A presentation on diabetic keto acidosis

1. CASE PRESENTATION
DIABETIC KETO
ACIDOSIS (DKA)
Presented by:
KUBAM VESEMEH BRANDONE
Nursing professional
development
NPD2206
BTSHP
On Wednesday 6th April

2. DEFINITION OF DIABETES
What is Diabetes Mellitus?
Diabetes Mellitus more commonly referred to as
Diabetes is a serious, chronic disease that occurs either
when the pancreas does not produce enough insulin (a
hormone that regulates blood glucose), or when the
body cannot effectively use the insulin it produces
WHO(1999). Raised blood glucose, a common effect of
uncontrolled diabetes, may, over time, lead to serious
damage to the heart, blood vessels, eyes, kidneys and
nerves.

3. DEFINITION CONT…
Type 1 diabetes (previously known as insulin-dependent,
juvenile or childhood-onset diabetes) is characterized by
deficient insulin production in the body. People with type 1
diabetes require daily administration of insulin to regulate
the amount of glucose in their blood. If they do not have
access to insulin, they cannot survive. The cause of type 1
diabetes is not known and it is currently not preventable
WHO(1999). Symptoms include excessive urination and
thirst, constant hunger, weight loss, vision changes and
fatigue

4. DEFINITION CONT…
Type 2 diabetes (formerly called non-insulin-dependent or adult
onset diabetes) results from the body’s ineffective use of insulin. Type
2 diabetes accounts for the vast majority of people with diabetes
around the world WHO(1999). Symptoms may be similar to those of
type 1 diabetes, but are often less marked or absent. As a result, the
disease may go undiagnosed for several years, until complications
have already arisen. For many years type 2 diabetes was seen only in
adults but it has begun to occur in children.
Impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG)
are intermediate conditions in the transition between normal blood
glucose levels and diabetes (especially type 2), though the transition is
not inevitable. People with IGT or IFG are at increased risk of heart
attacks and strokes.

5. DEFINITION CONT….
Gestational diabetes (GDM) is a temporary condition
that occurs in pregnancy and carries longterm risk of type
2 diabetes. Bellamy L, Casas JP, Hingorani AD, Williams
D(2009) The condition is present when blood glucose
values are above normal but still below those diagnostic
of diabetes WHO(2013). Women with gestational diabetes
are at increased risk of some complications during
pregnancy and delivery, as are their infants. Gestational
diabetes is diagnosed through prenatal screening, rather
than reported symptoms.

6. DEFINITION CONT….
What is Diabetic Keto acidosis (DKA)?
• A state of absolute or relative insulin deficiency aggravated by ensuing
hyperglycemia, dehydration, and acidosis-producing derangements in intermediary
metabolism, including production of serum acetone Abdulmoein E (2020)
• Can occur in both Type 1 Diabetes and Type 2 Diabetes.
In type 2 diabetics with insulin deficiency/dependence
 This is presenting symptom for approximately 25% of Type 1 Diabetics.
 DKA is the leading cause of morbidity and mortality in children with diabetes
Abdulmoein E (2020)
 In new-onset diabetes, DKA can be prevented through earlier recognition and
initiation of insulin therapy.
 Caution is necessary in management of paediatric DKA due to increased risk of
cerebral edema

7. CAUSES AND PREVALENCE
•Severe infections or other illnesses leading to severe dehydration due to decrease of insulin levels.
• It can occur in people who have little or no insulin in their blood (Diabetes type 1).
•When the blood sugar levels are high (Diabetes type 2).
•Globally, an estimated 422 million adults were living with diabetes in 2014, compared to 108 million in
1980. The global prevalence (age-standardized) of diabetes has nearly doubled since 1980, rising
from 4.7% to 8.5% in the adult population. This reflects an increase in associated risk factors such as
being overweight or obese. Over the past decade, diabetes prevalence has risen faster in low- and
middle-income countries than in high-income countries.Diabetes caused 1.5 million deaths in 2012.
Higher-than-optimal blood glucose caused an additional 2.2 million deaths, by increasing the risks of
cardiovascular and other diseases. Forty-three percent of these 3.7 million deaths occur before the
age of 70 years. The percentage of deaths attributable to high blood glucose or diabetes that occurs
prior to age 70 is higher in low- and middle-income countries than in high-income countries
GBD(2013).
•A total of 835 deaths were found among DKA patients, with a mortality rate of 0.38%. The overall
mortality rate was higher among males admitted with DKA (40.5 deaths per 10,000 cases of DKA) than
females (35.3 deaths per 10,000 cases of DKA) Amleshun R and Jyotsnav J(2020).

