consciousness. The Glasgow Coma Scale (GCS) may be used in some settings.

2. Monitor lab work.
All electrolyte levels should be monitored along with pH levels, ketones, and plasma glucose.

3. Review imaging scans.
CT scans or MRIs can be used to assess for dilated ventricles in the brain. Treatment should not be delayed for suspected cerebral edema.

Acute Confusion Interventions

1. Administer insulin.
IV insulin is the standard treatment for DKA as the patient needs insulin rapidly to decrease glucose and ketone levels.

2. Avoid overhydration.
Fluid replacement is another priority intervention though overhydration can lead to cerebral edema so nurses must carefully rehydrate.

3. Consider magnesium.
Magnesium deficits can contribute to cognitive symptoms such as tremors, agitation, and seizures. Magnesium levels should be checked and corrected.

4. Wear a medical alert bracelet.
In the event that DKA occurs when no one is around or the patient is too confused to verbalize, a medical alert bracelet can be lifesaving.

Risk For Deficient Fluid Volume Care Plan 

Dehydration and electrolyte imbalances can result from fluid losses.

Nursing Diagnosis: Risk For Deficient Fluid Volume

Related to: 

• Vomiting 
• Kussmaul respirations 
• Polyuria 
• Glycosuria and osmotic diuresis 

Hint: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred. Nursing interventions are directed at prevention. 

Expected Outcomes: 

• Patient will identify causes and related symptoms causing fluid loss 
• Patient will remain normovolemic as evidenced by urine output, electrolyte levels, and vital signs within normal limits 

Risk For Deficient Fluid Volume Assessment

1. Assess vital signs and respirations.
Dehydration will cause tachycardia and low blood pressure. Kussmaul respirations are another common finding. These rapid, shallow breaths are a result of the body’s attempt to correct acidosis in the blood. A fruity odor on the breath is a classic accompanying sign.

2. Monitor electrolytes.
Potassium levels will typically be elevated initially but will drop as fluid volume decreases while magnesium and sodium levels will be deficient. All electrolytes should be replaced and may resolve simply with fluid or insulin administration.

3. Assess kidney function urine output.
Acute kidney injury can result due to osmotic polyuria and volume depletion. Progression to chronic kidney disease is a concern and increases mortality. Urine output should stabilize with treatment. Monitor serum creatinine levels and eGFR decline.

Risk For Deficient Fluid Volume Interventions

1. Administer isotonic solutions initially.
Fluid replacement alone will begin to lower blood glucose. Initial isotonic therapy of 0.9% saline is recommended. A transition to a hypotonic solution such as 0.45% saline may be used as long as sodium levels remain normal.

2. Give dextrose once glucose levels stabilize.
Once glucose levels reach 250 mg/dL, dextrose should be given to prevent further ketosis.

3. Offer oral fluids.
If the patient is alert and oriented and can safely swallow, or if their DKA is mild, oral fluid resuscitation is also advised.

4. Educate on symptoms for prevention.
To prevent a recurrence of DKA or when to seek prompt treatment, educate the patient on symptoms such as polydipsia, polyuria, (early signs) nausea and vomiting, flushed skin, weakness, and fatigue.

References and Sources

1. American Diabetes Association. (n.d.). Diabetes & DKA (Ketoacidosis) | ADA. American Diabetes Association. Retrieved March 30, 2022, from https://www.diabetes.org/diabetes/dka-ketoacidosis-ketones
2. Diabetic Ketoacidosis | Diabetes. (2021, March 25). CDC. Retrieved March 30, 2022, from https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html
3. Gosmanov, A. R., Gosmanova, E. O., & Dillard-Cannon, E. (2014). Management of adult diabetic ketoacidosis. Diabetes, metabolic syndrome and obesity : targets and therapy, 7, 255–264. https://doi.org/10.2147/DMSO.S50516
4. Henriksen, K. (2021, July 14). Diabetic Ketoacidosis Symptoms, Causes, Diagnosis, and Treatments. EndocrineWeb. Retrieved March 30, 2022, from https://www.endocrineweb.com/diabetic-ketoacidosis
5. Inward CD, Chambers TLFluid management in diabetic ketoacidosis. Archives of Disease in Childhood 2002;86:443-444. https://adc.bmj.com/content/86/6/443
6. Ling, L., Chen, J., Zeng, H., Ouyang, X., & Zhu, M. (2020, February 12). The incidence, risk factors, and long-term outcomes of acute kidney injury in hospitalized diabetic ketoacidosis patients – BMC Nephrology. BMC Nephrology. Retrieved March 30, 2022, from https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-020-1709-z
7. Trachtenbarg, D. E. (2005). Diabetic Ketoacidosis. American Family Physician, 1;71(9), 1705-1714. https://www.aafp.org/afp/2005/0501/p1705.html

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