DKA Nursing Diagnosis Care Plan: Comprehensive Guide for Nurses

Diabetic ketoacidosis (DKA) is a dangerous complication of diabetes characterized by hyperglycemia, metabolic acidosis, and ketonemia. Primarily affecting individuals with type 1 diabetes, DKA can also occur in those with type 2 diabetes under certain conditions. The fundamental issue in DKA is a critical lack of insulin, preventing glucose from entering cells for energy. In response, the body breaks down fat, producing ketones, which accumulate and acidify the blood to hazardous levels.

Prompt recognition and treatment of DKA are crucial to prevent severe consequences like coma and death. Nursing care for patients with DKA is multifaceted, requiring meticulous monitoring and intervention. This includes the careful administration of intravenous insulin and fluids, along with continuous patient education on DKA symptom recognition and preventative measures.

This article provides a detailed Dka Nursing Diagnosis Care Plan, outlining the essential nursing assessments, interventions, and care plan examples to guide effective patient management.

Nursing Process for DKA

The nursing process for DKA is systematic and patient-centered, encompassing assessment, diagnosis, planning, implementation, and evaluation. Nurses play a pivotal role in each stage, ensuring timely and appropriate care to reverse DKA and prevent complications.

Nursing Assessment for DKA

A thorough nursing assessment is the cornerstone of effective DKA management. It involves gathering subjective and objective data to understand the patient’s condition comprehensively.

Review of Health History

1. Assess Presenting Symptoms: Begin by inquiring about the patient’s current symptoms. Key warning signs and symptoms of DKA include:

• General: Unexplained weight loss (particularly in new-onset type 1 diabetes due to dehydration), generalized weakness, fatigue, and drowsiness.
• Central Nervous System (CNS): Altered level of consciousness, headache, and blurred vision.
• Gastrointestinal (GI): Nausea, vomiting, diffuse abdominal pain, and decreased appetite.
• Genitourinary (GU): Increased urination (polyuria).
• Integumentary: Dry skin.
• Musculoskeletal: Myalgia (muscle pain) and muscle stiffness.

2. Evaluate Insulin Use History: For patients with known diabetes, especially type 1, assess their insulin regimen and adherence. Inquire about:

• History of nonadherence to prescribed insulin therapy.
• Missed insulin doses due to nausea, vomiting, or inconsistent meal schedules.
• Challenges with self-administering insulin due to physical or cognitive limitations.
• History of insulin pump malfunctions if applicable.

3. Investigate for Infections: Probe for any recent or current infections, such as urinary tract infections (UTIs), pneumonia, or surgical site infections. Infections are significant stressors that can elevate blood glucose levels and exacerbate DKA. Conditions causing vomiting and reduced oral intake further complicate glucose management.

4. Medication Review: Obtain a complete medication history, paying attention to:

• Oral antidiabetic medications, particularly SGLT2 inhibitors, which have been associated with an increased DKA risk.
• Corticosteroids and antipsychotic medications, as they can also contribute to DKA development.
• Substance use history, as substance abuse can impact medication adherence and diabetes management.

Physical Assessment

1. Monitor Vital Signs: Closely monitor vital signs as they provide critical clues about the patient’s physiological status. Expected findings in DKA include:

• Fever or hypothermia (in the presence of infection).
• Tachycardia (elevated heart rate).
• Tachypnea (rapid breathing).
• Kussmaul respirations (deep, labored breathing pattern indicative of metabolic acidosis).

2. Conduct a Physical Examination: A comprehensive physical exam can reveal signs of dehydration, cerebral edema, and infection:

• General Appearance: Ill-appearing, weak, possible weight loss, and fever.
• CNS: Decreased mentation, drowsiness, decreased reflexes (hyporeflexia), headache, and confusion.
• Integumentary: Dry skin, dry mucous membranes, poor skin turgor (a sign of dehydration), and flushed skin.
• Respiratory: Labored, deep, rapid breathing (Kussmaul breathing), and fruity-scented breath (due to acetone production). Cough may be present if infection is a trigger.
• Cardiovascular: Poor capillary refill.
• GI: Vomiting, abdominal tenderness upon palpation.
• Genitourinary: Decreased urine output (in severe dehydration).

3. Assess for Ketones: Ketone presence is a hallmark of DKA. Assess for:

• Ketone odor on breath (fruity smell).
• Ketonuria (ketones in the urine), which will be confirmed by diagnostic testing.