8. PATHOPHYSIOLOGY
• Hyperglycemia results from impaired glucose uptake because of insulin
deficiency and excess glucagon with resultant gluconeogenesis and
glycogenolysis.
•Glucagon excess also increases lipolysis with the formation of
ketoacids.
•Ketone bodies provide alternative usable energy sources in the
absence of intracellular glucose.
•The ketoacids (acetoacetate, β-hydroxybutyrate, acetone) are products
of proteolysis and lipolysis
• Hyperglycemia causes an osmotic diuresis that leads to excessive loss
of free water and electrolytes.
•Resultant hypovolemia leads to tissue hypoperfusion and lactic acidosis

9. DKA CRITERIA OF DIAGNOSIS
•Hyperglycemia > 250 mg/dl
•Dehydration
•Ketonemia & Ketonuria
•Metabolic Acidosis
opH < 7.30
oBicarbonate < 18 mEq/L

10. DEGREE OF SEVERITY IN DKA

11. CLINICAL MANIFESTATIONS
Ketoacidosis is responsible for the initial presentation in up to
25 – 75 % of children
•Early manifestations: vomiting, polyuria, dehydration.
•More severe: Kussmaul respirations, acetone odor on the
breath.
•Abdominal pain or rigidity may be present & mimic acute
abdomen.
•Cerebral confusion & coma ultimately ensue.

12. SIGNS AND SYMPTOMS
Signs:
•Dehydration
•Tachycardia
•Dry mucous membrane
•Delayed capillary refill
•Poor skin turgor
•Hypotension•
•Kussmaul breathing
•Decreased sensorial mental status, varies from sleepiness, drowsiness,
confusion, semi coma & coma

13. SIGNS AND SYMPTOMS CONT…
Symptoms of DKA:
•Polyuria
•Polydypsia
•Blurred vision
•Nausea/Vomiting
•Abdominal Pain
•Fatigue
•Confusion
•Coma

14. LABORATORY
•Blood glucose
• Urinary/plasma ketones
•Serum electrolytes
•BUN/Cr (Blood urea nitrogen/ creatinine kinase)
•Osmolarity
•CBC, blood culture (if infection is suspected)
• Venous blood gas

15. MANAGEMENT
Correction of the following:
•Dehydration
•Hyperglycemia
•Electrolytes deficits
•Metabolic acidosis
•Underlying precipitating factors
•Infection, omission of insulin, stress, ….etc

16. NURSING MANAGEMENT
Monitor vital signs
Check blood sugar and treat with insulin as ordered.
Start 2 large bore Ivs
Administer fluids as ordered.
Asses mental status.
Look for signs of infection (common causes of DKA)
Encourage a healthy diet
Check input and output
Educate client on the importance of follow up

17. CASE STUDY
Demographic information
Health facility: BBH
Department: Men's Ward
Name: xxxxxxx
Gender: male
Age: 33years
Marital status: married
Occupation: Driver
Educational level: ordinary level
Quarter: Nkor
Village: Nkov

18. CHIEF COMPLAIN
Generalized body weakness , excessive urination, excessive thirst and abdominal
pains
History of present illness
oClient warded with history of generalized body weakness, nausea, frequent
urination, chest pain, lost of appetite. Client also complained of abdominal pain x1
week.
oClient is a known DM on Metformin and Mixtard and non-complaint to treatment.
FHX: DM (+), HTN (-), Epilepsy (-)
oSHX: no surgical history
oSocial HX: (-) smoking, (-) alcohol
oMedication HX: Metformin and Mixtard

