DIABETIC KETOACIDOSIS

DESCRIPTION• Life threatening metabolic acidosis resulting from persistent hyperglycemia and breakdown 0f fats into glucose, leading to presence of ketones in blood

• Can be triggered by emotional stress, uncompensated exercise, infection, trauma, or insufficient or delayed insulin administration.

ASSESSMENTGENERAL ASSESSMENT• Includes health history, vital signs, cognitive function and mental status• Glucose monitoring log • Medication Administration• Oral intake for past 48 hours• Elimination pattern, Skin• Oxygenation, breath sounds, respiratory effort and pattern,• Weight and hourly intake and output.

ASSESSMENT

CLINICAL MANIFESTATIONS:•Thirst, nausea vomiting• Malaise, lethargy• Polyuria• warm dry skin• flushed face• Acetone (fruity) odor to breath• Kussmauls respirations (deep, nonlabored, rapid respirations)

ASSESSMENT

DIAGNOSTICS AND LABORATORY TEST FINDINGS:

• Serum Glucose: >250 mg/dL;• Plasma pH: <7.35• Plasma bicarbonate: <15 mEq/L• Serum ketones present• Urine positive for glucose and ketones• may have abnormal serum sodium and chloride levels and hyperkalemia

THERAPEUTIC MANAGEMENT

• Intravenous administration of fluids, electrolytes, and regular insulin to correct hyperglycemia and acidosis

• Supportive care as indicated such as NPO status, vasopressors and possible ventilator to respiratory support

THERAPEUTIC MANAGEMENT

A. INSULIN1). A bolus of IV regular insulin is given followed by a continous IV drip (0.1 unit/kg body weight) until the blood glucose level drops to 250 mg/ 100 ml or the pH= 7.30

2.) Once this blood level is reached, regular insulin is given on a sliding scale according to blood glucose.

3. As an alternative to IV infusion, IM administration of insulin may be given hourly.

4. Bedside blood glucose monitoring is done q1 to 2 hrs. to monitor the effectiveness of this therapy.

THERAPEUTIC MANAGEMENT

FLUID THERAPY:-Instituted to diminish the

hyperglycemia and to treat the large fluid deficit (dehydration) that accompanies DKA

1.) Normal Saline Solution is usually given at a rate of 1 to 2 L for the first hour, then is decreased to 500 mL/hr as tolerated by cardiac and respiratory systems.

THERAPEUTIC MANAGEMENT

2.) When the blood glucose level reaches 250 to 300, a 5% glucose solution (D5 1/2NS) is added to prevent hypoglycemia and to prevent cerebral edema

3.) Central venous pressure or hemodynamic monitoring may be necessary to evaluate the effectiveness of the therapy

THERAPEUTIC MANAGEMENT

C. POTASSIUM REPLACEMENT-Always necessary in DKA

1.) The initial serum potassium (K+) level is usually elevated

2.) with the reversal of the acidosis and the administration of insulin, the K+ shifts into the intracellular compartment and the serum level can drop rapidly.

THERAPEUTIC MANAGEMENT

3. Electro cardiographic monitoring is instituted to monitor for cardiac changes and due to hyper and hypokalemia and to monitor the effects of therapy on the serum K+ level.

4. Another electrolytes such as phosphate will also be replaces based on the result of laboratory profiles; bicarbonate is not given routinely in DKA because rapid correction of acidosis can cause severe hypokalemia

PRIORITY NURSING DIAGNOSIS

• Deficient Fluid volume• Risk for Injury•Risk for impaired skin integrity • Ineffective breathing pattern• Disturbed Sensory Perception• Knowledge deficit• Anxiety

PLANNING AND IMPLEMENTATION

A.Restore Fluid, electrolyte and glucose with IV infusions and medicationsAnalyze intake and output, blood glucose, urine ketones, vital signs, oxygenation and breathing pattern.