4. Evaluate for Cerebral Edema: Cerebral edema is a severe complication, especially in children, resulting from rapid blood sugar changes. Monitor for:

• Fluctuations in consciousness.
• Sustained bradycardia (slow heart rate).
• Incontinence.
• Abnormal pain responses.
• Decorticate or decerebrate posturing (signs of neurological damage).
• Lethargy.

Diagnostic Procedures

1. Blood Glucose and Blood Gas Analysis: Blood tests are essential to confirm DKA:

• Blood Glucose: Elevated blood glucose levels above 250 mg/dL are a primary diagnostic criterion.
• Arterial Blood Gas (ABG): Arterial pH below 7.3 indicates metabolic acidosis.
• Serum Bicarbonate: Serum bicarbonate levels below 15 mEq/L also confirm metabolic acidosis.
• Serum Ketones (Ketonemia): Presence of ketones in the blood is a key indicator.
• Anion Gap: Anion gap greater than 10 (mild DKA) or 12 (moderate to severe DKA) helps differentiate DKA from Hyperosmolar Hyperglycemic Syndrome (HHS).

2. Urinalysis: Urine testing will reveal:

• Glucosuria (glucose in urine).
• Ketonuria (ketones in urine).

3. Infection Workup: If infection is suspected, further tests may include:

• Complete Blood Count (CBC): Leukocytosis (elevated white blood cell count) is common in DKA, but marked leukocytosis or leukopenia may suggest sepsis.
• Chest X-ray: To rule out pneumonia.
• Serum Lipase: If pancreatitis is suspected.
• Cultures (urine, sputum, blood): To identify specific pathogens if infection is present.

4. Electrocardiogram (ECG): An ECG can detect electrolyte imbalances:

• Peaked T waves: May indicate hyperkalemia.
• U waves and flattened T waves: May indicate hypokalemia.

5. Imaging Studies: In specific situations, imaging may be ordered:

• CT scan of the abdomen: To assess for pancreatitis if elevated liver enzymes are present.
• CT or MRI of the head: To evaluate for cerebral edema if neurological symptoms are present.

Nursing Interventions for DKA

Nursing interventions for DKA are directed at correcting the metabolic derangements and preventing complications.

Reverse Diabetic Ketoacidosis

1. DKA Management Principles: The core treatment strategies for DKA are:

• Fluid resuscitation and maintenance.
• Insulin therapy.
• Electrolyte replacement.
• Supportive care.

2. Hydration Management: Dehydration is significant in DKA.

• Initiate intravenous fluid resuscitation immediately with 0.9% normal saline to restore volume, improve perfusion, and facilitate ketone clearance. Fluid replacement is crucial even before insulin administration.

3. Insulin Administration: Intravenous insulin is essential to reverse hyperglycemia and ketogenesis.

• Administer continuous IV infusion of short-acting insulin until blood glucose is below 200 mg/dL AND two of the following criteria are met: serum bicarbonate ≥ 15 mEq/L, pH > 7.3, anion gap ≤ 12 mEq/L.

4. Electrolyte Correction: Insulin therapy and fluid shifts can cause electrolyte imbalances.

• Administer electrolytes intravenously as prescribed, particularly potassium, to maintain cardiac, muscle, and nerve function.

5. Potassium Repletion: Hypokalemia is a major concern during DKA treatment.

• Monitor potassium levels closely and replete potassium (if hypokalemic) before initiating insulin infusion to prevent cardiac arrhythmias. Maintain potassium levels between 4.0-5.0 mEq/L.

6. Laboratory Monitoring: Frequent lab monitoring is vital.

• Perform hourly point-of-care glucose testing.
• Monitor serum glucose and electrolytes every 2 hours until stable, then every 4 hours.
• Obtain baseline Blood Urea Nitrogen (BUN).
• Monitor ABGs as needed to assess acid-base status.

7. Acid-Base Balance: Sodium bicarbonate may be considered in severe acidosis.

• Administer sodium bicarbonate cautiously for life-threatening decompensated acidosis, especially with concurrent sepsis or lactic acidosis. Be aware of the risk of cerebral edema, particularly in children, with bicarbonate administration.

Treat or Prevent Complications

1. Infection Management: Address underlying infections promptly.

• Administer appropriate antibiotics based on culture and sensitivity results. Initiate empiric antibiotics if infection is suspected while awaiting culture results.

2. Cerebral Edema Management: Prompt intervention is critical for cerebral edema.

• Administer mannitol as first-line treatment for cerebral edema. Closely monitor neurological status and mental status for early detection of cerebral edema.