19. VITAL SIGNS
•Temperature: 36.6oc
•PR: 82beats per minute
•RR: 22 c/m
•Oxygen saturation: 98%
•BP: 90/60mmhg
•Blood sugar: 443mg/dl

20. PHYSICAL ASSESSMENT
HEENT: Normal
Neck: no distended veins
Mental status: conscious and oriented x 3
Lungs: clear
Heart sounds: S1, S2 regular with no added sounds.
Abdomen: Not distended
Extremities: (-) oedema
Skin:poor skin tugor
P/E chronically looking ill

21. LABORATORY INVESTIGATION
CBC
• Wbc: 13.5 (normal value 3.5-9.5)
•Rbc: 9.04 (normal value 4.30-5.80)
•Gran %: 85.9% (40.0-75.0%)
•Urinalysis
•Ketones: +++
•Glucose: +++
•Leukocytes: +++
•MRDT: Neg
•RTT: Neg
•H pylori: positive
•ESR: 15mm/hr

22. MEDICAL DIAGNOSIS
DKA
Gastritis

23. NEEDS
oBreath normally.
oEat and drink adequately.
oEliminate body waste.
oMove and maintain desirable posture.
oSelect suitable cloth, dress and undress.
oSleep and rest.
oKeep the body clean and well groomed and protect the intergument.
oCommunicate with others in expressing motions, needs, fears, or opinions.
oWorship according to one’s faith.
oLearn, discover, or satisfy the curiosity that leads to normal development and health and
use the available health facilities

24. TREATMENT
Normal saline flush (1000cc)
Monitor vitals Bp Q 1hrly
Hold antihypertensive (target: SBP>110≤130/DBP>60≤85)
REGULAR INSULINE 15iu SQ
Regular insulin 50iu in N/S 500cc 0.9% stat at 269H/minute if B.S
high till and >200mg/dl
Serve D5 ½ N/S if B.S <250mg/dl
Monitor B.S Q1hrly
Omeprazole 40mg BID
D/c Metformin and Mixtard

25. NURSING DIAGNOSIS
Risk for Fluid Volume Deficit due to osmotic diuresis
secondary to DKA.
Unstable blood glucose levels related to decrease
production of insulin as evidenced by high blood sugar
levels
Imbalanced Nutrition, less than Body Requirements
related to insulin deficiency, as evidenced by
unexplained weight loss, increased urinary output, dilute
urine, high blood glucose levels, fatigue, and weakness

26. NURSING CARE PLAN
Nursing diagnoses Goal/outcomes Nursing
intervention
Rationale Evaluation
Risk for Fluid
Volume Deficit due
to frequent urination
secondary to the
disease condition
 The patient will
demonstrate adequate
hydration and balanced
fluid volume
Assess vital signs
and signs of
dehydration.
Commence a fluid
balance chart,
monitoring the input
and output of the
patient.
Start intravenous
therapy as
prescribed.
Encourage oral
fluid intake of at
least 2500 mL per
day
Hyperglycemia may
cause Kussmaul’s
respirations and/or
acetone breath.
Hypotension and
tachycardia may result
from hypovolemia, or
low levels of
intravascular volume.
To monitor patient’s
fluid volume
accurately and
effectiveness of
actions to monitor
signs of dehydration.
To replenish the
fluids lost from
polyuria and to

27. Nursing diagnoses Goal/outcomes Nursing
intervention
Rationale Evaluation
Educate the
patient (or
guardian) on how
to fill out a fluid
balance chart at
bedside.
Monitor patient’s
serum electrolytes
and recommend
electrolyte
replacement
therapy (oral or IV)
to the physician as
needed.
To help the patient
or the guardian take
ownership of the
patient’s care,
encouraging them to
drink more fluids as
needed, or report any
changes to the
nursing team.
Sodium is one of
the important
electrolytes that are
lost when a person is
passing urine.