B. Maintain Skin integrity; promote healing of impaired skin; prevent infection by turning and positioning client q 2 hours; provide pressure relief as indicated.Manage incontinence and perspiration with skin protective barriers and cleansing; provide adequate nutrition and oxygen support

PLANNING AND IMPLEMENTATION

C. Promote safety by analyzing vital signs, client communication, LOC and emotional response, and activity intolerance; implement falls prevention measures.

D. Assist client to verbalize concerns and cope effectively with illness and fears.

MEDICATION THERAPY

• IV infusions of NS• Regular insulin and • electrolyte replacement including potassium replacement as previously described.

CLIENT EDUCATION

• Instruct Client about the nature and causes of DKA (such as excess glucose intake), insufficient medications, or physiology and/or psychological stressors) and any new medications.

EVALUATIONA. Fasting blood glucose is within normal range

Serum pH is 7. 35 to 7.45Urine is negative for ketones

B. Client’s LOC and perceptual function returns to normal; elimination is normalSkin is intactBreathing pattern is normalFluids and electrolytes are balanced

C. Client verbalizes understanding f Diabetic Ketoacidosis, its causes, methods of prevention and new medications

Hyperglycemic Hyperosmolar Non-ketotic

Coma(HHNKC)

DESCRIPTION

Life-threatening metabolic disorder of hyperglycemia usually recurring with DM tyoe 2 and triggered by a variety of situations: Medications, infection, acute illness, invasive procedures or a chronic illness.

ASSESSMENT

GENERAL ASSESSMENT• Includes health history, vital signs, LOC,

cognitive and perceptual function• Elimination pattern• Skin, breathing pattern, breath sounds• Reflexes, sensory and motor function• I & O, weight• ECG, communication, glucose monitoring log• Nutrition pattern and meds taken within 7

days.

CLINICAL MANIFESTATIONS:symptoms gradually occur over 24 hours to

2 weeks and include: decreased LOC dry mucous membranes polydipsia hyperthermia impaired sensory and motor function + Babinski’s sign and seizures

ASSESSMENT

DIAGNOSTICS AND LABORATORY TEST FINDINGS: Elevated serum sodium Serum osmolality: >340mOsm/L Serum Glucose: >600 mg/dL abnormal serum potassium and

chloride NO serum ketones Normal serum pH

ASSESSMENT

THERAPEUTIC MANAGEMENT

Determine and treat triggering situation

Treat co existing health deviations

Provide fluid and electrolyte replacement

Provide regular insulin IV to normalize serum glucose/

PRIORITY NURSING DIAGNOSIS

Decreased cardiac output Deficient fluid volume Hyperthermia Disturbed Sensory perception Risk for impaired skin integrity Risk for aspiration Deficient knowledge

PLANNING AND IMPLEMENTATION

A. Provide normalized cardiac output, sensory perceptual function, fluid and electrolyte balance, Normal body temperature by administering fluids, medications and analyzing I & O, weight, vital signs, lab values, sensory and cognitive function.

PLANNING AND IMPLEMENTATION

B.Maintain intact skin by turning q 2 hrs, use of pressure relief aids, nutritional support, use of skin moisturizers and barriers, and management of incontinence.

C. Prevent aspiration using appropriate feeding precautions, elevate head of bed15 to 30 degrees during and after feeding for 1 hour; if BP too unstable to elevate HOB with feeding, then withhold oral feedings.

MEDICATION THERAPY

IV infusion of NS to replace fluids and sodium

Regular insulin IV to manage the hyperglycemia and potassium to replace losses and shifts.

CLIENT EDUCATION

Instruct client on HHNK, symptoms to report and administration of new medications.

EVALUATION

A.Client returns to normal LOC and perceptual function, elimination function and breathng patternFasting blood glucose id within normal rangeskin is intact

B.Fluid and electrolyte levels are balanced

C. Client verbalizes understanding of HHNK, symptoms to report and administration of new medications.

THE END… TNX FOR CAREFULLY LISTENING!!!!

BSN 4D- GROUP 3