3. Prevent Overhydration: Exercise caution with fluid administration in patients with renal failure or heart failure.

• Monitor for signs of overhydration, especially in vulnerable patients. Diuretics may be needed to manage pulmonary edema.

4. Prevent Hypoglycemia: Avoid overly rapid glucose correction.

• Monitor glucose levels carefully to prevent hypoglycemia during DKA treatment.

Provide Education to Prevent Recurrences

1. Glucose Monitoring Education: Ensure patient competency in glucose monitoring.

• Before discharge, review proper glucometer use and have the patient demonstrate technique.

2. DKA Prevention Education: Educate patients on self-management strategies.

• Instruct on adjusting insulin doses during illness (“sick day rules”) and when to check urine ketones (blood glucose > 250 mg/dL). Emphasize increased monitoring during illness and stress.

3. Maintain Target Glucose Range: Reinforce adherence to diabetes management plan.

• Educate on individualized target blood glucose ranges and the importance of insulin or antidiabetic medication adherence.

4. Referral to Specialist: Connect patients with specialized diabetes care.

• Refer to a diabetologist or endocrinologist for specialized diabetes management and education if not already under specialist care.

5. DKA Symptom Education: Ensure patient and family recognize DKA warning signs.

• Educate on symptoms requiring immediate medical attention, such as persistent vomiting, abdominal pain, difficulty breathing, and sustained high glucose levels (> 300 mg/dL).

6. Diabetes Self-Management Education (DSMES): Promote comprehensive diabetes education.

• Refer to a DSMES program to provide essential skills and support for long-term diabetes management.

7. Diabetes Educator Collaboration: Utilize the expertise of diabetes educators.

• Collaborate with diabetes educators to provide in-depth patient and caregiver education.

8. Case Management Referral: Address social determinants of health.

• Consider nurse case manager or social worker referral for patients needing assistance with medication costs, supplies, or independent diabetes management.

DKA Nursing Care Plans Examples

Nursing care plans for DKA provide a structured approach to care, prioritizing nursing diagnoses and guiding interventions to achieve desired patient outcomes. Here are examples of nursing care plans for common DKA-related nursing diagnoses:

Acute Confusion

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 maintain orientation to person, place, and time.
• Patient will not experience seizures, cerebral edema, or coma related to DKA.

Nursing Assessments:

1. Assess Cognition: Monitor for changes in cognitive function and level of consciousness using tools like the Glasgow Coma Scale (GCS).
2. Monitor Lab Values: Closely monitor electrolyte levels, pH, ketones, and plasma glucose.
3. Review Imaging: Evaluate CT scans or MRIs for signs of cerebral edema.

Nursing Interventions:

1. Administer Insulin: Provide IV insulin therapy as prescribed to reduce glucose and ketone levels.
2. Maintain Fluid Balance: Administer fluids cautiously to prevent overhydration and cerebral edema.
3. Magnesium Consideration: Assess magnesium levels and correct deficits, as magnesium deficiency can contribute to neurological symptoms.
4. Medical Alert Bracelet: Ensure the patient wears a medical alert bracelet to facilitate rapid identification and care in emergencies.

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output

Related to: Hyperglycemia, hypovolemia, acidosis, hypokalemia, hyperkalemia, myocardial injury

As evidenced by: Tachycardia, tachypnea, dyspnea, reduced oxygen saturation, hypotension, decreased central venous pressure (CVP), increased pulmonary artery pressure (PAP), chest pain, abnormal heart sounds, dysrhythmia, fatigue, change in level of consciousness, anxiety/restlessness, abnormal electrolyte levels, abnormal ABGs, elevated cardiac biomarkers

Expected Outcomes:

• Patient will demonstrate adequate cardiac output, evidenced by:
  • Systolic BP within 20 mmHg of baseline
  • Heart rate 60-100 bpm with regular rhythm
  • Respiratory rate 12-20 breaths/min
• Patient will maintain potassium levels within 4.0-5.0 mEq/L.

Nursing Assessments:

1. Monitor Vital Signs: Assess respiratory rate, heart rate, and blood pressure frequently, noting trends.
2. 12-Lead ECG Monitoring: Obtain and monitor 12-lead ECGs to assess for dysrhythmias and myocardial ischemia.
3. Monitor Labs: Track electrolytes, ABGs, and cardiac biomarkers to evaluate cardiac function and electrolyte balance.

