2. DIABETES MELLITES
Diabetes mellitus is a group of metabolic disease
results from the production of insufficient amount
of insulin by the pancreas. Without insulin the
body cannot utilize glucose. So creating high level
of glucose in the blood and a low level of glucose
absorption by the tissue.
Type 1 diabetes -- insulin dependant diabetes
Type2 diabetes-- Non insulin dependant diabetes
3. DIABETIC KETOACIDOSIS
Diabetic keto acidosis is an acute state of severe
uncontrolled diabetic that requires emergency
treatment with insulin and intravenous fluids.bio
chemically DKA is defined as an increase in the
serum concentration of ketons greater than 5
meq/l a blood glucose level of greater than 250
mg/l,blood PH less than 7.2 and HCO3 is 18meq/l
or less.
5. INFECTION MISSED INSULIN DOSE
STRESS NEW-ONSET DIABETES
EXCESS SECRETION OF
INADEQUATE
GLYCOGEN AND OTHER
INSULIN
COUNTER REGULATORY
HORMONES
DCREASE
INCREASED LIPOLYSIS GLYCOGENENOLYSIS GLUCOSE UPTAKE
OF ADIPOSE TISSUE AND
GLUCONEOGENESIS
BY THE LIVER HYPERGLYCEMIA
KETOGENESIS
OSMOTIC
KETOSIS DIURESIS
VOMITING
ACIDOSIS POTASSIUM
LOSS
DEHYDRATION
6. LACK OF INSULIN
DECREASED UTILIZATION INCREASED
OF GLUCOSE BY MUSCLE, BREAKDOWN
FAT AND LIVER OF FAT
INCREASED PRODUCTION •ACETONE
OF GLUCOSE BY LIVER BREATH INCREASED
•POOR APPETITE FATTY ACIDS
•NAUSEA
HYPERGLYCEMIA INCREASED
KETONE
•NAUSEA BODIES
BLURRED POLYURIA •VOMITING
VISION •ABDOMINAL PAIN ACIDOSIS
WEAKNESS DEHYDRATION
HEADACHE
INCREASINGLY
INCREASED THIRST RAPID
(POLYDIPSIA) RESPIRATIONS
7. COMMON CLINICAL FEATURES
Poly urea ,poly dipsia,poly phagia
Weight loss
Nausea and vomiting
weakness
Abdominal pain
Clouding of sensorium
Coma
Hyper ventillation –kuss mual pattern
Dehydration and shock
s
8. LABORATORY FINDINGS
Blood glucose greater than 14mmol/L[250 mg/l]
Arterial pH less than 7.3
Anion gap less than 10
Ketone urea
Arterial bicarbonate less than 15
Hyper magnesimia
Hypokalemia
Cardiac enzymes
Pco2-35it reflects respiratory compensation .
9. NURSING ASSESSMENT
Assess skin for dehydration like poor turgour,flushing,and dry
mucus membrances.
Observe for cardiac changes reflecting dehydration,metabolic
and electrolyte imbalance,tachycardia,hypotension,weak
pulse,ECG changes including elevated P wave flattendT wave
or inverted and prolonged QT intervals
Assess respiratory status kussmual breathing,acctone breaths
characteritic of metabolic acidosis
Assess gastro intestinal symptoms like nausea vomiting
extreme thirst,abdominal bloating,cramping,and diarrhoea
Genito urinary symptoms-nocturia and polyuria
Neurologic signs-
crying,restlessness,twitching,tremers,drowsiness,lethargy,hea
dache.
10. NURSING MANAGEMENT
Stabilize the patient’s airway,breathing,circulation
Obtain 16 gauge iv line on both site and assess cardiac
monitoring and pulse oxymetry.
Monitor serum glucose hourly and urine ketone
Monitor basic electrolyte,osmolarity and venousPHevery 4
hourly until pt is stable.
Determine and treat any underlyingcausesof DKAeg;;
pneumonia,UTIand MI
11. 1.FLUID REPLACEMENT[ADULT]
Give 1 litre of normal saline[0.9%]rapidly via No I8 gauge
cannula if cardiac function is normal.
Then one litre of normal saline/ hour, for 1st3 hrs for those
individuals who are in shock .
Then 250-500ml /hr of normal saline depending on hydration
status until blood sugar is 14 mmol/L[250 mg/L]. blood sugar
level<14 mmol/L 0.9%should be switched toD51/2NS or DNS
at 125 to 250ml/hour.