28. Nursing diagnoses Goal/outcomes Nursing
intervention
Rationale Evaluation
Unstable blood
glucose levels related
to decrease
production of insulin
evidenced by high
blood sugar levels.
Client’s blood glucose
level will decrease and
will be maintained at
normal levels (< 200
mg per day) after 3-5
days of nursing
intervention
Monitoring
capillary blood
glucose levels at
regular intervals as
prescribed.
Administer
insulin therapy or
oral anti-diabetic
drugs as prescribed
Monitor intake
and output and
chart daily (fluids)
Monitoring blood
sugar levels help to
limit the chances of
client going to hypo or
hyperglycemia
To decrease blood
glucose levels.
To avoid fluid
overload.
After 3 days of
nursing intervention
blood capillary
glucose levels
decrease to normal
(<200mg per day)

29. Nursing diagnoses Goal/outcomes Nursing
intervention
Rationale Evaluation
Advice client to
rest when blood
glucose level is
more than
250mg/dl
Activities can
increase the need of
glucose in the tissues
where as for patients
with diabetes, clients
glucose uptake to the
tissues is decreased
due to lack of insulin.

30. Nursing diagnoses Goal/outcomes Nursing
intervention
Rationale Evaluation
Imbalanced
Nutrition, Less than
Body Requirements
related to insulin
deficiency, as
evidenced by
unexplained weight
loss, increased
urinary output,
dilute urine, high
blood glucose
levels, fatigue, and
weakness
The patient will be able
to achieve a weight
within his normal BMI
range, demonstrating
healthy eating patterns
and choices.
Explain to the
patient the
relationship
between diabetes
and unexplained
weight loss.
Create a daily
weight chart and a
food and fluid
chart. Discuss with
the patient the
short term and
long-term goals of
weight loss.
To help the patient
understand why
unexplained weight
loss is one of the
signs of diabetes.
To effectively
monitor the patient’s
daily nutritional intake
and progress in
weight loss goals.

31. Nursing diagnoses Goal/outcomes Nursing
intervention
Rationale Evaluation
Help the patient
to select
appropriate dietary
choices to follow
60%
carbohydrates,
20% fats, 20%
proteins.
Refer the patient
to the dietitian.
These proportions
are ideal for diabetic
ketoacidosis patients.
To provide a more
specialized care for
the patient in terms of
nutrition and diet in
relation to diabetic
ketoacidosis.

32. OUTCOMES/CONCLUSIONS
Within 8 days of hospital management, control
BMP, U/A and blood capillary glucose levels were
all within normal ranges.
Conclusively DKA is a complication of diabetes
mellitus that comes as a result of (illnesses or
infections, non-compliance to treatment, lack of
information about disease condition, poor
nutritional status, sedentary lifestyle) and many
other factors.

33. RECOMMENDATIONS
The BBH administration should;
Deploy trained health care workers to social groups, markets, small christian
communities, churches and meeting houses to educate the population on the
risk factors of NCDs and their common signs and symptoms. Also on the
importance of routine health checks, advantages and disadvantages.
Train nurses to carryout health talks to clients and caregivers especially those
with diabetes mellitus and other NCDs on the importance of compliance and
regular check-ups.
Through collaboration with her local and international partners work on
strategies to reduce cost of care for people living with NCDs to help ensure it’s
continuity.
Organize free screening sessions for NCDs and outreaches at least 2 times a
year.

34. REFRENCE
1. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications. Part 1:
Diagnosis and Classification of Diabetes Mellitus (WHO/NCD/NCS/99.2). Geneva: World
Health Organization; 1999.
2. Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational
diabetes: a systematic review and meta-analysis. Lancet. 2009;373:1773–1779.
3. Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy
(WHO/NMH/ MND/13.2). Geneva: World Health Organization; 2013.
4. Abdulmoein Eid Al-Agha, MBBS, DCH, CABP, FRCPCH Associate Professor of Pediatric
Endocrinology, King Abdulaziz University Hospital Website: http://aagha.kau.edu.sa
5. GBD 2013 Risk Factors Collaborators. Global, regional, and national comparative risk
assessment of 79 behavioural, environmental and occupational, and metabolic risks or
clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of
Disease Study 2013. Lancet. 2015;386(10010):2287–323.
6. Kamleshun Ramphul and Jyotsnav Joynauth Diabetes Care 2020;43:e196–e197 |
https://doi.org/10.2337/dc20-1258

35. Thank you all and God Bless you
Merci à tous et que Dieu vous bénisse