Nursing Interventions:

1. Correct Electrolyte Imbalances: Prioritize potassium replacement before insulin administration if hypokalemia is present to prevent cardiac complications.
2. Oxygen Therapy: Administer supplemental oxygen as needed, especially in patients with pre-existing cardiac conditions.
3. Sodium Bicarbonate Consideration: Consider sodium bicarbonate for severe acidosis, particularly if sepsis or lactic acidosis is present.
4. Cardiology Consultation: Consult cardiology for persistent dysrhythmias despite DKA treatment.

Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion

Related to: Septic shock, acidosis, renal failure, vomiting, dehydration, hyperglycemia, cerebral edema

As evidenced by: Fever (>38.0 C) or hypothermia (<36.0 C), tachycardia, tachypnea, leukocytosis, hypotension, prolonged capillary refill time, change in level of consciousness, oliguria, nausea and vomiting, dry skin, poor skin turgor

Expected Outcomes:

• Patient will maintain optimal tissue perfusion, evidenced by:
  • Temperature 36.5-37.4°C
  • HR 60-90 bpm
  • RR 12-20 breaths per minute
  • SBP >90 mmHg
  • Urine output 0.5-1.5 cc/kg/hour
  • WBC 4,000-12,000/mm3
  • Capillary refill time <3 seconds
• Patient will maintain baseline consciousness and orientation.

Nursing Assessments:

1. Monitor Vital Signs: Assess for signs of sepsis and septic shock (fever/hypothermia, tachycardia, tachypnea, hypotension).
2. Monitor CBC: Evaluate WBC count for signs of infection or sepsis.
3. Assess Renal Function: Monitor BUN and creatinine levels to assess kidney function.

Nursing Interventions:

1. Administer IV Fluids: Provide aggressive IV fluid resuscitation with 0.9% normal saline.
2. Prevent Cerebral Edema: Monitor for signs of cerebral edema and administer mannitol or hypertonic saline if indicated.
3. Monitor Urine Output: Closely track urine output as an indicator of renal perfusion.
4. Administer Medications: Administer broad-spectrum antibiotics as ordered if infection is suspected.

Risk For Deficient Fluid Volume

Nursing Diagnosis: Risk For Deficient Fluid Volume

Related to: Vomiting, Kussmaul respirations, polyuria, glycosuria and osmotic diuresis

As evidenced by: (Risk diagnosis – no evidence by signs and symptoms)

Expected Outcomes:

• Patient will identify factors contributing to fluid loss and related symptoms.
• Patient will maintain normovolemia, evidenced by normal urine output, electrolyte levels, and stable vital signs.

Nursing Assessments:

1. Assess Vital Signs and Respirations: Monitor for tachycardia, hypotension, and Kussmaul respirations.
2. Monitor Electrolytes: Track electrolyte levels, noting potential imbalances (potassium, magnesium, sodium).
3. Assess Kidney Function and Urine Output: Monitor urine output and serum creatinine for signs of acute kidney injury.

Nursing Interventions:

1. Administer Isotonic Solutions: Initiate fluid replacement with isotonic solutions (0.9% saline).
2. Dextrose Infusion: Add dextrose to IV fluids once glucose levels reach approximately 250 mg/dL to prevent hypoglycemia and continued ketogenesis.
3. Offer Oral Fluids: Encourage oral fluid intake if the patient is alert and able to swallow safely.
4. Patient Education: Educate the patient on symptoms of dehydration and the importance of fluid intake.

Risk For Unstable Blood Glucose

Nursing Diagnosis: Risk For Unstable Blood Glucose

Related to: Lack of diabetic diagnosis, poor diabetes management, illness, injuries, stress, incorrect insulin dosing

As evidenced by: (Risk diagnosis – no evidence by signs and symptoms)

Expected Outcomes:

• Patient will verbalize factors contributing to unstable blood glucose.
• Patient will demonstrate correct insulin administration technique.
• Patient will maintain blood glucose levels within target range.

Nursing Assessments:

1. Assess Diabetes Understanding: Evaluate the patient’s knowledge of their diabetes diagnosis and management.
2. Review HgbA1c: Assess HgbA1c levels to evaluate long-term glucose control.
3. Insulin Understanding Assessment: Assess the patient’s understanding of insulin therapy and adherence.

Nursing Interventions:

1. Glucometer Technique Education: Observe and educate the patient on proper glucometer use.
2. Ketone Testing Education: Educate on urine ketone testing and when to perform it (e.g., during illness, hyperglycemia > 240 mg/dL).
3. DKA Cause Education: Provide education on factors that can trigger DKA (illness, stress, medication changes, alcohol intake).
4. Diabetes Educator Referral: Refer to a diabetes educator for comprehensive diabetes self-management training.

References

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