Assess blood pressure & heart rate frequently.
Monitor intake and out put for signs of fluid overload.
Monitor urine specific gravity to assess fluid changes.
12. INSULIN TREATMENT
Regular insulin 0.1 units/kg. as an IV bolus.
Then regular insulin infusion IV 0.14 units /kg./hour until
blood sugar reaches 14mmol/litre ( 250mg/dl) & follow IV
infusion protocol
1ml regular insulin = 100units
Start insulin infusion 6units/hr.
Doctor’s order x solution in volume 6units x 50
____________________________ = ____________
Strength of solution 100 units
300
_____ = 3ml/hr. ( 6units/hr.)
100
13. RATE OF INFUSION ACCORDING TO SLIDING SCALE OF
REGULAR INSULIN
CAPILLARY BLOOD GLUCOSE IN UNITS OF INSULIN / HOUR
MG/DL
<99 0.5ml/hr.
100______ 149 (5.6—8.2mmol) 1ml/hr.
150 ______ 199 ( 8.3_____11 ) 2ml/hr.
200 ______ 249 ( 11.1 ____13.8 ) 3ml/hr.
250_______299 (13.9____ 16.6) 4ml/hr.
300_______349 ( 16.7____19.4) 5ml/hr.
350_______399 ( 19.5_____22.2) 6ml/hr.
400_______450 ( 22.3_____24.9) 8ml/hr.
>450 ( > 24.9) 10ml/hr.
14. ANION GAP- Substract the major measured anion from
the major measured Cations (Cl +Hco3- Na)
• IV insulin infusion can be switched to subcutaneous
insulin according to sliding scale.
• Arterial bicarbonate rises 18.
• Anion gap 10 up to 12 + or- 2
• Urine aceton 3times negative
• Oral intake has resumed
• It is important to give the first subcutaneous insulin
approximately two hours before stopping the infusion
• Flush the entire IV infusion set with solution containing
insulin & dicard the solution ,then refill it again
• Keep separate IV line for insulin infusion and electrolyte
replacement
15. POTASSIUM REPLACEMENT
Aims to keep serum k+ between 4 to 5meq/ L to prevent
hyper or hypokalemea.
If initial potassium is <3.3 Hold insulin & replace K+
Do not give K+ direct IV, must be added to IV fluids
If K+ is >5 do not give Kcl recheck within hour
If k+ is 4__ 5 give Inj.kcl 20meq in each liter of fluid
If K+ is 3__4 give Inj.kcl 30meq in each liter of fluid
If K+ is <3 give Inj.kcl40meq in two hour & recheck
Follow sliding scale of K+ every 6th hourly until stable
16. BICARBONATE REPLACEMENT
If arterial PH <7 give 50ml of bicarbonate in 250ml of
0.45% NSS over one hour
Bicarbonate infusion to correct acidosis is avoided,during
the treatment of DKA because it precipitates further
sudden decrease in serum potassium .
INVESTIGATION AND OUTCOME BASED EVALUATION
Serum glucose initially and hrly until acctone disappear
Serum potassium initially and hrly if K+ < 3 or > 5
Electrolyte and renal function initially and then 6 hrly ..
Serum osmolarity , VBG,cardiac enzymes ,CBC
Urine analysis and urine culture if needed
17. COMPLICATION
Premature discontinuation of Ivinsulin can result in
prolonged DKA
Too rapid infusion of IVF in case of severe dehydration
can cause cerebral edema and death
If blood glucose level falls too fast or too slow,before
the brain has time to equilibrate,the water is pulled
from the cerebrospinal fluid and the brain causing
cerebraloedema and death
Hypoxiaand leads to ARDS
Hypoglycemia,venous and arterial thrombosis
18. PATIENT EDUCATION
Instruct to take insulin or oral diabetic agent as usual
Check blood sugar and urine sugar every 4 hrly
Report elevated glucose and urine acctone to physician
Usual meal plan cannot be followed substitute soft foods 6-
8 times /day
If any symptoms like vomiting and diarrhoe or fever
consume liquid diet every half to one hour to prevent
dehydration and provide calories
Inform physician about extreme fluid loss maybe
dangerous.
For type 1 diabetic, iniability to retain oral fluid needs
hospitallization to avoid DKA and possible coma