A presentation on diabetic keto acidosis

1. 1

2. What is diabetes mellitus?
 This is the disorders of the endocrine function in
which there is a relative lack of insulin or an absolute
absence of insulin. Insulin is required for glucose
(found in serum) to be transported into the cells if
glucose is not available to the cells. It remains in the
circulatory volume and fatty acids are used for energy
in its place resulting to (hyperglycemia and
ketoacidosis) the disease is categorized into type 1,
type 2, gestational and others.
2

3. What is diabetes mellitus?
 This is the disorders of the endocrine function in
which there is a relative lack of insulin or an absolute
absence of insulin. Insulin is required for glucose
(found in serum) to be transported into the cells if
glucose is not available to the cells. It remains in the
circulatory volume and fatty acids are used for energy
in its place resulting to (hyperglycemia and
ketoacidosis) the disease is categorized into type 1,
type 2, gestational and others.
3

4.  TYPE 1 DIABETES (Absolute insulin
insufficiency); this occurs due to an inability of
the Beta cells of the islets of langahans to secrete
insulin and is thought to have an auto-immune
bases where Beta cells are destroyed by an auto-
immune process. The insulin deficiency the leads
to hyperglycemia. which is also called Insulin
Dependent Diabetes Mellitus (IDDM).
4

5.  TYPE 2 DIABETES (insulin resistance with
varying degree of insulin secretory defects); the
Beta cells produce insufficient insulin and in
addition the appears to be a resistance of the cells
to insulin which is affected by obesity,
medications and other factors. It is also called
Non-Insulin Dependent Diabetes Mellitus
(NDDM)
5

6. What is Diabetic Ketoacidosis (DKA)?
 It is a life threatening condition that develops when
cells in the body are unable to get the glucose they need
for energy because of insulin deficiency.
 Without enough insulin our body begins to break down
fat as fuel.
 This process produces a buildup of acids in the blood
stream called ketones, eventually leading to diabetic
ketoacidosis if untreated.
6

7.  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).
 The prevelence of DKA Is 46 to 80 per 10,000 persons
per year among patients with diabetes, and the estimated
mortality rate of DKA episodes occur in patients with
new onset diabetes.
 It is more common in the elderly, obessed persons, people
with other conditions like diabetes type 1 and 2,
Hypertension and many others.
7

8.  Frequent urination.
 Extreme thirst.
 High blood sugar levels.
 Nausea and vomiting.
 Abdominal pain.
 Confusion.
 Fruity smelling breath.
8

9.  DKA is as a result of lack of insulin in the body and a
corresponding elevation of glucagon which leads to
increase in the release of glucose by the liver (a process
normally suppressed by insulin) from glycogen via
glycogenolysis and also through gluconeogenesis. This
excess glucose is then passed into urine, taking water and
solutes (Na+ and K+) along with it in a process known as
osmotic diuresis which leads to dehydration (polyuria),
increase thirst, and polydipsia. The absence of insulin also
leads to the release of free fatty acids from adipose tissue
(lipolysis), which are converted through a process called
beta oxidation (also in the liver) into ketone bodies. The
ketones bodies have a low PH and therefore turn the blood
acidic.
9

10.  Noticed symptoms such as (frequent urination, loss
of appetite, fruity smelling breath, nausea,
vomiting etc)
 Laboratory tests including blood and urine tests,
are used to confirm a diagnoses of Diabetic
Ketoacidosis.
 High blood glucose levels
 Glucose and ketone bodies in urine.
 Acidosis (PH lower than 7.30)
10

11.  Stabilize airway, breathing and circulation (as
need be)
 IV insulin therapy
 Watch for complications.
 Treat causes and complications.
11

12.  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 importance of follow up
 Educate clients on importance of compliance to
medication.
12

13. Demographic information
 Health facility: BBH
 Department: Men's Ward
 Name: xxxxxxx
 Gender: male
 Age: 33years
 Marital status: married
 Occupation: farming
 Educational level: primary school
 Quarter: Nsongi
 Village: Mensai
 Sub-division: Jakiri
 Division: Bui
 Region: North West
13

14. Generalized body weakness and nausea x 1 week
History of present illness
 Client warded with history of generalized body
weakness, nausea, frequent urination, chest pain,
lost of appetite. Client also reports that he has not
been able to pass stool x 1 week.
 Client is a known HTN x 15 years and was
recently diagnosed with diabetes mellitus x 2
days ago.
14

15.  FHX: DM (-), HTN (-), Epilepsy (-)
 SHX: no surgical history
 Social HX: (-) smoking, (-) alcohol
 Medication HX: on HCTz, Nifediprine,
Metformin and Glibenclamide.
15

16.  Temperature: 36.6oc
 PR: 106 beats per minute
 RR: 18 c/m
 Oxygen saturation: 94%
 BP: 100/80mmhg
 Blood sugar: 373mg/dl
16

17.  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: soft and distended
 Extremities: (-) oedema
 Skin: ok
17

18.  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
 Chest x-ray: Neg
18

19.  DKA complicated by UTI
 Hypotension
 Constipation
 In new diagnosed Dm/known HTN
19

20.  Breath normally.
 Eat and drink adequately.
 Eliminate body waste.
 Move and maintain desirable posture.
 Select suitable cloth, dress and undress.
 Sleep and rest.
 Keep the body clean and well groomed and protect
the intergument.
 Communicate with others in expressing motions,
needs, fears, or opinions.
 Worship according to one’s faith.
 Learn, discover, or satisfy the curiosity that leads to
normal development and health and use the available
health facilities
20

21.  Deficient knowledge related to lack of
information about disease condition as evidenced
by client request for information and questions
 Constipation related to limited fluid intake and
low fiber diet evidenced by client verbalising “ I
have not bean able to pass out stool for the past 1
week”
 Unstable blood glucose levels related to decrease
production of insulin as evidenced by high blood
sugar levels
21

22.  Normal saline flush (1000cc)
 Monitor vitals and u/o Q4H
 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
 Ceftriazone 2g Qd x 5days
 Azithromycin 500mg stat then 250mg Qd x 5days p.o
 Pcw 1g tid x 3days
 Bisacodyl 10mg Qd x 2days
 Rectal enema
 Artovastatin 20mg p.o QHS
22

23.  Pcw 1g p.o tid x 3days
 Metformin 1g BID x 30days
 Imxtard s/c 20iu QHM-15QPM (insulin
syringes(5) (1 sachet cotton, alcohol 100mls)
 Lisinoprol 20mg p.o Qd x 30
 Azithromycin 250mg p.o x 5days
 Cefixime 200mg p.o Qd x 7days
23

24. Nursing
diagnosis
Goals/outco
mes
Nursing
intervention
Rationale Evaluation
Deficient
knowledge
related to lack
of information
about disease
condition as
evidenced by
client request
for
information
and questions.
Client will
within 2 days
of nursing
intervention
demonstrate
good
understanding
about disease
condition and
possible
complications
.
Establish
rapport and
trust.
Explain the
signs and
symptoms of
disease
condition to
patient.
Educate
client on the
importance of
strict follow
up.
Create an
environment
of trust and
good rapport
because it will
facilitate a
good
relationship in
the learning
process.
Symptoms
of
hyperglycemi
a include
(frequent
urination,
high blood
glucose levels
Goal met as
client
verbalized
understanding
of the disease
condition and
complications
after 2 days
24

25. Nursing
diagnoses
Goal/outcomes Nursing
intervention
Rationale Evaluation
Thirst, loss
of appetite)
and others
25

26. Nursing
diagnoses
Goal/outcomes Nursing
intervention
Rationale Evaluation
Constipatio
n related to
limited fluid
intake and
low fiber diet
evidenced by
client
verbalizing “I
have not pass
stool for the
past 1 week”
Client will
state relief from
discomfort of
constipation
after 2 hours of
nursing
intervention
Encourage
client to take
in at least 2-3
liters of water
per day (if
not contra-
indicated)
Educate
client on
importance of
dietary
fibers/raw
fruits,
vegetables.
Administer
laxatives or a
cleansing
enema (if
To help
soften the
fecal mass.
it adds
bulk to stool
and makes
defecation
easier
because it
passes
through the
intestines
unchanged.
It helps
soften
impacted
stool and
promotes
Goal met as
client admits
relief from
discomfort of
constipation
after 45
minutes of
nursing
intervention
26

27. Nursing
diagnoses
Goal/outcomes Nursing
intervention
Rationale Evaluation
Perform
regular
exercises.
Also
helps to
promote
peristalsis.
27

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
Monitorin
g capillary
blood
glucose
levels at
regular
intervals as
prescribed.
Administe
r insulin
therapy or
oral anti-
diabetic
drugs as
prescribed
Monitor
intake and
output and
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)
28

29. Nursing
diagnoses
Goal/outcome
s
Nursing
interventio
n
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
29

30.  Within 5 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.
30

31. The BBH administration should;
 Deploy trained health care workers to social
groups, markets, 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.
 Organize free screening sessions for NCDs and
outreaches at least 2 times a year.
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